Chapter 36 Skin Integrity N Wound Care Flashcards
Functions of the skin
Protection
Temperature regulation
Sensation
Factors Affecting Skin Integrity
Genetics and heredity Age Chronic illnesses and their treatments ex diabetics can be affected because of sensation not able to feel (touch) Medications ex protozoan Poor nutrition Trauma
Define wounds
An injury to living tissue (especially an injury involving a cut or break in the skin)
Types of Wounds
Incision
Laceration
Abrasion
Incision sharp instrument
Laceration tissues torn apart often from accidents
Abrasion surface scrape either unintentional ex scraped knee from a fall
Types of Wounds
Contusion
Avulsion
Penetrating wound
Contusion blow from a blunt instrument
Avulsion injury of which the body structure is forceful detached by either trauma or injury
Penetrating wound penetration of the skin and the underlying tissues usually unintentional ex from a bullet or mental fragments
Assessment of Wounds
Objective judgement
Wound assessment charts provide a useful framework
Wound measurement is an important aspect of the assessment
Photographs
Ex week or two of no healing contact physician
Assessments of wounds
Related to lab work
WBCS decrease leukocyte count can delay healing and increase possibility of infection
Hemoglobin indicates poor oxygenation delivery to the tissues
Coagulation tests indicates excessive blood loss and prolonged clothing absorption
Serum protein indicates nutritional reserves for rebuilding cells
Albumin indicates nutritional status
Wound cultures confirm or rule out the presence of infection
Pressure Ulcers
Are areas of necrosis and ulceration where tissues are compressed between bony prominences and hard surfaces
Safety Alert
From the joint commission 2010 national patient safety goals (NPSGs)
Goal 14 prevent health care associated pressure ulcers (decubitus ulcers)
Rationale pressure ulcers continue to be problematic in all health care settings Most pressure ulcers can be prevented and deterioration at state 1 can be halted
Healthy skin vs Fragile skin
Healthy skin the subcutaneous layer contains blood vessels and cushioning fat new cells are made in the dermis
Fragile skin the subcutaneous layer has fewer and flatter fat cells the dermis produce cells slowly
Skin Integrity
Intact skin refers to the presence of normal skin and skin layers uninterrupted by wounds
What are the four stages of pressure ulcers?
Stage 1 nonblanchable erythema signaling potential ulceration
Stage 2 partial thickness skin loss (abrasion,blister,or shallow crater) involving the epidermis and possibly the dermis
Stage 3 full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia
Stage 4 full thickness skin loss with tissue necrosis or damage to muscle bone or supporting structures such as a tendon or joint capsule
Assessment of Pressure Ulcers
Location r/t a bony prominence Size Stage (can't stage in Fl) Color of the wound bed Necrosis or Escher Wound margins Surrounding skin Clinical signs of infection
Pressure Ulcers Interventions
Obtaining wound culture ex aerobic or anaerobic
Administer analgesic ex remove moist or outer dressing
Discard in bad
Cleanse wound ex irrigate or cleanse wound with NS
Assessment Risk Assessment Tools
Braden Scale predict risk a total 23 points below 18 considered at risk
Norton’s Pressure Area Risk Assessment total score of 24, 15-16 considered indications not predictions of risk
Push pressure ulcer scale for healing national pressure ulcer advisory panel
