Chapt 36- skin and wounds Flashcards
(20 cards)
Layers of skin
Epidermis, Dermis and Subcutaneous layer
Factors influencing Skin Integ
Nutrition, tissue perfusion, infection, age, mobility, cognition, moisture, medications
Sensation/cognition
diabetic nephropathy can be caused due to diabetics and getting edema
Venous Circulation
engorged tissue with a lot of waste products and results in edema, skin b.down and ulceration
Skin
Tanning, hygiene habit, diet, smoking
Types of wound
- length of time
- condition
- depth
Chronic
Heal from inside out
Wound healing- 3 types
Primary, Secondary, Tertiary
Primary Healing
Very clean wound usually via sutures and no scar
Secondary Healing
Wound can’t be brought together due to a lot of tissue lose
-no sutures work and SCAR
Tertiary Healing
- Wound edges are together(approximated)
- Used in BIG surgical wounds that are complicated by infection
- ex : abdominal and knee surgeries
- very wide scar
Phases of healing
inflam, proliferative and maturation
Complications
Dehiscence- separate or splitting open of layers of surgical wound
Evisceration- extrusion of viscera or intestine through surgical wound
Wound Draining
Serous Exudate, Sanguineous Exudate, Serosanguienous, prulent exudate, Purosanguienous exudate
Pressure Ulcer- Time and Pressure are the key variables in Ischemia
Time and Pressure- Large pressure for a short amount of time, or lighter pressure for an extended period of time.
Foot drop
Pt that stays in bed, their muscles and tendons will stay that way
- need to be moved and exercised
- boots are used to keep feet in position and their heal DOES NOT touch anything (take on and off)
- while off- put pillow from knee to ankle and heal should be in air = no PRESSURE
What can cause when a pt is bed bound
Shear and friction
Protective Mech for ischemia
Normal hyperemia- flush of blood flow to ischemic area and redden
Abnormal hyperemia- excessive vasodilation of tissue with induration (harderning
Stages of Pressure Ulcers
S1- localized, non-blanchable, red, over bony area.
-warm or cool and discoloration returns in 30 min
S2-open, pink, partial thickness, slough, blister/shiny or dry with slough and bruise
S3-Full thickness, necrosis to subcut but no bone visible
S4- exposed BONE/TENDON, necrosis, slough
Additional Pressure Ulcer Formations
Suspected Deep Tissue- skin intact, boggy, bruising or blister present
Unstageable Pressure Ulcer- full thicknness, wound has slough and eschar(black/brown): dont remove it
