Skin Integrity Flashcards
(30 cards)
concepts that impact tissue integrity
- sensory perception
- mobility
- nutrition
- perfusion
- gas exchange
- elimination
concepts that are negatively impacted when tissue integrity is disrupted
- infection
- pain
- fluid & electrolytes
- thermoregulation
a & p of integument
- hair – present everywhere but palms/ soles, root formed in dermis, thermal insulation, filter debris, color by melanin
- nails – keratin, protects finger/toes - preserves sensory fns, growth slows w/ aging
- skin – epidermis (epithelial cells w/ keratin = waterproof, no blood vessels, depend on underlying structures), dermis (nerves, hair follicles, glands/ blood vessels), subcutaneous tissue (anchors skin layers to underlying tissues, fat storage-energy, heat, insulator, cushioning)
- glands – sebaceous - produce sebum assoc w/ hair follicles, lubricate/soften skin, sweat - water and salt/cerumen, output depends on location, thermoregualtion
function of skin
- protection – thickened areas palms/soles s/t inc trauma
-
sensation – receptors located in skin - temp, pain, light touch, pressure
-** fluid balance** - can absorb water or excrete as sweat, about 600ml lost/day through sweat = insensible perspiration
-** temp regulation** - evaporation of sweat, controlled blood flow thru skin -
vitamin production – vitamin D made w/ melanin
-** immune response** – Langerhans cells facilitate uptake of allergens
changes in skin integrity
- state of individual health = direct impact on skin condition
- very thin/ obese
- fluid loss
- ecessive moisture
- jaundice
- skin disorders
risk factors for impaired skin integrity
- lifestyle variables
- age
- change in health status
- illness
- diagnostic procedures
- therapeutic measures – immobility
categories of impaired tissue integrity
all
- trauma
- loss of perfusion/ gas exchange – = pressure ulcers
- immunological disorders
- thermal radiation
- infection – bacterial, fungal, viral, infestations
- lesions
categories of impaired tissue integrity
Trauma
- incision (intentional)
- contusion
- abrasion (scrape)
- lacertatin (cut)
- puncture
- penetrating
- avulsion
- chemical
- thermal
- irradiation
- superficial, internal
categories of impaired tissue integrity
loss of perfusion/ gas exhange
- pressure ulcers/ bed sores
- venous statis ulcers
- diabetic ulcers
- arterial ulcers
- poor venous return, peripheral artery disease
categories of impaired tissue integrity
immunological disorders
- psoriasis
- Steven- Johnson Syndrome
- contact dermatitis
Steven-Johnson Syndrom
- potentially fatal acute skin disorder - high infection risk (sepsis, multi-organ failure - 5% mortality rate)
- characterized by: widespread erythema, macule formation, blistering, epidermal detachment/ sloughing
- typically triggered by reaction to medication – antibiotics (common offender), anit-seizure, NSAIDs, tylenol
- treatment – discontinue offending med, fluid/electrolyte replacement, supportive care – fluids, pain intervention
contact dermatitis
- allergic – latex, poison ivy, cosmetics, jewelry
- irritant – soap, diaper rash, pper spray, bleach
- s/s – pruritus, burning, edema, swelling, papule/ vesicle formation
categories of impaired tissue integrity
thermal/ radiation
- sunburn, radiation therapy
- not chemical burns – irritant dermititis
categories of impaired tissue integrity
infection
- bacterial – cellulitis, impetigo (staff/strep), acne
- fungal – candida albicans, tinea (ringworm)
- viral – herpes (shingles)
categories of impaired skin integrity
infestations
- pediculosos humanis capitis (head lice)
- pediculosis pubis (crabs)
- scabies
categories of impaired skin integrity
cancer
- skin lesion rule: ABCDE
- Asymmetry
- Border irregularity
- Color change and variation
- DIameter (6mm or greater)
- Evolving in appearance
Principles of wound healing
- hand hygiene and infection prevention
- body responds systemically to trauma in any of its parts
- adequate blood supply is essential
- normal healig is promoted when wound is free of foreign material
- body’s ability to handle altered skin integrity depends on person’s general state of health
- proper nutrition – glucose (high = bacteria food, 70-150), protein (albumin levels), vitamins/ minerals – iron, A/C/E - wound healing, collagen formation
types of wounds
- primary intention (little tissue loss) – surgical incision
- secondary intention (big tisse loss) – burn, pressure ulcer, sever laceration
phases of wound healing
- hemostasis (“blueprint”)
- inflammatory (“clearing the plot”)
- proliferation (“build the house”)
- maturation (“make things pretty”)
1st phase of wound healing
hemostasis (“blueprint”)
- occurs immediately after initial injury
- blood vessels constrict
- platelet aggregation – clots- prevent futher blood loss
- exudate forms
2nd phase of wound healing
inflammatory phase (“clearing the plot”)
- starts a couple hours after initial injury
- usually lasts 4-6 days
- WBCs move to wound:
- leukocytes – ingest baceria/ debris
- macrophages – ingest debris, release growth factors
- 5 signs of inflammation
- systemic response
3rd stage of wound healing
proliferation phase (“build the house”)
- lasts for several weeks
- new tissue built into wound space
- fibroblasts – connective tissue cells that synthesize and secrete collagen (foundation/walls) and growth factors
- capillaries grow across wound bringing o2 and nutrients
- thin layer of epithelial cells across wound
- granulation tissue - new tissue, pink/red, composed of fibroblasts and small blood vessels that fill open wound when it starts to heal
- collagen synthesis continues, peaks in 5-7 days
4th phase of wound healing
maturation phase (“make things pretty”)
- begins 3 weeks after injury - continue for months-years
- collagen deposits are remodeled = healed wound stronger and more like adjeacent tissue
- collagen continues to be deposited - compresses blood vessels = scar formation - avascular collagen tissue
- scar tissue weaker than noaml tissue, never fully restored
wound repair
partial thickness
- shallow wounds
- loss of epidermis and partial dermis
- epidermis regernates – wound healing
full thickness
- beyond erpidermis, into deep layer of dermis
- dermis does not regenerate
- scar formation – wound healing
