Skin Integrity & Wound Care

Question 1

describe the SKIN ANATOMY

Answer 1

EPIDERMIS;
- the TOP LAYER OF THE SKIN
*come lets get sun burnt

DERMIS;
- the INNER LAYER OF THE SKIN
- COLLAGEN

DERMAL-EPIDERMAL JUNCTION;
- separates the dermis & epidermis

Question 2

how do pressure injuries occur?

Answer 2

• due to UNRELIEVED PROLONGED PRESSURE

Question 3

what are other names for PRESSURE INJURIES?

Answer 3

• pressure ulcer
• decubitus ulcer
• bedsore

Question 4

describe the PATHOGENESIS of PRESSURE INJURIES

Answer 4

• PRESSURE INTENSITY
• PRESSURE DURATION
• TISSUE TOLERANCE

Question 5

functions of skin

Answer 5

• the LARGEST ORGAN of the body
• serves as a protective barrier
• sensory organ
• synthesizes vitamin D

Question 6

important focus on older adults

Answer 6

• have an easier breakdown and risk for injury in the skin;
  
  • decreased collagen formation
  • thinning muscle and tissue
  • decreased skin elasticity
  • slower wound healing

Question 7

who is AT RISK for pressure injuries?

Answer 7

• impaired sensory perception
• impaired mobility
• changes in LOC (dementia patients)
• diabetic/stroke/SCI/hip fracture patients

Question 8

definition of SHEAR

Answer 8

• the SLIDING MOVEMENT of SKIN and SUBQ. tissue while underlying muscle and bone are STATIONARY
• SKIN + SUBQ. adhere to surface, while bones/muscle slide in direction of body movement
• causes DEEPER FASCIAL LEVEL DAMAGE

Question 9

definition of FRICTION

Answer 9

• the force of TWO SURFACES moving across from one another
• affects the EPIDERMIS
  
  • painful and red; sheet burn
  • often seen in restless patients

Question 10

definition of MOISTURE:

Answer 10

• allows for more SOFTENED SKIN and creates more SUSCEPTIBILITY
• can cause MOISTURE-ASSOCIATED SKIN DAMAGE (MASD

Question 11

describe the stages of CLASSIFICATION OF PRESSURE ULCERS

Answer 11

Stage 1: Non-blanchable erythema of intact skin
 Stage 2: Partial-thickness skin loss with exposed dermis
 Stage 3: Full-thickness skin loss
 Stage 4: Pressure Injury: Full-thickness skin and tissue loss

Question 12

deep tissue pressure injury (DTPI)

Answer 12

• show case of dark marron discoloration
• probable injury to tissue underneath
• can have nonintact/intact skin
• from intense/prolonged pressure

Question 13

granulation tissue

Answer 13

new healing tissue; pink or red

Question 14

slough

Answer 14

dead tissue; cream/yellow color

Question 15

eschar

Answer 15

dead tissue; dry, black and hard

Question 16

exudate

Answer 16

drainage

Question 17

what are our WOUND CLASSIFICATIONS

Answer 17

• PARTIAL THICKNESS WOUNDS
• FULL THICKNESS WOUNDS
• PRIMARY INTENTION
• SECONDARY INTENTION

Question 18

unstageable wound injury

Answer 18

• OBSURED FULL-THICKNESS SKIN and tissue loss
• has tissue damage due to OBSCURED SLOUGH or ESCHAR
  
  • once removed can possibly be classified as either stage 3 or 4

Question 19

what are some COMPLICATIONS when it comes to wound healing?

Answer 19

• HEMORRHAGE
• INFECTION
• DEHISCENCE
• EVISCERATION

Question 20

HEMORRHAGE

Answer 20

bleeding out

Question 21

infection

Answer 21

showcase of fever, odor, purulent drainage, erythema, increased WBC, pain

Question 22

dehiscence

Answer 22

the opening of the wound

Question 23

evisceration

Answer 23

the opening of a wound and anatomical structures come out

**MEDICAL EMERGENCY; need covering of saline & surgery

Question 24

MEDICAL DEVICE-RELATED PRESSURE INJURY (MDRPI):

Answer 24

• where skin or underlying tissues are subjected to SUSTAINED PRESSURE or SHEAR from medical devices or equipment
• injury begins to CONFORM to pattern or shape of the device
  mainly seen in face, head, or ear region

Question 25

what are the TWO MAJOR TYPES OF WOUNDS?

Answer 25

CLOSED; - surface of skin is INTACT—damage of UNDERLYING TISSUES - ex. hematomas, stage 1 pressure injuries, contusions OPEN; - surface of skin is SPLIT, INCISED, or CRACKED - exposed underlying tissues - very high chance of INFECTION DEVELOPMENT

Question 26

primary intention

Answer 26

- closed wound - healing undergoes epithelialization - quick, minimal scaring - seen in hematomas, surgical incisions

Question 27

secondary intention

Answer 27

- open wound edges - healing undergoes granulation, tissue formation, wound contraction, & epithelialization - wounds with tissue loss/contamination

Question 28

tertiary intention

Answer 28

- open wound (for several days) - delayed healing process and closing - contaminated wounds and signs of inflammation

Question 29

what are factors that influence pressure injury formation & wound healing?

Answer 29

- NUTRITION (vitamins A & C - reduces steroid effects of healing/collagen synthesis - TISSUE PERFUSION - INFECTION - AGE - PSYCHOSOCIAL IMPACT OF WOUNDS

Question 30

heat therapy

Answer 30

- allows for VASODILATION - allows for flexibility - relaxation of muscles

Question 31

cold therapy

Answer 31

- use of vasoconstriction - for inflammation, wound sprains/strains - often for SOFT TISSUE INJURIES

Question 32

what types of heat and cold therapies can be applied?

Answer 32

- moist or dry compresses - warm soaks/cold soaks - hot and cold packs **NEVER APPLY DIRECT COLD OR HEAT TO SURGICAL WOUND **Always start at the LOWEST SETTING

Question 33

what are the types of EXUDATE?

Answer 33

- SEROUS - PURULENT - SEROSANGUINEOUS - SANGUINEOUS

Question 34

serous exudate

Answer 34

- clear, watery plasma

Question 35

purulent exudate

Answer 35

thick, yellow or brown, tan

Question 36

serosanguineous exudate

Answer 36

pale, pink, watery; mix of clear & red

Question 37

sanguineous exudate

Answer 37

bright red; sign of active bleeding

Question 38

tissue perfusion

Answer 38

- perfusion ability of oxygenated blood - RISK; - diabetic patients - peripheral vascular disease patients