• Barrier preventing invasion by microorganisms
• Regulate body temperture
• Sensations of pain, temperature, touch, pressure
• Produces and absorbs vitamin D
• Secretes sebum, including softening and lubricating

epidermis and dermis; under the dermis is subcutaneous layer

Outermost layer made of stratified squamous epithelial cells. Devided into 5 layers, innermost of which is the basal-cell layer, the cells responsible for replacing sloughed and damaged cells

Second layer composed of connetive tissue. Gives elasticity; blood vessels, nerve fibers, glands, and hair folicles are embedded in this layer

consists of adipose tissue and provides support and blood flow to the dermis

glands within the dermis, secrete oil subtance called sebum, made up fat, cholesterol, protein, and salts.

sweat glands

produce a watery secretion

• aging
• overall health status
• nutritional status
• energy/activity level

• Epidermis thins and has lower water content, leading to dry skin
• Elasticity and some of the fatty cushion is lost, resulting in wrinkles and fragile skin
• Blood vessels in the skin also become more fragile with aging, leading to easy bruising

Break in the skin or mucous membrane resulting from physical means. It may be superficial or deep

break in the skin and could be superficial or deep.

Example: abrasion, laceration or puncture

No break in the skin. Example: contusion and scchymosis, injuries may be caused by a blow or another type of blunt force or trauma

classification of wounds according to the continuity of the surface it covers (tissue involved)

Refer to depth of injury and are used most frequently to refer burns

Envolve only epidermis

Envolve entire epidermis and part of the dermis; sweat glands and hair follicles are intact

Evolve epidermis and dermis extending to subcutaneous tissue, possibly even muscle and bone

Clear wound has not been invaded by pathogenic microorganisms; clear wound heal without infection

Septic wound. Pathogenic microorganism have invaded the wound

Intentional wound made by a surgeon for therapeutic purposes using sharp cutting instrument; it is a clean wound that heals without infection

Lesion caused by unrelieved pressure; this in turn damges underlying tissues

• Occur mainly in pp who are chair-bound, bed-bound, altered LOC that cause them to be immobile
• Older Adults are at greater risk b/c of the fragility of the skin
• Moisture on the skin from sweating or incontinence can lead to skin breakdown
• Malnutrition reduced nutrient stores including protein for tissue repair
• Shearing pressure cause injury (tissue hypoxia); this occurs when the head of the bed is elevated
• Friction occurs when a client is moved in  bed
• Factors can be assessed to determine an individual client's relative risk using scales shuc as Braden Scale or Norton Scale

Score 16 or less pt has higher risk

The skin is intact, although nonblanching erythema (no color change) will be noted.

Client reported: tingling, painful, firm, soft, warmth, buring, edema, hardness, darker skin clients may have skin discoloration

Involves superficial or partial thickness skin loss with blister or abrasion-like appearance. It may also look like a shallow crater.

Further discription: shiny or dry shallow ulcer without slough or bruising

Stage III Pressure Ulcers

Full thickness skin loss (fat visible). Necrotic tissue will be seen in the subcutaneous layer that extend down to but not through underlying fascia. The ulcer will appear as a deeper crater with or without undermining of surrounding tissue.

Eschar and Slough presents (need to be remove before healing)

Bone/tendons is not visible

darker type, can't see underneath, black or brown necrotic tissue in the wound bed

soft, white, almost slight up constinence, stringy subtance attached to wound bed. Yellow, tan, gray, green, brown

Damge of muscle, bone, and supporting structures such as tendons or joint capsule; undermining of tissue and sinus tracts may also be present

Slough or eschar maybe present

Cineoustract: when put Q tipe in, lost Q tip, it may move to another part of body

True depth of injury is unknown until eschar or slogh is removed.

The truth depth can't determined, but it is either stage III or IV.

Remove eschar or slough, done surgically

Turn pt, keep them dry, get pt out of bed, provide protein, smooth pt sheat, position pt (less pressure). Dependent area: area has more pressure

Protein fired in wound, blood fluid in the area bringing Oxygen and nutriens for healing, scab that seals the skin, network of fiber, damage tissue heal 3-4 days

Granual tissue form fibrin network, epithelial cells going from edge to center, 4-21 days

Connective tissue filling --> scar

Depend on wound, can takes weeks or years to heal. A wound has 80 % of a strength as before, more suceptable to the re-injury.

An abnormal amount of collagen is laid down, forming hypertrophic scar

• Aging
• Infection
• Health
• Medication Antiinflammatory-slown doen fiber tissue
• Nutrition (protein, Vitamin C-enhances protein synthesis)
• Malnutrition of tissue
• Circulation
• Res-heal itself during sleep (Important)
• Hygiene: clean and dry
• Zinc helps body to heal muck quicker (provide zinc in stage III and IV)

Wound Heal by Natural Function: Primary Intention

• Little loss of tissue. Tissue return normal with little inflammation: surgical incision
• Skin edges are approximated, or closed without infection
• Healing occur quickly, minimal scar formation
• Prevent infection and secondary breakdown

• Occurs when wound is extensive, wound edges can't be approximated. Need more granulation to close the wound
• The healing time is more prolonged
• Scar is deeper and  more extensive
• Risk for infection
• Burn, pressure ulcers, servere laceration
• Loos of tissue

• Delay classure
• Types of drains
• Greater risk tobe infected

Sutures, staples, and clips are devices used to help approximate the adges of the wound. 7-10 days

risk is greater within the first 48 hr, if pressure dressing don't successfully stop the bleeding, surgical intervention may be necessary

Infection results from pathogenic microorganism invading the wound (s/s: redness, heat, and pain)

Purulent exudate: consisting leukocytes, liquefied dead tissue debris, and dead and living bacteria may be noted.

Pt can be anorexic, nauseous, febrile and have chill (s/s of infection)

Order a wound culture and antibiotics will be administered after the culture is obtained

Wound's suture line accidently reopens by sneez or caugh. It also may be occur b/c of infected suture line. Pt state they "feel something giving way"

Place pt in bed with head of bed low to eliminate gravity and with the knees bent to decrease pull on the suture line. Cover the wound bed with large sterile dressing moistened with normal saline. Make sure pt lying on bed. Don't do anything makes it worse

Occurs when the edges of suture line separate and the internal organs pill out. Complication including infection, poor nutrition, failure of suture material, dehydration, excessive coughing

measuring devices for width and length

Plain or impregnated with an anti-microbial, this dressing packs and fills the wound, absorbs drainage. This dressing used for full and partial thickness wounds with drainage. May be applied dry to voer wound or damp to damp dressing to pack a wound requiring debrodement

This dressing is occlusive to microorganisms and liquids and promotes absorption of wound exudates

Protects the wound and promotes autolytic debridement (the removal of dead tissue from wound). This dressing are impermeanle to bacteria

Purpose is to absorb drainage, the advantage of this type od wound coverage is that it only has to be changed three times per week

Water or glycerin is primary component of this dressing. Maintians a moist of wound surface and provides some absorption. This dressing are permeable to oxygena and can fill dead space in wound