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chapt 32
skin integrity and wound care
118
Nursing
Undergraduate 1
10/05/2011

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Term
Epidermis
Definition
The top layer, or outermost portion of the skin.
Term
Dermis
Definition
layer of the skin below the epidermis. 2nd layer.
Term
Subcutaneous tissue
Definition
underlying layer that anchors the skin layers to the underlying tissue of the body. 3rd layer.
Term
Functions of the skin: Protection
Definition
-acts as a barrier to water; microorganisms, and damaging ultraviolet rays of the sun.
-protection against infection.
-injury to underlying tissues and organs is decreased by the intact skin.
-prevents loss of moisture from the surface and underlying structures.
Term
Functions of the skin: Temperature regulation
Definition
-The evaporation of perspiration draws heat from the skin.
-Blood vessels in the skin dilate to dissipate heat.
-in cold conditions, blood vessels in the skin constrict to diminish heat loss.
-In cold conditions, contraction of pilomotor muscles cause the hair to stand on end, forming a layer of air on the body for insulation(gooseflesh or goose bumps).
Term
Functions of the skin: Psychosocial
Definition
-External appearance is a major contributor to self-esteem.
-Important role in identification and communication.
Term
Functions of the skin: Sensation
Definition
-Millions of nerve endings in the skin provide the sense of touch, pain, pressure, and temperature.
-sensory impulses from the skin allow the body to adjust to the environment, in conjunction with the brain and spinal cord.
Term
Functions of the skin: Vitamin D production
Definition
-A precursor for vitamin D is present in the skin, which, in conjunction with ultraviolet rays from the sun, produces vitamin D.
Term
Functions of the skin: Immunological
Definition
-A breach in the surface of the skin triggers immunological responses in the skin.
Term
Functions of the skin: Absorption
Definition
Substances, such as medications, can be absorbed through the skin for local and systemic effect.
Term
Functions of the skin: Elimination
Definition
Water, electrolytes, and nitrogenous wastes are excreted in small amounts in sweat.
Term
What is found in the EPIDERMIS
Definition
-Sweat pores
-Hair
Term
What is found in the DERMIS?
Definition
-Sebaceous gland
-Arrector pili muscle
-Eccrine sweat gland
-Nerve
-Hair follicle
-Papilla
Term
What is found in the SUBCUTANEOUS TISSUE?
Definition
-Arteriole
-Venule
Term
Functions of the skin
Definition
-Protection
-body temperature regulation
-Psychosocial
-Sensation
-Vitamin D production
-Immunological
-Absorbtion
-Elimination
Term
Factors affecting the skin
Definition
-unbroken and healthy skin and mucous membranes defend against harmful agents
-resistance to inury is affected by age, amount of underlying tissue, and illness.
-adequately nourished and hydrated body cells are resistant to injury.
-Adequate circulation is necessary to maintain cell life.
Term
Developmental Considerations (For skin)
Definition
-Infant's skin and mucous membranes are easily injured and subject to infection.
-A childs skin becomes increasingly resistant to injury and infection.
-The structure of the skin changes as a person ages.
-The maturation and epidermal cells is prolonged, leading to thin, easily damaged skin.
Term
Causes of skin alterations
Definition
-Very thin and very obese people are more susceptible to skin injury.
->Fluid loss during illness causes dehydration.
->Skin appears losse and flabby.
-excessive perpiration during illness predisposes skin to breakdown(keep good hygiene when sick)
-jaundice causes yellowish, itchy skin.
-Diseases of the skin cause lesions that require care.
Term
Intentional Wound
Definition
is the result of planned invasive therapy or treatment. These wounds are purposefully created for therapeutic purposes.
Term
Unintentional Wound
Definition
These wounds occur from unexpected trauma, such as from accidents, forcible injury(gunshot wound or stabbing), and burns. Because wounds occur in an unsterile environment, contamination is likely. Wound edges are usually jagged, multiple traumas are common, and bleeding is uncontrolled. These factors creat a high risk for infection and a longer healing time.
Term
Open Wound
Definition
Occurs from intentional or unintentional trauma. The skin surface is broken, providing a portal for entry for microorganisms(EX:incisions and abrasions).
Term
Closed Wounds
Definition
Result from a blow, force, or strain caused by trauma such as a fall, an assault, or motor vehicle crash. The skin surface is not broken, but soft tissue is damaged, and internal injury and hemorrhage may occur(Ex: ecchymosis and hematomas).
Term
Acute wounds
Definition
Such as surgical uncisions, usually heal within days or weeks.
Term
Chronic Wounds
Definition
Do not progress through the normal sequence of repair. the healing process is impeded. The wound edges are often not approximated, the risk of infection is increased, and the normal healing time is delayed(pressure ulcers, atrial or venous insufficiency).
Term
Primary intention
Definition
intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by this method.
Term
Secondary intention
Definition
have edges that are not well approximated. large, open wounds, such as burns,major trauma, which require more tissue replacement and are often contaminated, commonly heal by this method. Form scare tissue.
Term
Tertiary intention
Definition
are those wounds left open for several days to allow edema or infection to resolve or exudate to drain, and the are closed.
Term
Hemostasis
Definition
Involved blood vessels contrict and blood clotting begins.
Term
Exudate
Definition
Fluid that accumulates in a wound; may contain serum, cellular debris, bacteria, and white blood cells.
Term
Inflammatory Phase
Definition
White blood cells move to wound.
Term
Proliferation Phase
Definition
Granulation tissue is formed to fill the wound.
Term
Granulation tissue
Definition
New tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill in open wound when it starts to heal.
Term
Maturation Phase
Definition
Collagen is remodeled forming a scar.
Term
Contusion
Definition
is caused by a blunt intrument and may result in bruising or hematoma.
Term
Abrasion
Definition
is the rubbing or scraping of epidermal layers of skin.
Term
lacerations
Definition
is the tearing of skin and tissue with a blunt or irregular instrument.
Term
Avulsion
Definition
is the tearing of a structure from normal anatomic position.
Term
Principals of wound healing
Definition
-intact skin is the first line of defense against microorganisms.
-Surgical asepsis is used in caring for a wound.
-The body respounds systematically to trauma of any of its parts.
-An adequate blood supply is essential for normal body response to injury.
-normal healing is promoted when wound is free of foreign material.
-The extent of damage and the person's state of health affect wound healing
-Response to wound is more effective if proper nutrition is maintained.
Term
Primary Intention Healing
Definition
-tissue surfaces closed
-minimal or no tissue loss.
-Formulation of minimal granulation and scarring.
Term
Secondary Intention healing
Definition
-extensive tissure loss
-edges cannot be closed
-Repair time longer
-scarring greater
-susceptibility to infection greater.
Term
Tertiary intention healing(delayed primary intention)
Definition
-initially left open
-edemal,infection, or exudate resolves.
-then closed.
-needs to be clean and stay clean.
Term
Phases of wound healing
Definition
-hemostasis
-inflammatory
-proliferation
-maturation
Term
What happeneds during Inflammatory phase
Definition
-begins at time of injury
-prepares wound for healing
-hemostasis(blood clotting) occurs
-Vascular and cellular phase of inflammation
Term
What happends during Hemostasis
Definition
-Occurs immediately after initial injury
-involved blood vessels constrict and blood clotting begins
-Exudate is formed causing swelling and pain
-increased perfusion results in heat and redness
-Platelets stimulate other cells to migrate to the injury to participate in other phases of healing.
Term
What happeneds during inflammatory phase
Definition
-follows hemostasis and lasts about 4-6 days.
-WBCs move to the wound
-Macrophages enter wound area and remain for extended period
-They ingest debris and release growth factors that attract fibroblasts to fill in wound.
-Patient has generalized body response.
Term
What happeneds during Proliferation phase
Definition
-phase begins within 2-3 days of injury and may last up to 2-3 weeks
-new tissue is built to fill wound space through action of fibroblasts.
-capillaries grow across wound
-a thin layer of epithelial cells forms across wound
-Granulation tissue forms a foundation for scar tissue development.
Term
What happeneds during Maturation phase
Definition
-final stage of healing begins about 3 weeks to 6 months after injury
-collagen is remodeled
-new collagen tissue is deposited
-scar becomes a flat, thin, white line.
Term
Factors affecting wound healing: Age
Definition
age-children and healthy adults heal more rapidly.
Term
Factors affecting wound care:circulation and oxygenation
Definition
adequate blood flow is essential
Term
Factors affecting wound care: Nutritional status
Definition
healing requires adequate nutrition
Term
Factors affecting wound care: Wound condition
Definition
specific condition and wound affects healing.
Term
Factors affecting wound care: Health status
Definition
Corticosteroid durgs and postoperative radiation therapy delay healing.
Term
Wound complications
Definition
-infection
-hemorrhage
-dehiscence and evisceration
-fistula formation
Term
Maceration
Definition
Is caused by overhydration related to incontinence that causes impaired skin integrity.
Term
Necrosis
Definition
is dead tissue present in the wound that delays healing.
Term
Edema
Definition
is swelling at a wound site that interferes with blood supply to the area.
Term
Desiccation
Definition
is the process in which the cells dehydrate and die.
Term
Psychological effects of wounds
Definition
-pain
-anxiety
-fear
-change in body image
Term
Factors affecting pressure ulcer development
Definition
-aging skin
-chronic illnesses
-immobility
-malnutrition
-fecal and urinary incontinence
-altered level of consciousness
-spinal cord and brain injuries
-neuromuscular disorders
Term
Risk factors for pressure ulcers
Definition
-Friction and shearing
-immobility
-Inadequate nutrition
-Fecal and urinary incontinence
-Decreased mental status
-Diminished sensation
-Excessive body heat
-Advanced age
-Chronic mental conditions
-Poor lifting and trasferring techniques
-Incorrect positioning
-Hard support surfaces
-Incorrect application of pressure-relieving devices
Term
Dehiscence
Definition
is the partial or total spearation of wound layers as a result of excessive stress on wound sthat are not healed.
Term
Evisceration
Definition
protrusion of viscera through an incision.
Term
Fistula
Definition
is an abnormal passage from an internal organ to the outside of the body or from one internal organ to another.
Term
Pressure ulcer
Definition
is a wound with a localized area of tissue necrosis.
Term
Ischemia
Definition
deficiency of blood in a particular area.
Term
Friction
Definition
occurs when two surfaces rub against each other.
Term
Shear
Definition
Results when one layer of tissue slides over another layer.
Term
Eschar
Definition
Is a thick, leathery scab or dry crust that is necrotic(dead tissue) and must be removed before the stage can be determined accurately.
Term
Factors affecting wound healing: Wound condition
Definition
Specific condition of wound affects healing.
Term
Factors affecting wound care: Health status
Definition
Corticosteroid drugs and postoperative radiation therapy delay healing.
Term
Wound Complications
Definition
-Infection
-Hemorrhage
-Dehiscence and evisceration
-Fistula formation
Term
Psychological effects of wounds
Definition
-Pain
-Anxiety
-Fear
-Change in body image
Term
Factors affecting pressure ulcer development
Definition
-aging skin
-chronic illness
-immobility
-malnutrition
-fecal and urinary incontinence
-altered level of consciousness
-spinal cord and brain injuries
-neuromuscular disorders
Term
Risk factors for pressure ulcers
Definition
-friction and shearing
-immobility
-inadequate nutrition
-fecal and urinary incontinence
-Decreased mental status
-diminished sensation
-excessive body heat
-advanced age
-chronic mental conditions
-poor lifting and transferring techniques
-incorrect positioning
-hard support surfaces
-incorrect application or pressure-relieving devices
Term
Risk assessment tools
Definition
-Braden scale for predicting pressure sore risk
-Norton's pressure area risk assessment form scale
Term
Mechanisms in pressure ulcer development
Definition
-External pressure compressing blood vessels
-Friction or shearing forces tearing or injuring blood vessels
Term
Stages of pressure ulcers: Stage 1
Definition
nonblanchable erythema of intact skin
Term
stages of pressure ulcers: Stage 2
Definition
Partial-thickness skin loss
Term
stages of pressure ulcers: Stage 3
Definition
Full-thickness skin loss; not involving underlying fascia
Term
Stages of pressure ulcers: Stage 4
Definition
Full-thickness skin loss with extensive destruction
Term
Stages of pressure ulcers: Unstageable
Definition
Base of ulcer covered by slough and or eschar in wound bed.
Term
assessment of pressure ulcers
Definition
-location of the ulcer related to a bony prominence
-size of ulcer in centimeters including length(head to toe), with(side to side), and depth
-presence of undermining or sinus tracts
-stage of ulcer
-color of the wound bed
-location of necrosis or eschar
-condition of the wound margins
-integrity of surrounding skin
-clinical signs of infection
Term
assessment of pressure sites
Definition
-inspect pressure areas for discoloration and capillary refill or blanche response.
-inspect pressure areas for abrasions and excoriations
-palpate the surface temperature over the pressure area sites.
-palpate bony prominence and dependent body areas for the presence of edema
Term
assessment of laboratory data
Definition
-leukocyte count
-hemoglobin level
-blood coagulation studies
-serum protein analysis
->albumin level
-results of wound culture and sensitivities.
Term
Nursing Diagnoses
Definition
-Risk for impaired skin integrity
-impaired skin integrity
-impaired tissue integrity
-risk for infection
-pain
Term
Goals in planning client care: Risk for impaired skin integrity
Definition
-maintain skin integrity
-avoid or reduce risk factors
Term
Goals in planning client care:impaired skin integrity
Definition
-Progressive wound healing
-regain intact skin
Term
Goal in planning client care:Client and family education
Definition
-Assess and treat existing wound
-Prevention of pressure ulcers
Term
Measures to prevent pressure ulcers
Definition
-providing nutrition
-maintaining skin hygiene
-Avoiding skin trauma
-providing supportive devices
Term
Providing Nutrition
Definition
-fluid intake
-protein, vitamins, zinc
-dietary consult
-weight/lab data monitoring
Term
Maintaining skin hygiene
Definition
-mild cleansing agents
-avoid hot water
-Reduce irritants
-moisturizing lotions, skin protection
Term
Avoiding skin trauma
Definition
-smooth,firm surfaces
-semi-fowler's position
-frequent weight shifts
-exercise and amubulation
-lifting devices
-reposition q 2 hours
-turning schedule
Term
Providing supportive devices
Definition
-mattresses
-beds
-wedges,pillows
-miscellaneous devices
Term
Treating Pressure ulcers
Definition
-minimize direct pressure
-schedule and record position changes
-provide devices to reduce pressure areas
-Clean and dress the ulcer using surgical asepsis
-never use alcohol or hydrogen peroxide
-obtain C&S, if infected
-Teach the client
-Provide ROM exercise
Term
Cleaning a pressure ulcer
Definition
-clean with each dressing change.
-use careful, gentle motions to minimize trauma
-use 0.9% normal saline solution to irrigate and clean the ulcer.
-report any drainage or necrotic tissue.
Term
Wound assessment
Definition
-inspection for sight and smell
-palpation for appearance, drainage, and pain
-sutures, drains or tube, and manifestation of complications.
Term
Presence of infection
Definition
-wound is swollen
-wound is deep red in color
-wound feels hot on palpation
-drainage is increased and possibly purulent
-foul odor may be noted
wound edges may be separated with dehiscence present.
Term
Exudate
Definition
-Material such as fluid and cells that have escaped from blood vessels during inflammatory process
-deposited in tissue or on tissue surface
-3 major types
-serous
-purulent
-sanguineous(hemorrhagic)
Term
Serous Exudate
Definition
-mostly serum
-watery, clear of cells
-Example: fluid in a blister
Term
Purulent Exudate
Definition
-thicker
-presence of pus
-Color varies with organisms
Term
Sanguineous Exudate
Definition
-hemorrhagic
-Large number of RBCs
-Indicates severe damage to capillaries
Term
Mixed Exudate
Definition
-Serosanguineous
-Clear and blood-tinged drainage
-Purosanguineous
-Pus and blood
Term
Purposes of wound dressings
Definition
-Provide physical, psychological, and aesthetic comfort.
-remove necrotic tissue.
-prevent, eliminate, or control infection.
-absorb drainage.
-maintain a moist wound environment
-protect wound from further injury
-protect skin surrounding wound.
Term
Type of Wound Dressings
Definition
-Transparent film
-Impregnated inadherent
-Hydrocolloids
-Clear absorbent acrylic
-Hydrogel
-Telfa
-Gauze dressings
-Polyurethane foam
-alginate
Term
Gauze
Definition
-Retain dressings on wounds
-Bandage hands and feet
Term
Elasticized
Definition
-provide pressue to an area
-improve venous circulation in legs
Term
Binders
Definition
-Support large areas of body
-Triangular arms sling; straight abdominal binder
Term
Types of Bandages
Definition
-roller bandages
-cicular turn
-spiral turn
-figure-of-eight turn
-recurrent-stump bandage
Term
Types of binders:Straight
Definition
Used for chest and abdomen
Term
Types of Binders: T-binder
Definition
Used for rectum, perineum, and groin area
Term
Types of binders:Sling
Definition
Used to support an arm
Term
Types of drainage systems
Definition
-Open systems
-Penrose drain
-Closed system
-Jackson-pratt drain
-hemovac drain
Term
Color classification of open wounds
Definition
R=Red-protect
Y=yellow-protect
B=Black-debride
-Mixed wound-contains components of RY&B wounds
Term
Topics for home care teaching
Definition
-supplies
-infection prevention
-wound healing
-appearance of the skin/recent changes
-Activity/mobility
-nutrition
-pain
-elimination
Term
Factors affecting the response to hot and cold treaments
Definition
-method and duration of application
-degree of heat and cold applied
-Patient's age and physical condition
-Amount of body surface covered by the application
Term
Effects of applying heat
Definition
-dilates peripheral blood vessels
-increases tissue metabolism
-reduces blood viscosity and increases capillary permeability
-reduces muscle tension
-helps relieve pain
Term
Effects of applying cold
Definition
-constructs peripheral blood vessels
-reduces muscle spasms
-promotes comfort
Term
Devices to apply heat
Definition
-hot water bags or bottles
-electric heating pads
-aquathermia pads
-hot packs
-moist heat
-sitz baths
-warm soaks
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