Term
| WHat are the three layers of skin? |
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Definition
Epidermis -1st layer
No blood vessels
Regenerates easily
Dermis- 2nd layer
connective tissue
Nerves, blood vessels, hair follicles
Subcutaneous 3rd layer
Anchors skin to underlying tissue
Stores fat for energy
Heat insulator
Cushioning for protection |
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Term
| What are the functions of the skin? |
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Definition
Protection- infection, injury to tissues, loss of moisture, UV rays
Temperature regulation
Psychosocial
Sensation
Vitamin D Production
Immunological- breach in skin triggers immunological response
Absorption – medications
Elimination – water, electrolytes, wastes |
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Term
| Who is at risk for wounds? |
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Definition
Impaired integrity
Diseases of the skin such as eczema and psoriasis may have a genetic predisposition and often cause lesions that require special care.
With good nourishment and hydration skin helps resist injury
Age
Kids 2 & <, skin is thinner & weaker
Elders- thin skin, decreased circulation and collagen formation
Amount of tissue
Very thin or obese people
Health conditions
Adequate circulation
Fluid loss through fever, vomiting, or diarrhea (dehydration)
Excessive perspiration, often associated with being ill, predisposes the skin to breakdown, especially in skin folds. |
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Term
| What are the three classifications of wounds? |
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Definition
How the wound was acquired
Intentional
Unintentional
Based on length of time wound present
Open or closed
Acute or chronic
By thickness of wound or how deep it is
Partial thickness (all or part of dermis intact)
Full thickness (entire dermis severed
Complex (dermis and underlying fat tissue damaged or destroyed |
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Term
| How do intentional and unintentional wounds differ? |
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Definition
Intentional Wounds- planned invasive therapy or treatment
Surgery
IV therapy
Lumbar puncture
Unintentional are accidental
Trauma (stabbing, gunshot, burns)
Edges jagged, contaminated
Infection high risk |
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Term
| How do open and closed wounds differ? |
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Definition
Open wound- occurs from intentional or unintentional trauma (incision, abrasion)
Acts as portal of entry for microorganisms
Bleeding, tissue damage may occur
Increased risk for infection
Closed wound- results from blow, force, or strain from trauma (fall, assault, MVA)
Skin isn’t broken but soft tissue is damaged
Hemorrhage may occur
Hematoma, ecchymosis |
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Term
| How do partial thickness and full thickness wounds differ? |
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Definition
Partial Thickness: Injury to but not through the dermis
Full Thickness: Injury through the dermis and into deeper tissue (i.e., fascia, muscle) |
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Term
| How do acute and chronic wounds differ? |
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Definition
Acute Wounds
Heal within days to weeks
Edges approximated
Risk of infection lessoned
Chronic Wounds
Wound edges not approximated
Risk of infection ↑
Healing delayed
Examples
Venous insufficiency
Arterial
Pressure Ulcers |
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Term
| What are the four phases of wound healing? |
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Definition
Hemostasis
occurs immediately to control bleeding
Exudate forms (WBC’s, fluid)
#2- Inflammation
4-6 days when WBC’s clean up the wound
#3-Proliferation
new tissue fills wound over severalweeks (granulation tissue)
#4- Maturation
Begins about 3 weeks after injury and collagen tissue is made stronger to form a scar |
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Term
| What factors affect wound healing? |
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Definition
Factors occurring directly in the wound
Pressure, desication (dehydration), maceration (overhydration), trauma, edema, infection, necrosis
Systemic Factors occurring throughout body
Age
Circulation and oxygenation
Nutritional Status- ck pre albumin!!
Medications (steroids, radiation)
Wound condition (large, contaminated )
Immunosuppression (AIDS, lupus, chemo)
Health Status |
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Term
| What are some wound complications? |
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Definition
Infection #1
Hemorrhage -1st check of post op patient
Dehiscence
Evisceration
Fistula |
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Term
| What should you do in event of evisceration? |
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Definition
Evisceration
Most serious complication of dehiscence
Protrusion of viscera through the incision
Immediately cover with saline dampened sterile towels & call MD
High risk patients
obese,
Malnourished
Infected wound
“Something popped”
Excessive coughing, vomiting, straining |
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Term
| What is healing by primary intention? |
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Definition
Clean surgical incision
*Skin edges are well approximated (closed) with sutures / staples
*Risk of infection low |
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Term
| What do pink, red, yellow, and black in the wound bed signify? |
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Definition
Pink = epithelial tissue
Red = granulation tissue
ywllow = slough
black = eschar |
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Term
| What four factors are important in wound assessment? |
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Definition
Wound Bed
Tissue quality/color
Exudate
Infection
Peri-wound Skin
Wound margins
General condition
Current Treatment
Pain (onset, location, duration, characteristics, aggravating factors, etc.) |
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Term
| WHat are the types of exudate? |
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Definition
Serous
Serosanguinous
purulent |
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Term
| What are the signs of infection? |
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Definition
| erythema, edema, induration, fever, odor, pain |
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Term
| WHat should be done with black tissue in wounds? |
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Definition
Necrotic tissue usually black but may also be brown, gray, or tan
The eschar (scab) requires removal before the wound can heal
Remove eschar by –
Sharp -using a scalpel or scissors to cut away the dead tissue
mechanical - scrubbing the wound or applying a wet-to-moist or dry dressing, chemical -using collagenase enzyme agents
Autolytic- using a dressing that contains wound moisture to help the body produce enzymes to break down the eschar. |
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Term
| WHat is a pressure ulcer? Who is at risk? |
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Definition
Definition—Wound with localized area of tissue necrosis
Acute or chronic
Develops over bony prominence
Due to pressure + shear or friction
At risk population
Aging skin, chronic illness, malnutrition
Fecal and urinary incontinence
Altered level of consciousness
Spinal cord injuries
Neuromuscular diseases |
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Term
| What is ischemia, why is it important in pressure ulcers? |
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Definition
Insufficient circulation deprives tissue of oxygen and nutrients leading to ischemia (deficiency of blood circulation to a particular area), hypoxia, edema, inflammation, and ultimately, necrosis and ulcer formation
May form in as little as 1-2 hours |
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Term
| Who is at risk for shearing? |
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Definition
Shear (one layer of tissue slides over another layer. Shear separates the skin from underlying tissues.
Patients who are pulled rather than lifted
Patients sliding down in bed |
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Term
| How do you treat a stage I pressure ulcer? |
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Definition
Protect from moisture.
Protect from pressure.
Frequent turning/repositioning
Pressure relieving devices.
Use hydrocolloid dressing or transparent film dressing |
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Term
| How do you treat a stage II pressure ulcer? |
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Definition
Partial-thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater
Use an occlusive or saline dressing to promote scar formation.
Maintain a moist healing environment.
Use of prescribed ointments or creams.
Eat a high protein diet to promote wound healing.
Debridement—removing dead skin or tissue. |
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Term
| How do you treat a stage III pressure ulcer? |
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Definition
Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
Requires debridement through:
Wet to dry dressings
Surgical intervention
Proteolytic enzymes
May use Negative Pressure Wound Therapy(Wound Vac) |
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Term
| How do you treat a stage IV pressure ulcer? |
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Definition
Stage IV-- Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (eg, tendon or joint capsule). Sinus tracts may also be associated with stage IV ulcers.
Cover with a non-adherent dressing every 8 to 12 hours.
May require surgical grafting.
Neglect is the major cause of this type of pressure ulcer.
May use Negative Pressure Wound Therapy(Wound Vac)
Electrical Stimulation |
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Term
| How do you treat an unstageable pressure ulcer? |
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Definition
| It mst be debrided to allow further evaluation |
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Term
| How can you prevent pressure ulcers? |
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Definition
Assess the skin
Cleanse the skin routinely and whenever any soiling occurs.
Use skin moisturizers for dry skin.
Avoid massage over bony prominences.
Protect the skin from moisture associated with episodes of incontinence or exposure to wound drainage.
Minimize skin injury from friction and shearing forces.
Investigate reasons for inadequate dietary intake of protein and calories. Administer nutritional supplements or more aggressive nutritional intervention as needed.
Improve mobility and activity.
Document measures used to prevent pressure ulcers and the results of these interventions. |
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Term
| What is the purpose of a dressing? What are the types? |
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Definition
Provide physical, psychological, and aesthetic comfort
Prevent, eliminate, or control infection
Absorb drainage
Protect the wound from further injury
Protect the skin surrounding the wound
Sterile dressing
Clean dressing
Occlusive dressing
Wet to moist dressing |
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Term
| WHat is a transparant dressing? |
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Definition
Transparent- Allow exchange of oxygen
Tegaderm- small wounds, minimal drainage |
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Term
| What is a hydrocolloid dressing? |
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Definition
Hydrocolloid- Occlusive/semi-occlusive limiting O2 exchange
Duoderm- partial/full thickness wounds; light to moderate drainage; wounds with necrosis |
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Term
| What are hydrogels used for? |
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Definition
Hydrogels- Maintain moist environment
Burns, necrotic or dry wounds with minimal exudate |
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Term
| How do you clean closed (sutured) wounds? |
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Definition
Top to bottom
Middle to outer
Clean to dirty |
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Term
| How do you clean open wounds? |
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Definition
Inner to outer in circular motion
Always clean to dirty
Clean 1 inch beyond dressing |
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