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Nursing
Skin Integrity and Wound Healing
| Question | Answer |
|---|---|
| Skin layers | Epidermis (outer), dermis, subcutaneous tissue |
| Skin appendages | Hair, nails, sweat glands, sebaceous glands |
| Functions of the skin: protection | Intact skin- protects against physical and chemical injury. Melanin- protects against sun's ultraviolet rays. Sebum- acidic ph, retards microbial growth. Skin flora- inhibits growth of pathogens. |
| Functions of the skin: metabolism | Skin synthesizes Vit D from sun |
| Functions of the skin: Thermoregulation | dilation and constriction of blood vessels, vasoconstriction causes shivering which warms, sweating cools the body via evaporation |
| Functions of the skin: Sensation | Sensitivity to pain, heat, and cold prevents injury |
| Functions of the skin: Communication | Facial expression and physical appearance |
| Characteristics of normal skin | Color, temperature, moisture, texture and thickness, odor, turgor (hydration status) |
| Factors affecting Integumentary Function | Circulation, nutrition, condition of epidermis, allergy, infections, abnormal growth rate, systemic diseases, burns |
| Mechanical forces affecting integumentary function | Friction: skin rubbing against firm surface. Shear: layers of tissue rub together. Pressure. Abrasion: skin rubs against hard surface. Laceration: open wound/cut usually involved with knives. Puncture wound: sharp, pointed object goes thru tissue |
| Pressure Ulcers | Pressure intensity blanching: turns lighter in color. Pressure duration. Tissue tolerance. |
| Risks for Pressure Ulcers | Sensory impairment, impaired mobility, alteration in LOC, shear and friction, moisture |
| Stage I Pressure Ulcer | Persistent red, blue or purple tones; no open skins area. |
| Stage II Pressure Ulcer | Partial-thickness skin loss; presents as an abrasion or blister. |
| Stage III Pressure Ulcer | Full-thickness skin loss with damage or necrosis of subq tissue; presents as a deep crater |
| Stage IV Pressure Ulcer | Full-thickness skin loss with extensive destruction; necrosis or damage to muscle, bone, or other structures. |
| Unstageable Pressure Ulcer | Full-thickness loss covered by slough or eschal |
| Manifestations of altered integumentary function | Pain, pruritus: itching, rash: characteristics, distribution, lesions |
| Hemostasis Stage of Wound Healing | Vasoconstriction and clot formation |
| Inflammatory Stage of Wound Healing | Vasodilation and phagocytosis. Localized redness, edema and pain. Up to 3 days. |
| Proliferative Phase of Wound Healing | 3-24 days. Wound fills in with granulation tissue. Collagen mixes with granulation tissue and supports re-epithelialization. |
| Maturation Phase of Wound Healing | Up to 2 years depending on extent of wound. Collagen scar continues to gain strength for several months. |
| Primary Wound Healing | Describes a wound closed by approximation of wound margins or by placement of a graft or flap, or wounds created and closed in the operating room. |
| Secondary Wound Healing | Describes a wound left open and allowed to close by epithelialization and contraction |
| Tertiary Wound Healing | Useful for managing wounds too heavily contaminated for primary closure but appear clean & well vascularized after 4-5 days of open observation. Over this time, the inflammatory process has reduced bacterial concentration of wound to allow safe closure |
| Individual Factors affecting wound healing | Age, obesity, smoking, medications, stress |
| Systemic Factors affecting wound healing | Nutrition and fluids: Protein/albumin, Vit A & C, Zinc. Circulation and oxygenation: DM and shock. Immune cellular function. |
| Local Factors affecting wound healing | Nature of the injury. Presence of infection. Local wound environment. |
| Complications of Wound Healing | Hemorrhage, interstitial fluid loss, hematomas, infection, fistula- an abnormal connection b/w an organ and vessel, dehiscence- splitting of wound, evisceration- organ outside of body |
| Five cardinal signs of localized injury/infection | 1. Redness 2. Heat- increased blood 3. Edema- fluid and cells accumulate 4. Pain- from change in ph, chemicals, swelling 5. Altered function |
| Subjective Data | Normal skin status, hx of skin problems, injuries, wounds, risk identification: infections, pressure ulcer risks |
| Objective Data | Physical exam: inspection of skin- color, temp, turgor, odor, and integrity. Diagnostic tests and procedures. Nutritional status. |
| Wound Assessment | Type, location, size. Traumatic or stable. Character of drainage. Closure-staples and sutures. Palpation of wounds |
| Nursing diagnosis | Impaired skin integrity, impaired tissue integrity, risk for impaired skin integrity, risk for infection, imbalanced nutrition: less than body requirements, pain |
| Implementation | Health promotion, Prevention of pressure ulcers: positioning and skin care, use of pressure reducing surfaces. Pt teaching: hygiene, protection from sun, pressure ulcer prevention. |
| Implementation: Acute Care | Prevent and manage wounds. Remove nonviable tissue, manage wound exudate, protect wounds (dressing), monitor lab values, nutritional support, teach pt appropriate wound care. |
Created by:
senmark
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