integumentary
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| Skin | show 🗑
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| Epidermis | show 🗑
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| show | is the second layer, consists of a framework of elastic connective tissue. Nerves, hair follicles, and blood vessels are located in this layer
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| subcutaneous tissue layer | show 🗑
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| Functions of the Skin | show 🗑
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| show | line the cavities that open to the outside of the body,joining the skin.They can be found in dsigestive tract and respiratory passages.
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| Mucous membranes | show 🗑
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| Factor that Affects Skin Integrity | show 🗑
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| Factor that Affects Skin Integrity | show 🗑
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| show | Adequately nourished and hydrated body cells are resistant to injury
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| Factor that Affects Skin Integrity | show 🗑
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| Developmental Considerations | show 🗑
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| Developmental Considerations | show 🗑
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| Developmental Considerations | show 🗑
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| show | very thin and obese people tend to be more susceptible to skin irritations and injury
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| show | fluid loss through fever, vomiting, or diarrhea reduces the fluid volume of the body
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| show | Excessive perspiration is often associated with being ill. predisposes for breakdown in the skin folds.
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| show | jaundice a condition cause by excessive bilew pigments in the skin, result in yellowish skin color.
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| show | Diseases of the skin such as eczema and psoriasis have genetic predisposition and often cause lesions that require special care
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| show | Itching
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| Wound | show 🗑
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| show | result of planned invasice therapy and treatment. Wound edges are clean and bleeding in controlled, the risk for infection is decreased
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| show | are accidental trauma, (stabbing, gunshot and burns)wound edges are jagged, multiple trauma and bleeding is uncontrolled. High risk for infection
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| show | the skin surface is broken, providing portal of entry for microorhanisms. -delayed healing process
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| Closed Wound | show 🗑
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| show | Ex.Surgical incisionm usually heal within days or weeks. The edges are well approximated and less risk of infection
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| Chronic Wound | show 🗑
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| show | bruising
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| show | Ex. surgical incision with minimal tissue loss
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| show | have edges that are not well approximated.Ex. large open wound
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| show | secondary intention
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| show | are wounds that are left open for days to allow dedema or infection to resolve or exudate to drain, then closed
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| Granulation Tissue | show 🗑
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| Phases of Wound Healing | show 🗑
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| Hemostatsis | show 🗑
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| Exudate | show 🗑
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| show | the accumulation of exudate, increased perfusion cause heat and redness
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| show | last about 4-6 days, WBC's and macrophages move to the injured site.WBC's ingest bacteria, Macrophages ingest debris and release growth factors. Pt has elevated temp & increased WBC's & general malaise
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| Proliferation, (fibroblastic, regenerative, or connective tissue Stage | show 🗑
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| Maturation Phase | show 🗑
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| Scar | show 🗑
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| show | Age, circulation, nutritional status, wound condition, health status
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| show | Desiccation-dehydration, Maceration-overhydration,Trauma, Edema, Infection,slough, necrosis(eschar)
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| show | infection can occur as a result of nosocomial infections. symptoms appear within 2-7 days after injury occured.
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| Symptoms of infection | show 🗑
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| Osteomyelitis | show 🗑
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| Sepsis | show 🗑
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| Hemmorrhage | show 🗑
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| Dehiscence and evisceration | show 🗑
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| Fistula Formation | show 🗑
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| Psychological Effects of Wounds | show 🗑
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| Pressure ulcer | show 🗑
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| show | Aging skin, chronic illnesses, immobility, malnutrition, fecal and urinary incontinence, altered level of consciousness, spinal cord and brain injuries, neuromuscular disorders
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| show | Crumbs in the bed/chair, pressure from Iv monitor, soiled or wet bed/clothes, poor hygiene/perspirations, irritant, and friction
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| show | Sacrum,Heel (Adult), Coccyx, Hips, Shoulder, occiput(children), Ears,
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| show | tearing or compressing of blood vessels
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| Satges of Pressure ulcers | show 🗑
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| Satges of Pressure Ulcers | show 🗑
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| Stage 1 intervention | show 🗑
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| show | Reduce pressure, protect skin, maintain moist wound bed, minimal to moderate absorbant dressing, such as foam, tegaderm, hydrocolloid, monitor drainage and adequate hydration
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| show | Debridement, mechanical (wet to dry), surgical, autolytic, chemical (enzymatgic), and biological (Maggot therapy) therapys
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| show | debridement, mechanical (wet to dry), surgical, autolytic, chemical, biological
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| show | Spinal cord injury, poor nutrition, use of steroids, low systemic BP, low serum protein level (albumin), smoking, low hemoglobin, and vascualr disease and diabetes
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| show | skin is intact, ishemic tissue injury that develops due to pressure and shear
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| Unstagable ulcer | show 🗑
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| show | Stage 3 and 4 will only reach 70% tensile strength (elasticity) once healed, pt continues to be high risk
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| show | lenth x width x depth
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| Prevention | show 🗑
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| Serous | show 🗑
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| Sangous | show 🗑
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| purulent | show 🗑
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| serosanguous | show 🗑
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| Purpose of Wound Dressings | show 🗑
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| Red Open wound | show 🗑
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| Yellow open wound | show 🗑
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| show | covered with eschar, requires debridement
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| Mixed open wound | show 🗑
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| show | impaired skin integrity, risk for infection, impaired tissue integrity, ineffective tissue perfussion:peripheral Ex. Diabetic Neuropathy
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Created by:
agoin182
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