Exam #2

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Exam #2
2012-09-18 00:57:04
Skin integrity wound healing

Skin integrety and would healing
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  1. Primary function of the skin is for?
    • Protection
    • Dynamic organ-acts as a barrior against invasion against bacteria and excessive loss of h2o, provides fat h2o storage, vit D synthesis, excretion of waste.
    • Major organ in hormonal and production synthesis.
  2. Avascular superficial layer (not vascular)
  3. Typically traumatic or sugical in origin.  These wounds occur suddenly, move rapidly and predictably through the repair process and result in duralbe close.
    Outside in-reduction of infection wound cycle.  Wounds are brought together manually.
    Acute wound
  4. Wounds that fail to proceed narmally through the repair process. Chronic wounds are frequently caused by vascular compromise, chronic inflammation or repetitive insult to the tissue, and either fail to close in trimely manner or fail to result in durable closure.
    Chronic wound
  5. Begins at the time of the injury.  Last for 3-4 dys.  Initiates the healing cascade and removes the debre and prepares for new tissue.  Swelling, redness, heat, and pain
    Inflammatory phase

    • If pt is immunocomp. inflammation will be supressed.
    • Infection is greater in people on steriods or have AIDS
  6. Collagene starts to fill the void of the bed and grandulation tissue.  New blood vessels develop and wound starts to get smaller
    4-21 days
    Proliferative or Reconstructive
  7. Restrengthening with in the collagene
    3-4 wks can last up to 2 years
    Maturation or Remodeling phase
  8. Adhesive, tape, glue, sutures or staples.  Skin and wound are brought together and are closed.
  9. Tissue loss-skin is brought together (bottom-up) by new tissue.  Wound contraction plays an important role.  It fills from the bottom up with grandulation.  Bigger scar.  Prolonged healing and more suseptible to infection.  Scar can break down.  Longer process
  10. Prepared site left open and closed by primary closure or using skin grafts or flaps
  11. A contact dermatitis in the perineal region, with the physical signs of one or any combination of erythema, swelling, oozing, vesiculation, crusting, and scaling.
    Usually contact with urine or feces. 
    Breif or under pad has been used.
    Itches, papuals, wheeping, painful, and irritating.
    Perineal dermatits
  12. The nurse wants to be sure and gently clean with a ph balance perneal skin clenser and apply a antifungal product.
    Perineal dermatitis
  13. Prevention Highlights of Perineal dermatitis
    • Identify pt at risk for incontinence
    • Gental cleansing-ph balance-no rinse or scrubbing
    • Moisture-to prevent skin repairs lipis for intact skin-barrior cream
    • Protect skin from irritants
    • consider containment devices for urinary and or fecal incontinence.
  14. A traumatic wound occurring principally on the extremities of older aduls as a result of friction alone or shearing and friction forces which separate the epidermis fromt he dermis or which separate both the epidermis and the dermis from the underlying structures
    • skin tears
    • Elder-frail skin-geratric syndrome.
  15. Prevention highlights to skin tears
    • Identify pts at risk
    • Avoid skin care products that dry skin
    • Avoid scrubbing and rubbing the skin
    • Use good transferring, positioning, turning, and lifting techniques to reduce friction and shear.
    • Use protective padding
    • Encourage pat to wear long sleeves and pants to protect skin
    • Avoid adhesives or remove adhesies with care
    • Use non-adhesive wraps to secure dressings.
  16. Management hightlights for skin tears
    • cleanse wound with nl saline
    • Approximate skin tear flap
    • Eliminate friction and shearing forces
    • Use a dressing that supports a moist wound healing environment and protects fragile surrounding skin
  17. A pressure ulcer is localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear or friction.  A number of contributing or confounding factors are also associated with pressure ulcers.
    Pressure ulcer
  18. The most important to prevent ulcers
  19. Intact skin w/non blanchable reness of a localized area.  Darkly pigmented skin may not have a visible blanching: its color may differ from the surrounding area.
    The area may be painful, firm, soft,warmer, of cooler as compared to adjacent tissue.  Difficult to detect in individuals with dark skin tones.
    Pressure ulcer stage 1
  20. Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough.  May also present as an intact or open/ruptured serum-filled blister-that will eventually pop.  Presents shiny or dry shallow ulcer without slough or bruising. 
    Pressure ulcer stage II
  21. Full thickness tissue loss.  Subcut fat may be visible but bone, tendon, or muscle are not exposed.  Slough may be present but does not obscure the depth of tissue loss.  May include undermining and tunneling.
    Pressure ulcer stage III
  22. Stageing is what are the pressure ulcer?
  23. Full thickness tussue loss with exposed bone, tendon or muscle.  Slough or eschar may be present on some parts of the wound bed.  Undermining and tunneling. 
    Osteomylitis can occure.
    Pressure Ulcer stage IV
  24. Can not reverse a stage of the pressure ulcer until its?
    Completely healed
  25. Full thickness tussue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and or eschar (tan, brown or black) in the wound bed.
    Unable to see base of ulcer
    unstageable pressure ulcer
  26. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.  the area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
    Suspected deep tissue injury
  27. Chronic skin and subcut lesions usually found on the lower extremity at the pretibial and medial supra malleolar areas of the ankle. 
    Age is a risk
    "Gator area"
    Brown staining, shallow depth, wound margins are irrigular, heavy to mederate drainage-may have pitting edema, pain is minimal unless infected.
    Peripheral pulses are usually palpitated and capillary reill is usually nl.
    Venous ulcers
  28. Prevention to venous ulcers
    • Treat varicosities: control weight, exerc. avoid crossing legs, avoid tight clothing
    • Compression therapy to improve venous return
    • Strenthen calf muscles by walking
  29. Management highlights to Venous ulcers:
    Cleanse wound with noncytotixic wound cleaner or nl saline at each dressing change.
    Debride necrotic tissue unless contraindicated due to vascular status.
    Protect periwound skin from maceration
    Choose appropriate compression therapy
    Manage wound infection
    Concider short duration of topical antimicrobials
  30. Ulcers occurring due to the complication of dm, which may make the foot insensate to forces of friction, shear and pressure; may lead to dryness, cracking, callus formation and fissuring of the extremities with resulting ulcerations. 
    Great risk of infection, gangrene and possible amputation.  Happens to ambulatory people not bedridden.
    Most amputes ti related
    High risk w/ age
    Find it early
    Pulses and cap. refill are usually nl.
    Diabetic foot ulcers
  31. Prevention highlights for dm ulcers:
    • Identify pt at risk for the ulcers
    • Refer high-risk pt to foot care for on going care.
    • Annuall foot screen, appropriate footwear selection, daily inspections of feet, management of simple foot problems.
  32. Management highlights to dm ulcers:
    Refer to wound experts
    Maintain dry stable eschar or non-infecte ischemic, neuropathic wounds.
    Manage edema if present.
    Initiate a custimized exercise program base on patient limitations and or wound complications
  33. Ulcers that care caused by impairment in circulation that results in ischemia necrosis and eventually ulcers.  Desease artery.
    Arthrosclerosis is the major contributor.
    Toe tips-web-phalange heads, around the malleous areas exposed to pressure or repetetive trauma.  Skin is thin and dry. 
    Hair loss of lower ext. atrophy of suqut tissue