Mod 3: Integ & Wound (Part 1)

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  1. Anatomic Structures of the Skin 
    Skin layers
    Glands: Sebaceous, Eccrine, Apocrine
    Nails: Hard plates of keratin

    Epidermis, Dermis, Subcutaneous (adipose)

    Glands: Sebaceous: protective lipid, sebum secreted through hair follices

    Eccrine: coiled tubules produce sweat that reduces body temp

    Apocrine: become active during puberty.
  2. =>Purpose of the Skin
    • Provide a protective covering for the body
    • Slow down fluid loss from the body
    • Regulate body temperature
    • Provide sensory perception
    • Produce vitamin D
    • Repair surface wounds
  3. =>Subcutaneous Tissue
    • Consists of loose connective tissue filled with fatty cells
    • Generates heat and provides insulation
    • Absorbs shock
    • Reservoir for calories
    • Appendages of the Skin
    • Eccrine sweat glands
    • Apocrine glands
    • Sebaceous glands
    • Hair
    • Nails
  4. Integumentary Health History
    • Changes in the skin, and location
    • Severity Onset, duration, and recurrence
    • Exposure to drugs, toxins, chemicals, people with similar skin condition
    • Use of treatments: patient's self care.
    • Presence of systemic disease: lupus, excema, psoriasis
    • "PQRSTU"
  5. SKIN inspection
    • Provide privacy
    • Use adequate lighting
    • Control room temperature
    • Visualize entire skin
    • paying particular attention to bony prominences & skin creases
    • Assess color and hygiene
    • Assess lesions and identify: just describe the symptoms
  6. Normal Variations of the Skin
    • Skin color ranges from whitish pink, olive, to dark brown tones
    • Pigmentary demarcation lines
    • Moles
    • Non-pigmented striae
    • Freckles
    • Birth marks
    • Tattoos
  7. Skin Lesion Configurations

    Annular and arciform
    • Linear (in a line).
    • Annular and arciform (circular or arcing).
    • Zosteriform (linear along a nerve route): shingles or herpes
    • Grouped (clustered).
    • Discrete (separate and distinct).
    • Confluent (merged).
  8. Abnormal Skin Color Changes
    Pallor: anemia-decreased hematocrit, shock-decreased perfusion, vasoconstriction, brown skin appears yellow-brown, dull. 

    Cyanosis: Increased amount of unoxygenated hemoglobin. Central-chronic heat and lung disease cause arterial desaturation, Peripheral: exposure to cold/anxiety. ail beds look dusky.

    Jaundice:Increase serum bilirubin due to liver inflmmation or hemolytic disease such as after severe burns or some infection. Sclera is yellow.
  9. =>Areas to Assess for Skin Color Changes in Dark Skinned Clients
    ScleraConjunctivaBuccal mucosaTongueLipsNail BedsPalms
  10. =>Normal Aging Changes  of SKIN
    • Thinning of skin: loss of subcutaneous skin
    • Uneven pigmentation
    • Wrinkling skin folds
    • decreased elasticity
    • Dry skin
    • Diminished hair
    • Increased fragility
    • increased potential for injury
    • Reduced healing ability: more likely to get wounds

  11. =>Abnormal Skin Changes
    • -->Vascular lesions
    • ecchymosis:   
    • petechiae
    • purpura
    • spider angioma
    • venous star
  12. ecchymosis:
     Large, bruise like lesion caused by collection of extravascular blood in dermia and sbuecutaneous layer. Trauma and bleeding
  13. petechiae
    Pinpint, discrete diposits of blood in the extravascular tissues, vissible through theskin or mucous membrane.

    Significance: Inflammation, makred vasodilation, blood vessel trauma, blood dyscrasia.
  14. Purpura:
    Purpura is purple-colored spots and patches that occur on the skin, and in mucus membranes, including the lining of the mouth.
  15. spider angioma
    an abnormal collection of blood vessels near the surface of the skin.
  16. Venous Star
    A small red nodule formed by a dilated vein in the skin. It is caused by increased venous pressure.
  17. -->Precancerous or cancerous lesion (abcde)
    • asymmetrical shape
    • border uneven
    • color blue/black or variegated
    • diameter > 6 mm
    • evolving, ever changing

    • =>Skin Cancer warning signs are:
    • -Asymmetry:when half of the mole does not match the other half
    • - Border: when the border (edges) of the mole are ragged or irregular.
    • -Color: when the color of the mole varies throughout
    • -Diameter: if the mole's diameter is larger than a pencil's eraser.
  18. Clubbing
    is a deformity of the fingers and fingernails associated with a number of diseases, mostly of the heart and lungs.
  19. Palpation of the Skin Assess for:
    • Moisture
    • Temperature
    • Texture
    • Turgor
    • Mobility
  20. -Definition of a Pressure Ulcer & scale used?
    Any lesion caused by unrelieved pressure that results in damage to underlying tissue.

    • The most preferred tool is the Braden Scale for Predicting Pressure Sore Risk. It consists of six categories: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The total score can range from 6 to 23 with a lower score indicating a higher risk. The level of risk indicates the intervention strategies that should be used.
    • --A lower total score indicates a higher risk for pressure ulcer development
  21. =>Factors Affecting Skin
    • Integrity
    • Immobility
    • Malnutrition
    • Prolonged moisture
    • Decreased mental status
    • Decreased sensation
    • Advanced age
  22. =>Pressure Ulcers  & stages
    -Pressure ulcer, pressure sore, decubitus ulcer, and bedsore are terms used to describe impaired skin integrity

    -Tissues receive oxygen and nutrients and eliminate metabolic wastes via the blood

    -Any factor that interferes with blood flow, cellular metabolism, oxygen: kills cell

    -Pressure affects cellular metabolism by depriving tissue circulation…>tissue ischemia…..>cell death

    Staging of Pressure Ulcers

    1st Sign – persistent blanching of skin over pressure point

    Stage I – non-blanchable reddened area

    Stage II – blister, abrasion

    Stage III - subcutaneous tissue damage

    Stage IV - muscle and bone damageStages of Pressure Ulcers
  23. ULCER Stages:
    • Stages 1: Intact skin appears red but unbroken, localized redness in light skin will blanch

    Stage 2:Partial thickness skin erosion with loss of epidermis or also the dermis. Superficial ulcer looks shallow, like an abrasion or open blister with a red pink wound bed.

    • stage 3:Full th ickness pressure ulcer extendeing into the subcutaneous tissue and
    • resembling a crater. May see subcutaneous fat, but not muscle, bone or tendon.

     Stage 4: Full thickness pressure ulcer involved all skin layers and extends into supporting tissue, muscle, tendon orbone exposed with eschar
  24. =>Pressure Ulcer Assessment  & Documentation
    • Location
    • Stage
    • Dimensions
    • Presence of tunnels, undermining
    • Visible necrotic tissue
    • Exudate
    • Granulation tissue
    • Epithelialization

    =>Documentation: Location Stage Size Length, width, depth Location(s) and depth(s) of tunnels, undermining Color Drainage Odor Type and number of skin closures, if any
  25. Goals & Interventions for skin integrity.
    • => Goals
    • Promote wound healing: By end of shift, pt. will engage in 2 measures to promote wound healing.
    • Prevent infection:Pt. will not show signs of infection at the area of skin breakdown during the hospital stay.Maintain skin integrityPromote comfort

    => Intervention: 

    • Turn client every 2 hours
    • Place client in an oblique positions
    • Use positioning devices
    • Use a trapeze or other lifting device
    • Keep skin clean and dry
    • Apply skin barrier Provide adequate nutrition and hydration
  26. =>Principles of wound care for the ulcer 
    =>General Guidelines for Treatment of Open Wounds
    Debridement, Cleansing, Dressing application

    =>General Guidelines for Treatment of Open WoundsCleanse all open wounds with normal saline solution.Do not use antiseptics as wound cleansers on uninfected wounds (eg, Betadine, Dakins, Hydrogren Peroxide, Acetic Acid)Lightly pack wound cavities to full depth to prevent abscesses and reduce dead spaceChoose dressing to maintain a moist wound environment and meeting the characteristic needs of the wound
  27. =>Treatment Guidelines for Stage I to IV Pressure Ulcers
    • =>Treatment Guidelines for Stage I Pressure Ulcer
    • Keep individual off area to eliminate pressure
    • Barrier cream may be used.
    • Apply Q8h and PRN soiling (following manufacturer instructions)
    • Apply gentle cleansing between applications of cream
    • Do not massage

    • =>Topical Treatment Guidelines for Stage II Pressure UlcerPartial thickness wound with minimal-moderate exudate.
    • Might treat with:Transparent Dressing
    • Hydrocolloid dressingThin Adhesive FoamMoist saline dressing (changed frequently)

    =>Topical Treatment Guidelines for Stages III-IV Pressure UlcersFull thickness wound with moderate exudate and no necrosisHydrocolloid dressingAlginate Composite, foamMoist Packing Wound Vac

    =>Topical Treatment Guidelines for Wounds with EscharEnzymatic debriding agent, Hydrogel, or transparent film dressings (to soften eschar)NOTE: Leave intact and monitored QD unless signs of infection appear
  28. Dehiscence:
     Separation and disruption of previously joined wound edges, usually occurs when a primary healing site bursts open.

    May be caused by:

    infection causing an inflammatory process, granulation tissue not strong enough to withstand forces imposed on wound, obesity due to adipose tissue having less
    blood supply and slower healing, pocket of fluid (seroma or hematoma)
    developing b/w tissue layers and preventing the edges of the wound from closing
  29. Evisceration:
     Occurs when wound edges separate to the exten that intestines
    protrude through wound
  30. =>Complications of Wound Healing
    • Hemorrhage
    • Infection
    • Dehiscence
    • Evisceration
    • Fistulas
    • Delayed Wound Closure
  31. =>Assess for Internal bleeding 
    Swelling of the affected body part

    Hematoma – a localized collection of blood underneath the tissues Change in the type and amount of drainage from surgical drain S/S hypovolemic shock
  32. =>Assess for external hemorrhaging
    Risks for post-op hemorrhage is greatest during the first 24 to 48 hours after surgery
    Assess dressings, drains
    Assess all wounds closely, monitor throughout shift.
  33. =>Signs of Infection
    Vital signs: Fever>101, inc. HR, RRTenderness and pain at the wound site

    Elevated white blood cell count

    Edges of wound may appear inflamed

    • Drainage may be odorous and purulent; color or drainage depends on causative organism
    • Pain
  34. Erythema:
    Red/Bright Skin.

    Hyperemia: increased blood flow through engorged areterioles, such as in iniflmamation, fever, alcholol intake, blushing.

    -Polycythemia: increased red blood cells, capillary stasis.

    -Carbon monoxide posioning: bright cherry red in face and upper torsoe

    -Venous stasis: decreased blood flow from area, enourged venules, prelude to necrosis with pressure shores
  35. Licencification
    Thickening of the skin with accentuatied normal skin marking.
  36. Serous:
    bodily fluids pale yellow and transparent
  37. Serosanguinous:
     thin or semi thick waterpy pink or pale, red drainage.
  38. Eccymosis:
    Dark red, purple, yellow or green color, depending on age of bruise.
  39. Purulent
    ; thick yellow gray or green drainage contains pathogenic microorganisms along with withte cells, inflammatory cells and dead, dying bacteria.
  40. wheal:
     FIrm, edematous irregularly shaped area, diameter variable: insect bites.
  41. Nodule:
    a growth that forms under skin
  42. Vesicle:
     circumsized, superficial collection of serious fluid, <.5 cm in Diameter. Ex: varicella (chicken pox) and Herpes.
  43. Pustule:
    Elevated, superficial lesion filled with purulent fluid. Ex: acne
  44. Excoriation:
    area in which epidermis is missing expose the dermis. Ex: abrasion, scratch.
  45. Keloid:
    Hyperthropied scar beyond wound margins thickening. Overgrowth of collagenous tissue at the site of a skin injury.
  46. Lesion:
    a region in an organ or tissue that has suffered damage through injury or disease such as a wound unlcer, absess, or tumor
  47. Paresthia:
     a sensation of tingling,tickling, prickling or burning of a person's skin with no apparent long-term physical effect.
  48. Primary skin lesions: 
    1. Macule: flat color change (freckle)

    2. Patch: larger than 1 cm macule (mongolian spot, measles, rash)

    3. Nodule: solid elevated, hard or soft lesion (fibroma)

    4. Papule (palpable (solid, elveated-warts). Include Plaques

    5. Wheal: superficial, raised, transient, eythematous lesion with fluid held (mosquito bite, allergic reaction), includes Uticaria (hives)

    6. Vesicle: elevated cavity containing free clear liqpuid. Ex: herpes simplex, early varicella/chickenpix, herpes zoster (shingles), contact dermatitis.

    7: cyst: encapsulated, fluid filled cavity in dermis, tensely elevates skin8. Pustule: turbid fluid (pus) in cavity. Ex: impetigo, acne
  49. Jaundice:
    Increase serum bilirubin due to liver inflmmation or hemolytic disease such as after severe burns or some infection. Sclera is yellow.
  50. -Uremia:
    renal failure causes retained urochrome pigments in the blood
  51. => Objective Data.
    **Inspect/Palpate Skin:
    -Benign pigmentatiions: Freckles, Nevus (mole), Birthmarks-widespread color changes: Pallor-white, erythema-red, cyanosis-blue, Jaundice-yellow

    =>Temp: Hypothermia: Generalized coolness (high fever), expected with immobilized extremityHyperthermia: Occurs w/ increased metabolic rate, fevers

    => Moistue: Diaphoresis:profuse persiron due to increased metablic rate; Occurs with thyrotoxicossis & stimulation of NS due to pain. Dryness: parched lips, dry mucuous

    => Texture: Hyperthyroidism: skin feels like velvet vs. hypothyroidism:ating in rough and flaky

    => Edema: fluid accumulion in intracellular spaces, imprint thumbs into ankle malleolus to check. +1 to + 4 from milk to Pitting Edema.-unilateral edema: local/perpihera cause?

    => Mobility & Turgor: decreased with edema

    => Vascularity/Bruising: Cherry angiomas. Mulitple bruises at diff stages of healing may be physical abuse. Document Tats.

    => Lesions:
  52. Adhesions:
     Bands of scare tissue that form b/w or around organs. May occur in the abdominal cavity or b/w the lungs and pleura. Creates intestinal
    obstruction in the abdomen.
  53. Fibroblasts:
    the immature connective tissue cells that migrate into the
    healing site and secret collagen, in time the collagen will strengthen the
    healing site and create scar tissues. 
  54. Hypertrophic scars:
     inappropriately large, raised red and hard
    scars, occurs when an overabundance of collagen is produced during healing. 
  55. Imflammatory response:
    A sequential reaction to cell
    injury. It neutralizes and dilutes the inflammatory agent, removes necrotic
    materials, and establishes and environment suitable for healing and
    repair.  Intensitiy of response depends
    on severity of injury and on person’s reactive capacity. 
  56. Regeneration & Repair
    the replacement of lost cells and tissues with cells of the same
    type. The ability of cells to regenerate depends on the cell type.

    Healing as a result of lost cells being replaced by connective tissue. Repair is more common type of healing and usually results in scare
  57. Dermis:
    the connective tissue below the epidermis, very vascular, collage forms and responsible for skin’s mechanical strength with primary cell
    type: fibroblast.
  58. Intertriginous:
    areas where skin surfaces overlap and run on each other
  59. Keratinocytes:
     synthesized from epidermal cells in the basal layers, they flatten and die to form the outer skin layer, produce a fibrous protein-keratin
    for barrier protection.
  60. Pruritus
  61. mole/nevus
    benign overgrowth of melanocytes.
  62. Primary Skin Lesions vs. Secondary
    Macule, Papule, Vesicle, Plaque, Wheal, pustule

    Secondary: Fissure, Scale, Scar, ulcer, atrophy, excoriation
  63. Primary Intention: Three phases
    Secondary & Tertiary Intentions
    • Primary: healing tackles places when wound margins are neatly approximated.
    • i. Initial: inflammatory phase, incision area fills with blood and platelets release growth factors.Injury area is composed of fibrin clots, erythrocytes, neutrophils.
    • ii. Granulation: Fibroblasts make collages, surface epithelium at the wound edges begin to regenerate.
    • iii. Maturation phase and scar contraction: active movement of myofibroblasts to close the skin edges and mature scar forms.

    b. Secondary: wounds that occur from trauma, ulcers or infection with large amounts of exudate. Gaping wound edges.

    c. Tertiary: Delayed primary intention, usually results in a larger and deeper scar than primary or secondary intention.
  64. Describe factors that promote wound healing.
    Moisture,dryness, HBOT, nutrition, antipyretics

    • Vitamin A: accelerates epithelization,
      Vit B: acts as coenzymes
    • Vit C: assists in synthesis of collagen and new
    • Vit D: Facilitates calcium abortion

      Adequate 02,rest or local mobilization, blood supply and proper nutrition. 
  65. Describe factors that delay wound healing, and common complications of wound healing.
    a. Delay wound healing:  Nutritional deficiencies in Vit C, Protein, zinc, Inadequate blood supply, corticosteroid drugs (impair wbc phagocytosis, inhibit fibroblast function, dpress granulation tissue formation and contraction), infection, smoking (nicotine vasoconstricts) mechanical friction on wound, advanced age (slow collagen synthesis,, altered phagocytic and immune responses), obesity, diabetes mellitus (decreases collagen synthesis, reduced oxygen supply and nutrients secondary to vascular disease), poor general health and anemia.

    Wound complications: Adhesions, contraction, dehiscence, evisceratiion, excess granulation tissue, fistula, infection, hemmorage, hypertropic scar and keloids
  66. Identify nursing interventions indicated for the patient with a pressure ulcer
    local care of wound plus adequate nutrition, pain management, control of medical conditions and pressure relief. Measure the wound. May involved debridement, application of dressing and relief of pressure. Massage is contraindicated in the presence of acute inflammation. Surgical/mechanical/enzymatic debridement methods of eschar. Clean ulcer with noncytotoxic solutions that won’t damage fibroblasts. Irrigration pressure: 4-15 psi. Keep ulcer moids to enhance reepithelization
  67. Discuss common skin tests and procedures used in diagnosing skin and related disorders.
    a. Punch biopsy, excisional, incisional, shave biopsies

    b. Microscopic tests: KOH, Tzanck test, culture, mineral oil slides, immunofluorescent studies

    c. Miscellaneous: wood’s lamp/black light and Patch Test.
Card Set:
Mod 3: Integ & Wound (Part 1)
2014-09-14 22:07:54
Nursing Mod3 Integumentary wound

Integumentary Wound Healing
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