Skin Integrity/Wounds

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Author:
kathleenagrace
ID:
53667
Filename:
Skin Integrity/Wounds
Updated:
2010-12-06 01:42:26
Tags:
Nursing
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Description:
Test 3
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  1. Wound Healing:
    Homeostasis
    • immediately post injury
    • vessels contrict
    • clotting begins- scab
    • permeability: plasma and blood leak out to form exudate
    • Exudate fills wound, spreads it open
    • Swelling = pain
    • platelets attract others to site
  2. Wound Healing:
    Inflammatory
    • lasts 4-6 days
    • WBC mosve to wound
    • Leukocytes: ingest bacteria, collect debri
    • Macrophages: ingest debri, release growth factors to heal
    • Fibroblasts: fill wound
  3. Wound Healing:
    Proliferation (Regeneration, Connective, Fibroblast)
    • Fibroblasts build new tissue
    • Granulation tissue fills the wound
    • wound covered by meshwork of skin cells that grow over the tissue
    • Builds a wound bed (beneath gran. tissue)
    • Fibrogen builds a bridge (granulation)
  4. Maturation
    • collagen continues deposition
    • scar is formed
  5. Pressure
    disrupts bloodflow to wound area
  6. Desiccation
    • cells dehydrate
    • dryp up
    • crust over
  7. Maceration
    • overhydration
    • impaired skin integrity
  8. Trauma
    • repeated wound
    • unable to heal
  9. Edema
    inadequate oxygen and nutrients
  10. Infection
    bacteria increases stress on body
  11. Necrosis
    dead tissue that delays healing
  12. Pressure Ulcer
    • wound of localized area of tissue necrosis
    • Risk Factors: immobility, nutrition/hydration status, moisture, mental status, age
  13. Stage I Pressure Ulcer
    • observable alterations
    • first indication is blanching
    • termperature-consistency sensation
    • persistent redness
  14. Stage II Pressure Ulcer
    • Partial Thickness
    • Epidermis/Dermis
    • superficial abrasion, blister, shallow crater
  15. Stage III Pressure Ulcer
    • Full Thickness
    • Damage/Necrosis of SubQ tissue
    • may extend down also
    • deep crater w/out undermining of adjacent tissue
  16. Stage IV Presure Ulcer
    • Full Thickness
    • Extensive Destruction
    • damage to muscle, tissue, bone, structures
  17. Wound Appearance
    • location: nearest bony prominence
    • size: mm/cm
    • approximation of edges
    • dehescence/evisceration
    • color and around
    • foreign objects
    • Red: protect
    • Yellow: cleanse
    • Black: debride
  18. Wound Drainage
    • Exudate: drainage
    • Serous: clear, watery
    • Sanguineous: looks like blood
    • Serosanguineous: mixture of serum and RBC
    • Purulent: WBC, liquified dead debri, bacteria
  19. Wound Sutures/Staples
    • Skin Sutures: hold tissue/skin together
    • Retension Sutures: obese or risk for dehisence
  20. Hot/Cold Treament
    • increase temp or lengthening time can cause serious damage
    • Heat: max vasodilation @ 20-30 min
    • Cold: max vasoconstrictor @ 15*C
  21. Epidermis
    top layer of skin
  22. Dermis
    second layer of skin
  23. Exudate
    • plasma and blood leakage into wound site
    • swelling and pain
  24. Eschar
    • necrotic thick, leathery scab
    • must be removed to determine stage
  25. Granulation tissue
    • new tissue formed by fibroblasts
    • foundation for scar tissue
  26. Scar
    avascular collagen tissue
  27. Dehiscence
    partial/total separatoin of wound layers due to excessive stress on wounds not healed
  28. Evisceration
    • most serious complication
    • wound completely separates
    • protrusion of viscera through the incisional area
  29. Fistula
    abnormal passage from an internal organ to the ouside of the body, or from one internal organ to another
  30. Shearing Force
    one layer of skin slide over another
  31. Ischemia
    • local anemia resulting from poor circulation
    • rapidly followd by hyperemia
  32. Macerated
    softening or disintegration of skin in response to moisture
  33. Dressing
    protective covering placed over a wound

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