Skin Integ/Wound Heal
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- Results when skin rubs against a hard surface.
- Friction scrapes away the epithlial layer exposing epidermal or dermal layer.
- The edges of the primary wound are lightly pulled together.
- Granulation tissue is not visible and scarring is usually minimal.
- Wound support used to support a specific body part or to hold dressing in place.
- The use of velcro has increased ease of applications and comfort.
The removal of foreign material or dead tisue from a wound to discourage the growth of microorganisms and to promote healing.
What are the types of Debridement?
What Is Surgical Debridement?
Use of sharp instruments to debride the wound-Surgical procedure.
What is Enzymatic Debridement?
Process of placing chemical products within the wound to help breakdown necrotic debris
What is Autolytic Debridement?
- Removal of debris and necrotic tissue using body's own fluid and cells.
- Occurs when an occlusive dresing is applied ove a wound and lef in place while wound exudate and body fluids build up.
What is Mechanical Debidement?
Removal of necrotic or devitalized tissue from a wound using friction, hydrotherapy, scraping or wet-to-dry-dressings.
- Total or partial disruption in wound edges.
- Wound seperation, most commonly used to descrie surgical inscisions in which the skin has seperated by underlying subq has not.
- Underlies the epidermis, is the thickest skin layer and is composed of tough connective tissue.
- Major cell is Fibroblast which produces collagen and elastin.
- Well Vascularized, Contains lymphatic vessels and nerve tissues
- The process of continuously sheding of the thin outermost layer of the epidermis.
- (Process of shedding the stratum corneum or horny layer)
- The skin's outer layer, is avasuclar and composed of layers of stratified squamous epithelial cells.
- Specializes to form the hair, nails, and glandular structures.
- Relies on dermis for nutrition
The process in partial-thickiness wounds, in the third phase the proliferation phase, epidermal cells, which appear pink, reproduce and migrate across the suface of the wound.
What are the phases of Wound Healing?
- Process takes 12-24 months to complete.
- The protrusion of viscera through an abdominal wound opening.
- Can follow dehiscence of the opening.
- Extends deeply enough to allow the abdominal fascia to separate and internal organs to protrude.
- An abnormal tube-like passageway that forms between two organs or from one organ to outside of the body.
- (ie recto-vaginal fistula permits feces to enter the vagina)
Define Granulation Tissue:
- Proliferation Phase begins with development of beefy, red and granular tissue that consists of collage embeded with macrophages, fibroblasts and capillary buds.
- Last 4 after injury to 21 days in normal healing full thicknes wound.
- The localized collection of blood.
- Appears as a swelling or mass underneath the skin surface often with a bluish color.
- An open wound or cut.
- Most only affect the upper layers of skin and subcutaneous tissue underneath.
- Skin that is continually exposed to moisture softens.
- Appears wrinkled and is lighter in appearance than healthy tissue.
- Increasing its susceptibility to trauma and infection.
Define Pressure Ulcer
A localized area of tissue destruction caused by compression of soft tissue over a bony prominence and an external surface for a prolonged period of time.
- Drainage contains white cells and microorganisms and occurs when infection is present.
- Thick, opaque and can vary from yellow, green, tan, depending on organism.
- Presence of undermining/tunneling.
Drainage is bloody a from an acute laceration.
Drainage is pale yellow, watery, and like th fluid from a blister.
Drainage is pale pink-yellow, thin and contains plasma and red cells.
Define Subcutaneous Tissue
- Underlies the skin.
- Primarly consists of fat and connective tissue that support the skin
Functions of Skin Include:
- Metabolism - Vit D
Characteristics of Normal Skin Include
- Temperature - Warm
- Moisture - Dry
- Texture and Thickness - Elastic, Smooth
- Odor - Free of
Affecting Factors of Integumentary Function
- Condition of Epidermis
- Abnormal Growth Rate
- Individual factors (age, weight, smoker Medication, stress)
Disruption of normal skin integrity can cause:
- Open Wounds
Types of Wound Healing:
- Primary Intention-Shallow or clean surgical
- Secondary Intention-Full-thickness tissue loss
- Tertiary Intention-Delay between injury and wound closure
Subjective Data Assessment Includes
- Risk Identification-Factors that may delay healing
- Dysfunction Indentification-Ask about present wounds.
Objective Data Assessment Includes:
- Physical examination of skin
- Wound assessment.
Possible Nursing Dx in Skin include
- Impared Skin Integrity.
- Impared Tissue Integrity. (mucous membrane corneal intgumentary or subq)
- Risk for Impaired Skin Integrity.
What is Friction
- Occurs when two surfaces rub together.
- (ie skin rubs against wrinkled bedding)
What is Shear
- Occurs when tissue layers move on each other causing blood vessels to stretch as they pass through subq Tissue.
- (ie Clients skin remains immobile bc of friction but deeper structures, facia, move with client bc of attachment to bone)
Types of Dressing include:
- Transparent Films
- Contact Layers
- Silver Dressings
An Alginate Dressing is used for
Absorption, indicated for deep or moderately draining wounds
Hydrogels dressings are used for
Encourage granulation within full-thickness wounds and privde comfort for tender, partial-thickness wounds.
Foams in Dressing are used for:
Hydrophilic polyurethane used for partial and full thickness wounds with small to moderate drainage, foams provde absorption and protection.
Contact Layer Dressings are
- nonadherent dressing that will not stick to wound surface.
- Minimizes disruption of new cells.
Silver Dressing wounds are:
antimicrobial dressing used for infected wounds.
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