Primary function of the skin is for?
- 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.
Avascular superficial layer (not vascular)
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.
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.
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
- If pt is immunocomp. inflammation will be supressed.
- Infection is greater in people on steriods or have AIDS
Collagene starts to fill the void of the bed and grandulation tissue. New blood vessels develop and wound starts to get smaller
Proliferative or Reconstructive
Restrengthening with in the collagene
3-4 wks can last up to 2 years
Maturation or Remodeling phase
Adhesive, tape, glue, sutures or staples. Skin and wound are brought together and are closed.
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
Prepared site left open and closed by primary closure or using skin grafts or flaps
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.
The nurse wants to be sure and gently clean with a ph balance perneal skin clenser and apply a antifungal product.
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.
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.
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.
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
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.
The most important to prevent ulcers
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
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
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
Stageing is what are the pressure ulcer?
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
Can not reverse a stage of the pressure ulcer until its?
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
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
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
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.
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
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
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
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.
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
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