Skin Integ/Wound Heal

• 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.

• Mechanical
• Surgical
• Enzymatic
• Autolytic

Use of sharp instruments to debride the wound-Surgical procedure.

Process of placing chemical products within the wound to help breakdown necrotic debris

• 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.

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.

• Hemostasis
• Inflammatory
• Proliferative
• Maturation
• 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)

• 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.

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.

• Underlies the skin.
• Primarly consists of fat and connective tissue that support the skin

• Protection
• Thermoregulation
• Sensation
• Metabolism - Vit D
• Communication

• Temperature - Warm
• Moisture - Dry
• Texture and Thickness - Elastic, Smooth
• Odor - Free of

• Circulation
• Nutrition
• Condition of Epidermis
• Allergy
• Infection
• Abnormal Growth Rate
• Individual factors (age, weight, smoker Medication, stress)

• Pain
• Pruritus
• Rashes
• Lesions
• Open Wounds

• Primary Intention-Shallow or clean surgical
• Secondary Intention-Full-thickness tissue loss
• Tertiary Intention-Delay between injury and wound closure

• Risk Identification-Factors that may delay healing
• Dysfunction Indentification-Ask about present wounds.

• Physical examination of skin
• Wound assessment.

• Impared Skin Integrity.
• Impared Tissue Integrity. (mucous membrane corneal intgumentary or subq)
• Risk for Impaired Skin Integrity.

• Occurs when two surfaces rub together.
• (ie skin rubs against wrinkled bedding)

• 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)

• Transparent Films
• Foams
• Hydrocolloids
• Hydrogels
• Alginate
• Collagens
• Composites
• Contact Layers
• Silver Dressings

Absorption, indicated for deep or moderately draining wounds

Encourage granulation within full-thickness wounds and privde comfort for tender, partial-thickness wounds.

Hydrophilic polyurethane used for partial and full thickness wounds with small to moderate drainage, foams provde absorption and protection.

• nonadherent dressing that will not stick to wound surface.
• Minimizes disruption of new cells.

antimicrobial dressing used for infected wounds.