What are the 3 categories on the skin integrity spectrum?
- Intact skin & tissues
- Partial thickness injury.
- Full-thickness injury.
A partial thickness injury means that only the ______ is affected, but a full-thickness injury means that the ____ and ______ ____ may be affected as well.
epidermis; dermis; subcutaneous tissues
What is debridement?
Removal of dead, damaged or infected tissue.
What is granulation?
Connective tissue that forms on the surface of a healing wound.
What is emollient?
Agent that softens the skin or treats dry skin.
What are 7 alterations to skin integrity?
Age related changes Trauma/injury Loss of perfusion Immune reaction (ex: allergies - hives) Infections & infestations Thermal/radiation injury Lesions
How is the skin integrity altered in infants and the elderly?
Thinner skin
Fewer sebaceous gland secretions
Less muscle mass & subcutaneous fat
How is skin integrity altered in adolescents?
Acne (due to increased sebaceous secretions)
What are the 4 degrees of wound contamination? Describe each.
- Clean wounds: closed & uninfected
- Clean, contaminated wounds: open, but no infection/inflammation
- Contaminated wounds: s&s of infection present
- Dirty, infected wounds: pus, smelly
List some risk factors for pressure ulcers.
Incorrect positioning Impaired mobility Decreased sensation Poor hygiene Poor nutrition Incontinence Advanced age Altered mental status
Describe the 4 stages of pressure ulcer formation (general - not specific to any assessment tool)
- Superficial redness
- Partial thickness damage
- Full-thickness damage to muscle
- Damage to bone
What are some things to look for when assessing a wound?
Location
Size
Any drainage?
Signs of infection
What laboratory data might be collected in would/skin assessment?
Glucose levels
CBC (infection)
Serum protein levels
Wound culture & sensitivity if infected
What are 5 measures to prevent pressure ulcers?
Proper nutrition (high protein) Maintain skin hygiene Avoid skin trauma Provide supportive devices (ex: pillows) Health promotion (education, sun safety)
