Skin/Hair/Nail basics
What are the 3 layers of skin.
Epidermis, Dermis, Hypodermis
This is the term for itching of the skin, typically follows the formation of inflammatory lesions
Pruritis
What is the main tool used to measure the risk of skin breakdown? What are the different sections of assessment of the tool?
Braden skin assessment
Sensory perception, Moisture, Activity, Mobility, Nutrition, Friction & Shear
This is a non-blanchable area of erythema with no open skin areas.
Stage 1 Pressure Ulcer
This is an infection that progresses to underlying bone
Osteomyelitis
What are the 6 main functions of the skin?
Protection, absorption, excretion, secretion, regulation, sensation
This is the term for an are of skin with no pigmentation.
Vitiligo
Hemostasis
This is an open area of skin that progresses to the point of ligament/tendon/bone visualization. It is surrounded by non-blanchable and/or macerated skin tissue
Stage 4 pressure ulcer
This occurs when there is tissue death surrounding the wound bed due to decreased vascularization and blood flow. The tissue can be hypoxic, grey in color, or black
Tissue necrosis or gangrene
List 3 changes that the older adult experiences related to skin.
Loss of elastin, collagen, and subcutaneous fat causing thinner skin; decreased skin turgor; decreased rate of epidermal layer repair; decreased efficiency of glands; increased risk of skin breakdown (pressure injury risk), decreased melanin
These are the clinical cues to assess for when determining risk of melanoma. (think how you assess a skin lesion)
Asymmetry
Border irregularity
Color variation
Diameter more than 6mm
Evolution of lesion over time
What are the 3 phases of wound healing?
Inflammatory phase - upon injury, platelet aggregating and release of thromboplastin
Proliferative phase - fibroblasts mograte into the wound bed to deposit collage and secrete growth factors; wound edges begin to contract; wound bed has the appearance of granulation
Remodeling phase - may last up to 2 years, macrophages stimulate gradual replacement of new, rapidly replaced collagen which increases strength of the wound
This is a open are of skin over a bony prominence. The wound bed cannot be visualized due to the presence of slough or eschar. Surrounding skin may be macerated or non-blanchable erythema
Unstageable
This is the terminology (diagnosis) for macerated, pale, white, or boggy skin tissue surrounding a wound bed
MASD (Moisture Associated Skin Damage) - often found in the peri area and mis-labeled a pressure sore
What is the name of the gland that supports each hair follicle? What is the glands main function?
The sebaceous gland
Secretes sebum which is a fluid that maintains hair moisture and condition
Which 3 skin findings are priority/urgent.
Acute lacerations, burn injuries, tissue injuries
What are the 4 wound classifications
Clean - made under sterile conditions involving the skin or vascular incisions - no risk of contamination
Clean-contaminated - made under sterile conditions but involving respiratory, gastrointestinal, genital, or urinary tract
Contaminated - exposed to contents of GI tract or infected fluid; also open or traumatic wounds
Infected - exposed to contaminants and exhibits evidence of infection prior to surgery
This is an open area of skin over a bony prominence where subcutaneous tissue can be visualized.
Stage 3 pressure ulcer
This is most commonly seen with surgical wounds when there is bleeding under the skin. Can lead to infection if untreated. Not typically seen in chronic non-healing wounds
Hematoma
This gland is the sweat-producing gland. It is responsible for maintaining normal body temperature.
Sudoriferous gland
What do we measure when assessing a wound? How do we properly measure a wound?
Length, width, depth, tunneling, undermining
Think of the body on the face of a clock, 12:00 at the head, 6:00 at the feet. Measure widest width straight across (do not angle the measuring tool). For undermining or tunneling, use a sterile q-tip
What is are 4 techniques used for pressure ulcer prevention.
Incontinence Care
Nutrition & hydration
Just move - turn q2h or shift weight 3 times per hour
Use pressure relieving products/surfaces
Reassess skin regularly
You should seek help early - early prevention and treatment
This is a deep maroon colored, non-blanchable, area of intact skin over a bony prominence
This is partial or total separation of previously approximated wound edges. Most commonly occurs about 5-8 days after surgery (while healing is still in the early stages)
Wound dehisence