Wound Stages
An open area over a bony prominence in which muscle is visible.
What is a Stage IV pressure ulcer
•Sweat gland openings and hair shaft, No blood vessels- topmost layer of the skin
What is Epidermis?
decreased supply of oxygenated blood flow to adipose tissue. increased risk for fungal and yeast infections in skin folds
What are increased risks of obesity? OER 10.2
Cracked, chipped, or splitting nail; excessively thick; presence of clubbing; ingrown nails
What is abnormal nail growth?
10.6
Braden scale score of 7
What is severe risk of pressure injuries?
A shallow open area, over a bony prominence, involving the epidermis and dermis
What is a Stage II pressure ulcer
Hair follicles, Blood vessels, Endocrine sweat glands
Nerve endings, Melanocytes, which determine skin color- oil glands
What is Dermis?
can cause wounds to develop, as well as cause delayed wound healing
How does diabetes affect skin?
full-thickness tissue loss, exposed cartilage, tendon, ligament, muscle, or bone, possibly Osteomyelitis
What is stage 1V pressure injury?
Fresh bleeding__________
clear, thin, watery plasma- during inflammatory stage________
thick and opaque, thick and opaque- not normal___
contains serous drainage with small amounts of blood______
What is Sanguineous exudate?
What is serous drainage?
What is purulent drainage?
What is Serosanguineous exudate
An unopened, dry, boggy, purple, non-blanchable area on a bony prominence
What is a Deep Tissue Injury
color such as pallor (paleness), cyanosis (blueness), jaundice (yellowness), or erythema (redness). Note if there is any bruising (ecchymosis)
What are terms used to document abnormal skin tone?
stasis dermatitis, edema, a brownish-leathery appearance to skin in the lower extremities, weeping fluid
What is venous insufficiency? OER 10.2
Full-thickness tissue loss into subq layer, crater, Undermining and tunneling may occur, possibly slough and eschar
What is a stage 3 pressure injury?
Type, location, size, degree of tissue injury, color of wound base, drainage, tubes or drains, signs sx of infection, wound edges, Pain
What do you include in a wound assessment?
A round, dry, black area on the foot or toe which is not painful with activity
What is an arterial ulcer?
Diaphoretic or clammy, Cool extremity, Edema, Lymphedema, Capillary refill greater than 3 seconds, Tenting
What are abnormal skin assessments when palpating?
Lack of O2 perfused blood via arteries. cool skin temperature, pale skin color, pain that increases with exercise, and possible ulcers
What is arterial insufficiency?
Erythema/Redness, Warmth, Swelling/edema at site, Tenderness, Purulent or malodorous drainage, Fever > 101 F, Malaise, Increased confusion
What are signs of an infection?
current symptoms, wounds, medical history, medications, treatments, symptoms of infection, stress, coping, smoking, quality of life.
What are interview question categories for skin disorders? OER 10.6
Occurs 2-3 days post injury, Epithelialization, Angiogenesis, Collagen formation, granulation tissue, Healthy: pink, moist, “bumpy”
What is PROLIFERATIVE PHASE- 3rd phase
4 Main functions of the skin
What is..Protection, sensation, temp regulation, excretion and secretion. Sebum helps prevent water loss from underlying tissues and to much water absorption during bathing/swimming. Melanin absorbs light and protects against ultraviolet rays. When exposed, the skin makes vitamin D, which is needed for absorbing phosphorus and calcium.
Skin has sensory organs for touch, pain, heat, cold, pressure.
Key nutrients for wound healing
what is: Protein, vits A, D, E, C, E, selenium, zinc, copper OER 10.2
Decreased subcutaneous fat and collagen breakdown leads to thinner, wrinkly skin. Decrease sweat leads to dry, itchy skin. Slower healing due to reduced circulation.
What are common aging affects on the skin?
Interventions to prevent pressure injuries?
change position q 2 hr, shift wt q hr, Lift heels off the bed, Avoid positioning directly on the trochanter, Use trapeze or lift sheet to reposition, Use pressure-reducing devices such as foam pads or mattresses, Pad bony prominences with pillows, Use pressure-reducing devices for patients in wheelchairs, Restore circulation by rubbing around a reddened area. Do NOT massage reddened skin or over a bony prominence, Wash & dry incontinent patients promptly, Avoid device related injury from cast, braces, etc., Friction and shear prevention, Provide adequate nutrition and hydration