skin/wounds chapter 29 and 51pellico

what to do for a gunshot wound

The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. exudate is A fluid rich in protein and cellular elements that oozes out of blood vessels due to inflammation and is deposited in nearby tissues

pustule

filled with puss, like acne or impetigo

cellulitus

it is bacterial skin infection, looks like a burn, put warmth on it

binders

large bandage

fissure

linear crack in the skin like a deep paper cut or skin really dry

hydrophilic

material that absorbs moisture

sanguineous drainage

pertaining to or containing blood, present with an acute laceration

petachiae

pinpoint, non blanching red spots that appear on skin due to blood leakage into the skin

macule

small spot, freckle, petechia

Langerhans cells

(involved in the immune response) in all layers, secretory cells secrete and maintain ph of the skin that carry surface receptors for immunoglobins

procedure for negative pressure wound therapy

*Use sterile gloves *Cut the foam to the shape and measurement of the wound *Place the drape to cover the wound and an additional 3-5 cm *Cut a 2-cm hole in the drape *Apply a vacuum device to wound *Ensure that negative pressure has been achieved

circulation

02 needed or healing is slowed hense ulcers secondary to venous insufficiency and pressure ulcers are so difficult to heal. When hemoglobin is reduced by more than 15% , like with severe anemia healing is impaired.

psoriases

15-35 yrs old hereditary, overproduction of keratin, treat cortocosteroids, moist skin then steroid oitment.

types of wounds

A laceration wound can be described as a separation of skin and tissue in which the edges are torn and irregular. ragged edges torn tissue An incision wound is described as a clean separation of skin and tissue with a smooth, even edge. An abrasion is a wound in which the surface layers of skin are scraped away. Friction to the skin Ulceration is a shallow crater in which skin or mucous membrane is missing. A puncture wound is a wound that occurs from penetration of the skin and underlying tissue

stages of pressure ulcers

A stage I pressure ulcer is a defined area of intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage II pressure ulcer involves partial thickness loss of a little bid of the dermis and presents as a shallow, open ulcer. A stage II could present as a blister, abrasion, or shallow crater. So it will go through the prelifiration stage of healing but won't go through granulation as granulation happens at subcutaneos or below A stage III ulcer presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Ulcers at this stage may include undermining and tunneling. at proliferation there will be granulation as it is deeper. Stage IV ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling

premalignant lesions at risk for skin cancer

ABCDE Asymetry Border Color Diameter Evolution

sweat glands

The eccrine sweat glands are found in all areas of the skin. Their ducts open directly onto the skin surface. The thin, watery secretion called sweat is produced in the basal, coiled portion of the eccrine gland and is released into its narrow duct. The apocrine sweat glands are larger than eccrine sweat glands and are located in the axillae, anal region, scrotum, and labia majora. Their ducts generally open onto hair follicles. The apocrine glands become active at puberty. In women, they enlarge and recede with each menstrual cycle. Apocrine glands produce a milky sweat that is sometimes broken down by bacteria to produce the characteristic underarm odor.

pressure ulcer

Result of the impeding of capillary blood flow to the skin or underlying tissue: • "Pressure ulcers usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." • "The skin can tolerate considerable pressure without cell death, but for short periods only." • "The duration of pressure, compared to the amount of pressure, plays a larger role in pressure ulcer formation." Pressure ulcers can develop in a variety of locations where bony prominences are located on a client. The most common are the coccyx and sacrum. A pressure ulcer can appear in less than 2 hours of time, depending on the factors present. Shearing force results when one layer of tissue slides over another layer. Patients who are pulled rather than lifted when being moved up in bed or from bed to chair to stretcher are at risk for injury from shearing forces

age consideration for skin conditions

The nurse would find liver spots in the older adult client. Also called senile lentigines, liver spots are pigmentation changes that occur on sun-exposed areas. Milia, lanugo, and acne vulgaris are not found in older adults. Milia are sebaceous retention cysts seen as white, opalescent spots around the chin and nose that appear during the first few weeks of life. Lanugo is fine hair that covers the body of the newborn. Acne vulgaris is a common skin disorder found in adolescents

heat and cold best practices

The nurse would make more frequent checks of the skin of an older adult using a heating pad. The nurse would fill an ice bag with small pieces of ice to about two-thirds full. The nurse would cover a cold pack with a cotton sleeve to keep it in place on an arm. The nurse would place cold therapy on a sprained wrist in the acute stage. The nurse would instruct the client not to lie or lean directly on the heating device. The nurse would apply moist cold to a client's eye for 30 minutes, every 2 hours.

dermis layer made up of

The true skin The dermis is the thickest layer of skin; it is primarily made up of fibroblast cells, which are important in remodeling and repair of skin. This connective tissue layer contains nerve endings, sensory receptors, capillaries, and elastic fibers. This layer has two zones, the papillary dermis and reticular dermis. The papillary dermis lies directly beneath the epidermis and is composed primarily of fibroblast cells capable of producing one form of collagen, a component of connective tissue The reticular layer lies beneath the papillary layer and also produces collagen and elastic bundles.

drainage

Serosanguineous pale pink-yellow, thin, and contains plasma and red cells Serous drainage is pale yellow and watery, like the fluid from a blister Sanguineous drainage is bloody, as from an acute laceration. Purulent drainage contains white cells and microorganisms and occurs when infection is present. It is thick and opaque and can vary from pale yellow to green or tan, depending on the offending organism.

specialty nurses for wounds

WOCNCB wound, ostomy and continence nursing board

granulation tissue

Soft, pink, highly vascularized connective tissue formed during wound repair

balneotherapy

a bath with therapeutic additives

what is happening during a full thickness wound repair

a full thickness wound extends through the dermis to subcutaneous tissue an maybe bone and muscle. Has slough. think ulcers, deep lacerations, burns. repair begins with proliferation phase but with granulation, beefy red, full of macrophages, fibroblasts, capillary buds. then connective tissue 4-21 days then maturation begins about 3 weeks after injury can last 2 years. use same foams etc a full thickness burn is third degree and is brown black cherry or pearly white. blisters may be present. dry leathery Thermal burns are hot liquid, flames, chemical etc

hygroscopic

a material that absorbs moisture from the air

what is happening during the partial thickness wound repair

a partial thickness wound has lost epidermis and some dermis, open shallow ulcer no slough or bruising healing involves hemeostasis and then inflammation and then during the proliferated phase epithelialization happens (epidermal cells, which appear pink, migrate across the surface of the wound. Once covered cells continue to reproduce until skin is normal. you will use foams like hydrophilic, hydrogels, collagens. a superficial partial thickness burn is first degree, epidermus pink and red no blister a moderate partial thickness burn is second degree and pink pale yellow-brown.

fibrinolytic

a substance that acts to break up fibrin, the fine filaments of blood clots

packing or filling

TUNNELING narrow passageway in the soft tissue of open wound. may be more than one within a wound. fill the tunnel and wound bed with 1/4 inch or 1/2inch wide packing gauze allows for healing from the base to surface UNDERMINING measured in cm and described in reference to the hours on a clock. 12 ocklock aligned with patients head. packing also used for vagina nasal septum.

benign changes in the elderly skin

Cherry angiomas (bright red "moles") Diminished hair, especially on scalp and pubic area Dyschromias (color variations): Solar lentigo (liver spots) Melasma (dark discoloration of the skin) Lentigines (freckles) Neurodermatitis (itchy spots) Seborrheic keratoses (crusty brown "stuck-on" patches) Spider angiomas (network of dilated capillaries radiating from a central arteriole) Telangiectasias (red marks on skin caused by stretching of the superficial blood vessels) Wrinkles (a small fold, ridge, or crease in the skin) Xerosis (dryness) Xanthelasma (yellowish waxy deposits on upper and lower eyelids) Ichthyosis (fish scale appearance of the skin)

unstageable wound

Full-thickness tissue 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. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined.

purpose of the following dressings

GAUZE absorbs, bandages secure dressings, TRANSPARENT can be sterile, use over infusion sites, allows air to get through but impervious to microorganisms, you can inspect the site. HYDROGEL 90% water provides ulcer with hydration, encourage granulation with full thickness wounds, provide comfort to partial thickness wounds, lots of drainage, we want it to drain HYDROCOLLOID they have hydrophilic colloid particles attached to the backing, absorbent not letting 02 in, normally tan looking SILVER antimicrobial, used for infected wounds FOAM effective negative pressure, provide absorption and protection. If you see puss use foam, exudate the wound ALGINATE highly absorbent goes into wound. absorbs 20x its weight

prescribed heat therapy for a patient's leg wound

Heat produces maximum vasodilation in 20 to 30 minutes. No more than this If heat is continued beyond that time, tissue congestion and vasoconstriction occur for unknown reasons.

hematoma

Localized accumulation of blood in a body tissue, organ, or space as a result of broken blood vessel

sjorgens disease

blistering petachiae, (a collection of tiny bruises.), inflammation

interventions BRADEN SCALE

braden scale, measures 6 categories SENSORY PERCEPTION 1-4 1. completely limited,(no moaning, flinching) or 2. very limited, (responds only to pain) 3. slightly limited, (limited pain) 4. no impairment (responds to verbal commands, no sensory deficit and can voice pain.) EXPOSURE TO MOISTURE 1. constant moist perspiration, urine 2. very moist, linen change 1xshift 3.occasionally moist, linen 1xday 4. rarely moist, usually dry. ACTIVITY 1. bedfast 2. chairfast 3. walks occassionally 4. walks frequently MOBILITY 1 completely immobile 2. very limited 3. slightly limited 4. no limitation NUTRITION, USUAL FOOD PATTERN 1. very poor, never finishes meal 2. probably inadequate, rarely finishes 3. adequate, eats over half, 4 servings of protein 4. excellent FRICTION AND SHEAR 1. problem, needs moderate to max help moving, complete lift without moving sheets. 2. potential problem, moves feebly, needs minimum assistance but skin slides towards sheet. 3. no apparent problem, has sufficient muscle to move. less than 16 need intervention, total points are 23

dehiscense

accidental separation of wound edges especially surgical wound

anagen phase

active phase of hair growth

cyanoacrylate glue

adhesive glue, keep dry, no ointments until wound is completely healed. glue gradually sloughs away over a period of days.

obesity

adipose tissue is avascular, weak deffense against microbial invasion, impairs nutritional delivery.

individual factors

age, etc

athletes foot

antifungal clean and dry

dermatosis

any abnormal skin condition

subum

fat secretion of the sebaceous glands

types of dressings 3 main types

for absorption use gauze, hyrocholoid, for maintanane transparent film for dry wound TRANSPARENT FILMS adhesive semipermeable film dressings. Transparent dressing allows the nurse to assess a wound without removing the dressing; transparent dressings are especially used for peripheral and IV insertion sites FOAMS absorption and protection. hydrophilic polyurethrane used for partial and full thickness wounds with small to moderate drainage; foams provide HYDROCOLLOIDS hydrophilic colloid particles attached to a backing. The nurse uses a hydrocolloid dressing when caring for a client with superficial burn wounds as hydrocolloid dressings are self-adhesive, opaque, air- and water-occlusive wound coverings that keep wounds moist. Hydrocolloids would be used with light to moderate drainage and no infection. Hydrogels work with wounds that have minimal exudate HYDROGELS encourage granulation within full thickness wounds to provide comfort in tender, partial thickness wounds to assist in autolytic debridement of nectotic tissue in full thickness wounds. ALGINATE used for absorption, indicated for deep or moderately draining wounds. Antimicrobial dressings are appropriate for chronic wounds at risk for infection COLLAGENS contain collagen a major protein in the body for partial and full thickness wounds COMPOSITS dressings that combine 2 or more products to facilitate application and use. CONTACT LAYER nonadherent dressings that will not stick to wound surface, minimizes distruption of new cells SILVER DRESSINGS antimicrobial dressings used for infected wounds. GAUZE Gauze dressing is ideal for covering fresh wounds because of its highly absorbent nature. Gauze is applied to fresh wounds that are likely to bleed or wounds that exude drainage. For a patient with copious amounts of exudate, use these dressings • Alginates • Antimicrobials • Composites Types of dressing that would be appropriate with this type of wound are alginates, antimicrobials, and composites. These all work with heavy drainage and infected wounds.

diffuse

goes with inflammation

alopecia

hair loss hyperthyroidism (ie, overactive thyroid) is associated with fine hair. In many cases, chemotherapy and radiation therapy cause hair thinning or weakening of the hair shaft, resulting in partial or complete alopecia from the scalp and other parts of the body.

non pharmacological interventions for integumentary problems

heat and cold Heat decreases inflammation by speeding up inflammatory process, so leukocytes get to the area quickly. Heat vasodilation increasing pus, 02, nutrients to get to area, increase blood flow. Heat decreases musculoskeletal pain muscle relaxation. Use heat on : surgical wounds, infections, hemoroids, episiotomies. phlebitis, iv infiltration low back pain, menstrual, spasms cold can control localized bleeding decreases edema releives pain use on fractures, trauma, superficial lacerations, puncture wounds, sprains, muscle strains, sports injuries, arthritus, trauma muscoskeletal injuries

physical exam

color, vascularity, turgor, mobility, texture, presence or absence of lesions, size shape, pattern of distribution and color.

steristrips

commercially prepared adhesive strips. May eliminate the need for sutures.

hirsutism

condition of having excessive hair growth. Hair quantity and distribution can be affected by endocrine conditions. For example, Cushing's syndrome causes hirsutism, especially in women; hypothyroidism (ie, underactive thyroid) causes coarse hair

serasanguineous drainage

containing serum plasma and blood, pale pink yellow

dermis

contains dense connective tissue, blood vessels, nerves, hair follicles, glands

impetigo

crusty speading, moist red spots, you see it a lot on the face, common on kids its a bacterial infection

immune cellular function

immunosupressive drugs like steroids given to patients who have had a transplant so their bodies dont reject organ can have slower healing, chemo and radiation inhibit fibroblast replication and collagen synthesis.

nurse prevention

inspect pressure points daily clean regularly mild warm cleanser moisturize skin dont massage bony prominence minimize incontence, perspiration and wound drainage protect from friction and shear adequate calories mobility, rom etc reposition every 2 hours pillows avoid putting on trochanter limit time head of the bead is elevated lift dont drag for sitting move every hour use written plan for use of positioning and schedules

types of dressings

iodofoam is the long gauze ALGINATE DRESSINGS highly absorbant, go inside the wound, required to be covered, used for deep moderately draining wounds. GAUZE highly absorbent, allows 02 and can be saturated in saline, good for new surgical incisions, packing wounds HYDROCOLLOID WAFER DRESSING adhesive backed pad normally tanned and keep environment away from wound, moderately absorption. good for partial thickness wounds, shallow to full thickness wounds. HYDROGEL high % of water in matrix, sheetlike wafer causes cooling or can come in a tube of gel. good for partial thickness wounds, stages 2-4, cover dressing with gauze, good for minor burns or skin graft donor sites. POLYURETHANE FOAM pads of compressed foam, vary in thickness, sometimes adhesive, mild to moderate absorption, provide a moist wound surface, good for partial thickness wounds, absorbent covering for deep wounds that have been packed with a primary dressing. TRANSPARENT DRESSING clear film, maintain moist wound, no absorptive properties, good for Ivs, or wounds with minimal exudate.

dehiscence

is a total or partial disruption in wound edges. same as separation. wound separates but underlying subcutaneous tissue has not parted. drainage normally increases. obesity, poor nutrition, increased stress on incisional area increases risk.

denuded skin

is the loss of the epidermal layer of skin. can occur on buttocks or perineal area, result of urinary or fecal incontinence.

cyanosis

late sign and symptom of hypoxemia, as 5 g of hemoglobin (normal level is 15 g/dL) are desaturated before cyanosis is evident. In cases of carbon monoxide poisoning, the level of carboxyhemoglobin does not affect color, therefore the patient may be profoundly hypoxemic without evidence of cyanosis.

approximated

lightly pulled together

hematomas

localized collection of blood. it appears as swilling or mass underneath the skin suface. often bluish color. small hematomas are readily absorbed into the systemic circulation . larger hematomas may take weeks to reabsorb.

addisons disease

looks like A bronzed appearance, or "external tan

ecchymosis

looks like a bruise, discoloration due to bleeding under the skin

basal cell carcinoma

looks like a red nodule, normally benign, blister, red mole

how to assess lesions

measure with metric ruler, describe the color, type, size, location palpate to see if it is flat or raised, does it blanch with pressure, it may be malignant if and ABCDE's apply

touch receptors

merkel cells, regular touch meisner corpusle, fine touch or light pacinian corpusle deep touch

support surfaces of wounds

non powered mattresses at hosp matress overlay for extra support filled with air, gel, water and usually powered. Replacement mattress fits on standard bed usually powered. specialty beds completely new using air fluidized therapy. for prevention use pressure redistribution via "support surface" a specialized device for redistribution. Beds mattresses and cushions they are non powered and powered. most acute care are non powered

factors affecting wound healing

nutrition, curculation, 02, immune cellular dysfunction. Medications nature of injury Individual factors include age, obesity, smoking, drug therapy. local factors are the nature and location of the injury, infection, and type of dressing

squamous cell carcinoma

overgrowth and looks like open advanced scab. very treatable if you catch it early

xerosis

overly dry skin

confluent

patchy skin

melanoma carcinoma

deadly. looks worse than you have on your back.

hypopigmentation

decrease in melanin, loss of pigment. may be caused by a fungal infection, eczema

cytoxic

destruction of cells

vitiligo

destruction of melanocytes white patches on the skin, Vitiligo is a condition characterized by destruction of the melanocytes in circumscribed areas of skin and appears in light or dark as patchy, milky white spots, often symmetric bilaterally

epidermopoiesis

development of epidermal cells

serous drainage

drainage is pale yellow watery like from a blister

SDTI suspected deep tissue injury

during stage 2 there is 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. Presents as a shiny or dry shallow ulcer without slough or bruising (bruising indicates suspected deep tissue injury [DTI]). This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation. 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. DTI may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment

epithelialization

process in which pink epidermal cells reproduce and migrate over the surface of the partial thickness wound

desquamation

process in which thin outermost layer of epidermis continuously sheds.

evisceration

protrusion of internal organs through an open wound. What to do with an evisceration of an abdominal wound after a coughing episode. A client who has an evisceration of a wound is a medical emergency. The client should be placed in a low Fowler's position and, with the use of sterile techniques, the eviscerated structures should be covered with normal saline-moistened gauze. The surgeon should also be notified. The nurse should never reinsert protruding structures or apply a pressure dressing. This could cause the tissue to be injured

stutures

provided in surgical incision, sewing. removed 7-10 days.

viral wart

pryotherapy, or discections, antiviral

TYPES OF DRAINAGE purulent

pus production, white cells and microorganisms present when infection is present.

excoriation

raised red, like a blister, often found with infection or irritation

4 overlapping stages of the regenerative process

regenerative process is once you have a wound and how it heals STAGE 1 HEMOSTASIS Hemostasis involves the constriction of blood vessels and the beginning of blood clotting immediately after the initial injury.is the skins response to 2 immediate threats, 1, you are losing blood and 2, the barrier of the skin is compromised. blood vessels tighten together to plug the hole clogging it = vasocontriction. Now the protein called fibrin creates crosslinks on the top of the skin to prevent blood from flowing out and stops bacteria and pathogens from getting in. This takes about 3 hrs and the skin begin to turns red dignalling. Hemostasis involves the constriction of blood vessels and the beginning of blood clotting immediately after the initial injury stage 2 STAGE 2 INFLAMMATION bleeding is under control and barrier is secured so the body expands the blood vessels, (vasodilation) in order to send cells like wbc, (macrophages) to fight any pathogens that maybe got through, the macrophages phagotyze the pathogens or any damaged tissues by consuming them this is called phagocytosis. They also produce growth factors to spur healing. The inflammatory phase lasts about four to six days, and white blood cells and macrophages move to the wound. white blood cells and macrophages move to the wound. After 2 to 3 days after the wound the 3rd stage starts STAGE 3 PROLIFERATIVE has 2 types A) For partial thickness the epidermal cells, pink, produce and migrate across the surface of the wound. epithelialization) B) For full thickness The proliferation phase is characterized by the formation of granulation tissue (highly vascular, red tissue that bleeds easily). During the proliferation phase, new tissue is built to fill the wound space fibroblast cells enter the wound and produce collagen, which is a fibrous protein. The collagen forms connective skin tissue to replace the fibrin from before, epidermal cells divide and reform the outer layer of skin, the dermis contracts to help close the wound. The proliferation phase is characterized by the formation of granulation tissue (highly vascular, red tissue that bleeds easily). During the proliferation phase, new tissue is built to fill the wound space. 4th STAGE IS MATURATION/REMODELING the wound matures as the newly deposited collagen is rearranged and converted into specific types of collagen, this process can take over a year blood vessels connect and strengthen. new tissue can reach 50 to 80% of its original healthy function depending on the severity of the initial wound. The skin doesn't fully recover so scarring occurs. The maturation phase is the final phase of wound healing and involves remodeling of collagen that was haphazardly deposited in the wound; in addition, a scar forms. The nurse should understand that the integrity of the skin and damaged tissues is restored through resolution or the process by which damaged cells recover and re-establish their normal function, regeneration or cell duplication, and scar formation, which is the replacement of damaged cells with fibrous tissues. Leukocytosis means the increased production of white blood cells; whereas, phagocytosis is the process by which white blood cells consume pathogens, coagulated blood, and cellular debris.

surgical wound complications

remember that insufficient protein and vitamin C intake, weak tissue, muscular support due to obesity, and distension of the abdomen from accumulated intestinal gas are the likely causes of surgical complications. Premature removal of sutures or staples; unusual strain on the incision from severe coughing, sneezing, vomiting, dry heaves, or hiccupping; or compromised tissue integrity from previous surgical procedures in the same area are some of the other causes of surgical complication. Compromised blood circulation and serous fluid accumulation that prevents skin tissue approximation are the factors that interfere with wound healing.

debridement

removal of foreign material or dying tissue from a wound. SURGICAL DEBRIDEMENT using sharp instrument to debride the wound. done during surgery and bedside. Must specialize in this ENZYMATIC DEBRIDEMENT placing chemical products, like collagenase within the wound to help break down the necrotic debris AUTOLYTIC DEBRIDEMENT uses the bodys own fluids and cells. occlusive dressing or a hydrogel is applie over the wound and left while wound exudates. MECHANICAL DEBBRIDEMENT uses mechanical force. it is nonselective as it removes healthy granulating tissue also. Wet to Dry dressing wound bed is filled with saline moistured gauze, allowed to dry over several hours then remove along with intact necrotic tissue, can be painful.

plasmapherasis

removal of whole blood from the body, separation of its cellular elements by centrifugation, and reinfusion of them suspended in saline or some other plasma substitute, thereby depleting the body's own plasma without depleting its cells

diagnosis

risk for impaired skin integrity r/t immobility, poor nutrition, age, incontenence. impaired skin integrity r/t immobility, poor nutrition, age incontenence AEB a 3cmx4cm stage II sacral pressure ulcer impaired tissue integrity R/T infected surgical wound, diabetes, steroids, poor nutrition AEB large abdominal dihiscence.

assessment includes

risk identification dysfunctional identification physical exam

treatments for wounds

saline at beginning gauze for tunneling, some treated with iodine wound vac is a large sponge you cut to fit, sits in wound, then larger covering. it keeps wound moist and is a great choice.

Mohs surgery

scrape layer by layer of the skin till cancer free

visceration

shits coming out cover with saline gauze and call doc

macerated skin

skin has been continually exposed to moisture, becomes wrinkled and lighter in appearance than healthy skin. You are at risk if you are incontinent, diaphoresis, not drying after hygiene, skin folds increase of growth of yeast

slough

slough is yellow, tan, gray, green, brown

petechiae

small red spots, caused by bleeding.

smoking

smoking causes hemoglobin levels to decrease, vasoconstriction occurs, tissue oxygenation is impaired. long time smokers have increased platelets, hypercoagulation can lead to thrombi

wheal

somewhat irregular, relatively transient, superficial area of localized edema, ie mosquito bite or hive usually 0.1ml

telangiectases

spider like red marks on the skin caused by distention of the superficial blood vessels that blanch on pressure.

staples

stainless steel and often used with stutures. staples decrease infection removed 5-7 days

what medication negatively impact wound healing

steroids, anticoagulants.

bacterial infections

streptococcal and staphlococcal impetigo is a common one You treat it with

pressure ulcer prevention

support surfaces for pressure management via nonpowered mattresses: standard facility mattress, foam mattress overlays: made of visco-elastic foam (memory foam) or filled with air, gel, or water. replacement mattresses specialty beds

wound assessment

the parameters of wound assessment include: WOUND TYPE surgical or non surgical, acute or chronic WOUND LOCATION trochanter not hip WOUND SIZE measure length, width, depth CLASSIFICATION partial versus full thickness, stages if a pressure ulcer BASE % of viable vs non viable, health tissue pink to red. nonviable or nectrotic tissue white to yellow slough or brown to black (escher) DRAINAGE color amount consistency and odor. note the # of dressing changes, saturated. sometimes circled on the dressing and marked with date and time

primary and secondary lesions

they arise in normal skin, and secondary lesions arise from the changes on the primary lesion. secondary lesions are scales, crusts, fissures (athletes foot) ulcers,

sebaceous glands

they exit the epidermis and secrete sebum to keep skin soft and pliable. Associated with hair follicles, each follicle has a gland producing sebum

scale

thin flake of exfoliated epidermis

fungal infection

thrush athletes foot. treat with keeping clean and dry.

tzanck smear test glass slide etc.

tzanck smear test a test used to examine cells from blistering skin conditions, such as herpes zoster, varicella, herpes simplex, and all forms of pemphigus, (blistering disease). The secretions from a suspected lesion are applied to a glass slide, stained, and examined. (less)

subcutaneous tissue

under the dermis.

rete ridges

undulations and furrows that appear on the dermis - epidermis junction, they cement the 2 layers together, the basement membrane zone BMZ

papule

up to 0.5cm could be elevated nevus

vesicle

up to 0.5cm filled with serous fluid

Nutrition

vitamin A,C, E, protein, arginine, zinc, glucose, fat and water very important. nutritional deficiencies inhibit collagen synthesis and epitheliazation. Fats are building blocks for the cell membranes being formed.

viral infections

warts,

abrasian

wound in which skin or mucus membrane are rubbed or scraped away

fistula

Abnormal tubelike passage between organs or between an organ and the body surface, often as the result of poor wound healing

allergic reactions in the skin

Allergic reactions and skin inflammation are responses to injury mediated by histamine release. External or internal irritants can cause the reactions. The irritants may be chemical (e.g., skin creams, latex gloves, detergents, plants such as poison ivy or poison oak) or mechanical (e.g., rubbing against an irritant, such as wool). Foods and medications also may cause skin reactions. Dermatitis, an inflammation of the skin, most often produces epidermal and dermal damage or irritation, possibly accompanied by pain, itching, redness, and blisters. Chronic dermatitis produces changes in the epidermis, including thickening, scaling, and increased pigmentation. Treatment focuses on eliminating exposure to the allergen and may include lubrication of the skin and application of topical medications

sclerosis

An area of skin indurated (hardened) from collagen deposits in the cutaneous and subcutaneous tissue as a result of chronic inflammation is termed sclerosis. Examples include keloid formation, stasis dermatitis, and scleroderma.

Types of major wound healing are classified as primary and secondary and tertiary

PRIMARY INTENTION wounds with minimal tissue loss, clean surgical incision, shallow sutured wound, the edges are approximated, (lightly pulled together), granulated tissue is not visible, minimal scarring. surgical wounds heal by primary intention. SECONDARY INTENTION wounds have full thickness tissue loss, deep laceration, burn, pressure ulcers, they have edges that don't readily approximate. the open wound will fill with granulation tissue, then epithelial cells migrate over base, more scarring. TERTIARY INTENTION occurs when a delay ensues between injury and wound closure. also called delayed primary closure. When a deep wound is not sutured immediately or purposely left open until there is no sign of infection. or maybe they had a wound and didn't go to hospital and now it needs debridement.

drainage

THE PENROSE A HEMOVAC THE JACKSON-PRATT. THE PENROSE: drain is a hollow fat rubber tube places directly into the incision or into a stab wound in the incitional area. it allows fluid to drain through capillary action into absorbant dressing. HEMOVAC placed into a vascular cavity where blood drainage is expected after surgery. suction is maintained by compressing a springlike device. when inspecting it expect bloody drainage and ensure that it remains in the compressed state. suction can be interupted if leaks are present in the system or if the hemovac has filled with drainage. JACKSON-PRATT permits drainage to collect in a bulblike device that can be compressed to create gentle suction.

zosteriform

resembles herpes

eschar

tan brown or black

types of drains

NPWT NEGATIVE PRESSURE WOUND THERAPY also called a WOUND VAC NPWT is a method that uses specialized gauze or sponge dressings to fill a wound cavity, is covered by a transparent dressing, and then is connected to tubing and a machine that provides negative pressure to the wound. NPWT reduces excess moisture in the wound, reducing the bioburden (the number of microorganisms) and associated toxins •The Penrose drain is a hollow, fat rubber tube placed directly into the incision or into a stab wound in the incisional area. It allows fluid to drain through capillary action into absorbent dressings. Penrose drains may be advanced or shortened to drain different areas. •A Hemovac is placed into a vascular cavity where blood drainage is expected after surgery. Suction is maintained by compressing a springlike device. When inspecting a Hemovac drain, expect bloody drainage and ensure that it remains in the compressed state. Suction can be interrupted if leaks are present in the system or if the Hemovac has filled with drainage. •The Jackson-Pratt drain permits drainage to collect in a bulblike device that can be compressed to create gentle suction. Suction is lost when the bulb is expanded because of too much drainage or a leak in the system. With any drainage system, inspect the system to ensure that it is patent and functioning. Drains may or may not be sutured in place, so take care not to inadvertently remove them during inspection. Nurses promote optimal wound healing by ensuring that closed drainage systems function properly and by selecting dressings that adequately absorb wound drainage. For large amounts of drainage, the nurse may utilize collection devices, wound drainage management systems, or pouching to contain the drainage and protect the skin. Nurses also protect skin from irritation by protecting surrounding skin from caustic drainage or constant moisture. Drainage in an open drain occurs passively by gravity and capillary action, which is the movement of a liquid at the point of contact with a solid, which in this case is the gauze dressing. Open drains are flat, flexible tubes that provide a pathway for drainage toward the dressing. Closed drains are more efficient than open drains because they pull fluid by creating a vacuum or negative pressure. This is done by opening the vent on the receptacle, squeezing the drainage collection chamber, and then capping the vent

negative pressure wound therapy

NPWT= negative pressure wound therapy, also called a vacuum assisted closure= VAC it is a method that uses special gauze to fill a wound cavity, it is covered by a transparent dressing, and then it is connected to tubing and a machine that provides negative presssure to the wound. it reduces excessive moisture, reduces bioburden (the number of microorgansims). and toxins. it increases cell proliferation and perfusion in the wound. it speeds up tissue healing.

NPUAP

National pressure ulcer advisory panel decifer the stages of an ulcer. An RN must confirm the stage not an lpn.

function of the skin

first line of defense • Protection • Temperature regulation • Sensation • Immunological * fluid balance *vitamin synthasis The skin provides multiple functions: protection, temperature regulation, psychosocial, sensation, vitamin D production, immunological, absorption, and elimination.

plaque

flat elevated surface larger than 0.5cm often comes after a papule