Skin intergrity

15 percent of the body weight

skin anatomy
-you need to know this so you will know how to stage a pressure ulcer
epidermis is the flat dead cell end up at the top they are they barrier
keep us moist inside what is outside outside
inner most layer is the basal cell layer it always have constant moving
as they move to the top they are dead.
Know epidermis dermis and subcutaneous
Effects of aging
Decrease elastic , loss collagen ( the bottome layer )
Atrophy of the underline muscle b/c of the barrier isnt as elastic as it
should be lots of water loss, impair thermal regulation pain reception
etc
Pressure ulcer
Is result of tissue ischemis from lost of oxygen
Pthogensis of pressure ulcer
Pressure intensity : capillary pressure 15-32mmHG if tha goes
unrelieved the tissue is lack of oxygen then you get ischemic injury
Pressyre duration : you are not having as much mpressure but its still
as damaging
Tissue tolerance : still being studied: who you pt is how t
Hyperemia (focus)
A lot of vocab in the slide you should probably know
Is when there is vasodialition that present as redness that is the body
way of protecting itself.
Normal reactive hyperemia is transient ( increase in blood flow) that
occur in a brief period of ischemia
Hyposix, ischemic, necrosis
Common places : bony promixixes, heel, elbow , ear, nose , anything
that is restrictive are the area you wanna check
Abnormal reactive hyperemia: hyperemia over the area is longer than
1 hour , basically it remains red for over 1 hour even though you
remove the pressure
Blanching-put pressure on it and it turns lighter if it doesnt turn at all
it called none blanching hyperemia
For darker skin the blanching will not happen go to ligher area of skin ,
check of color or heat use halogen light

Staging an ulcer
Four stages plus 2
Stage 1 is the nonblancable erythemia of intact skin
Stage 2 is partial thickness loss of the epidermis or dermis its usually
the epidermis and alittle bit of the dermis , will present of blister,
abrasion
Stage 3 full thickness skin lost meaning there is necroisis of
subcutatnous tissue you get intot he fat area you dont get into the
muscle
Stage 4 is full thickness possibly into the muscle and to the bone
Other 2 stage ulcer
Unstageable : you cant see throught it eschar or slough (yellow green
tan grey) if you cant see the bed of the wound you are not seening the
wound its usually a stage 3 or 4
Suspected depth tissue injury
Deep purple or marron its difference from stage one is its not purple or
marron where stage one you just cant blanch
Risk factor for pressure ulcer
Impaire sensory perception inability to feel pain
Impair mobility why do they have impair mobility do they have spinal
cord injury where they cant feel anything
Alter level of consciousness inability to express or communicate
Shearing force-the skin adhere to the surface that person is on and
that person is moved it is a big risk factor . in the hospital you are
always moving your pt if they are sliding off the bed they are moving.
It rips the capillary thats where you have the ischemia
Friction:
Moisture : reduce the skin resistean , other place where they can get
moisture , vomitis , incontinent . mostiure reduce skin tolerance
Poor nutirition: they might not be getting what they need
Muscle atrophy decrease in subcutaneous tissue , if you dont have
muscle pad -underneath the bones are much heavier
Alter electrolyte and fluid blance
hypoabluminemia if the pressure shift of electrolyte inblamce pulls the
fluid out into the tissue that produce edema and the edma puts the
pressure on the tissue and you dont have the blood flow
infection: present with fever and dietphroic
impaired peripheral ciruculation : decrease circulation to the tissue ,
tissue that are almost hypoxic pt you look out for is shcock prolong
operation , vasopressin, cardiovascular diease

obesity: is a big risk factory you have the fold of ths skin you have to
look in those they might be a pressure ulcer there, adipose has poor
circulation added to the possibliy to thte pressure ulcer
cachexia lost of adipose tissue , thininig of the skin
ploypharmacy is when you are on multiple drugs
assessing the wound
if its red there is granulation of tissue its a healing
if slough is on it like white or yellow are attach the wound bed
usually it needs to be removed for the wound to heal
eschar black brown narcrotic tissue you need to find out what is
under that, wound nurse come in to debris
you want to measure the wound you need to know how big it is
when you are measureing the depth of the wound you would stick the
tip of the qtip in it and break it off or mark it with the pen
look at the exudate you want to know what it looks like , color,
amount , ordor you want to check the surrounding skin
wound classification
wound with tissue lost: pressure ulcer, burn , alceration heals by
secondary intenstion ( know this) it stays open longer have a higher
risk for infection and maybe scar
wound witout tissue lost : usucually a surgical incision heals by
primary intenstion (know this) there is still might be scaring
wound repair
inflmmatory response approx. 3 days , tissue trauma, redness ,
swelling, serious exudate is the clear liquid
epitheal prolifeoration migration takes about 15 days ( pay attention
to see how many days things happen). You want to keep the wound
moist, most dressing in the hospital everything is kept moist
usually when wound is heal its pink
clean pressure ulcer it should show healing in about 2 -4 weeks
full thickness wound invovling the dermis heal by scary
factory delaying healing
poor nutrition
infection: if its a tramatic wound it will show infection 2-3 days if its
surgical its 4-5 days
diabetes
immunosupression
steroids
character of wound dragainge
always asses aomoungt clor and odror

complication of wound healing

hematoma much of blood under the skin that is pressing
infection
dehiscence 3-11 days after surgry the layer of the skin and tissue
separates

debridement
removing of narcotic tissue
can be mecahanical , chemical or surgical
wet to dry dressing
autolystic its a synthetic dressing
dressing changes
wound bed moist
if there is exssive exudate
wound vac
put negative pressure on the wound
eduma reduction
the granulation of the wound bed its really difficult to get it sealed
usually its a big wound that is not healing
healing nutrition
zinc support collagen formation and protein systehis
iron hemologbin
copper copper fiber
vita k promoting blood cloting and infmmatlory phase
vita d for production fo tissue colleagn
vita c for tissues synthesis
vtia b for fiber cross linking
mangese collagan