Skin Intergrity

8/9/2019 Skin Intergrity

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Skin intergrity15 percent of the body weight

skin anatomy

-you need to know this so you will know how to stage a pressure ulcerepidermis is the at dead cell end up at the top they are they barrierkeep us moist inside what is outside outsideinner most layer is the basal cell layer it always have constant movingas they move to the top they are dead.Know epidermis dermis and subcutaneous

Eects of aging!ecrease elastic " loss collagen # the bottome layer $%trophy of the underline muscle b&c of the barrier isn't as elastic as itshould be lots of water loss" impair thermal regulation pain reception

etc

(ressure ulcer)s result of tissue ischemis from lost of o*ygen

(thogensis of pressure ulcer(ressure intensity + capillary pressure 15-,mm/ if tha goesunrelieved the tissue is lack of o*ygen then you get ischemic in0ury(ressyre duration + you are not having as much mpressure but its stillas damagingissue tolerance + still being studied+ who you pt is how t

yperemia #focus$% lot of vocab in the slide you should probably know)s when there is vasodialition that present as redness that is the bodyway of protecting itself.2ormal reactive hyperemia is transient # increase in blood ow$ thatoccur in a brief period of ischemiayposi*" ischemic" necrosis3ommon places + bony promi*i*es" heel" elbow " ear" nose " anythingthat is restrictive are the area you wanna check%bnormal reactive hyperemia+ hyperemia over the area is longer than

1 hour " basically it remains red for over 1 hour even though youremove the pressure

4lanching-put pressure on it and it turns lighter if it doesn't turn at allit called none blanching hyperemiaor darker skin the blanching will not happen go to ligher area of skin "check of color or heat use halogen light


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Staging an ulcerour stages plus

Stage 1 is the nonblancable erythemia of intact skinStage is partial thickness loss of the epidermis or dermis its usuallythe epidermis and alittle bit of the dermis " will present of blister"abrasionStage , full thickness skin lost meaning there is necroisis ofsubcutatnous tissue you get intot he fat area you don't get into themuscleStage 6 is full thickness possibly into the muscle and to the bone

7ther stage ulcer8nstageable + 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 thewound its usually a stage , or 6Suspected depth tissue in0ury!eep purple or marron its dierence from stage one is its not purple ormarron where stage one you 0ust cant blanch

9isk factor for pressure ulcer)mpaire sensory perception :inability to feel pain)mpair mobility :why do they have impair mobility do they have spinalcord in0ury where they cant feel anything%lter level of consciousness :inability to e*press or communicate

Shearing force-the skin adhere to the surface that person is on andthat person is moved it is a big risk factor . in the hospital you arealways moving your pt if they are sliding o the bed they are moving.)t rips the capillary that's where you have the ischemiariction+;oisture + reduce the skin resistean " other place where they can getmoisture " vomitis " incontinent . mostiure reduce skin tolerance(oor nutirition+ they might not be getting what they need;uscle atrophy decrease in subcutaneous tissue " if you don't havemuscle pad -underneath the bones are much heavier%lter electrolyte and uid blance

hypoabluminemia if the pressure shift of electrolyte inblamce pulls theuid out into the tissue that produce edema and the edma puts thepressure on the tissue and you don't have the blood owinfection+ present with fever and dietphroicimpaired peripheral ciruculation + decrease circulation to the tissue "tissue that are almost hypo*ic pt you look out for is shcock prolongoperation " vasopressin" cardiovascular diease


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obesity+ is a big risk factory you have the fold of ths skin you have tolook in those they might be a pressure ulcer there" adipose has poorcirculation added to the possibliy to thte pressure ulcercache*ia lost of adipose tissue " thininig of the skinploypharmacy is when you are on multiple drugs

assessing the woundif its red there is granulation of tissue it's a healingif slough is on it like white or yellow are attach the wound bedusually it needs to be removed for the wound to healeschar black brown narcrotic tissue you need to


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complication of wound healinghematoma much of blood under the skin that is pressinginfectiondehiscence ,-11 days after surgry the layer of the skin and tissueseparates

debridementremoving of narcotic tissuecan be mecahanical " chemical or surgicalwet to dry dressingautolystic it's a synthetic dressing

dressing changeswound bed moist

if there is e*ssive e*udate

wound vacput negative pressure on the woundeduma reductionthe granulation of the wound bed its really di?cult to get it sealedusually it's a big wound that is not healing

healing nutrition@inc support collagen formation and protein systehisiron hemologbin

copper :copper

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Skin Intergrity