Week 9 - Ch. 31 - Skin
Week 9 - Ch. 31 - Skin
Week 9 - Ch. 31 - Skin
Protection
Body temperature regulation
Psychosocial
Sensation
Vitamin D production
Immunologic
Absorption
Elimination
Developmental Considerations
In children younger than 2 years, the skin is thinner and
weaker than it is in adults.
An infants skin and mucous membranes are easily
injured and subject to infection; a childs skin becomes
increasingly resistant to injury and infection.
The structure of the skin changes as a person ages; the
maturation of epidermal cells is prolonged, leading to
thin, easily damaged skin.
Circulation and collagen formation are impaired, leading
to decreased elasticity and increased risk for tissue
damage from pressure.
Types of Wounds
Intentional or unintentional
Open or closed
Acute or chronic
Partial thickness, full thickness, complex
Hemostasis
Clotting and blood vessel constriction
Inflammatory
Fluid release, WBCs move to wound
Proliferation
Regeneration of tissue
Maturation
New tissue, scar tissue formation
Wound Complications
Infection
Hemorrhage
Dehiscence and evisceration
Fistula formation
Mechanisms in Pressure
Ulcer Development
External pressure compressing blood vessels
Friction or shearing forces tearing or injuring blood
vessels
Size of wound
Depth of wound
Presence of undermining, tunneling, or sinus tract
Pain
Anxiety
Fear
Impact on activities of daily living
Change in body image
Wound Assessment
Presence of Infection
Wound is swollen.
Wound is deep red in color.
Wound feels hot on palpation.
Drainage is increased and possibly purulent.
Foul odor may be noted.
Wound edges may be separated, with dehiscence
present.
Application of Bandages
Roller bandages
Circular turn
Spiral turn
Figure-of-eight turn
Recurrent-stump bandage
Types of Binders
Straight: used for chest and abdomen
T-binder: used for rectum, perineum, and groin area
Sling: used to support an arm
Open systems
Penrose drain
Closed systems
Jackson-Pratt drain
Hemovac drain
R = redprotect
Y = yellowcleanse
B = blackdbride
Mixed woundcontains components of RY&B wounds
Supplies
Infection prevention
Wound healing
Appearance of the skin/recent changes
Activity/mobility
Nutrition
Pain
Elimination
Methods of heat
application:
Hot water bags or
bottles
Electric heating pads
Aquathermia pads
Hot packs
Warm, moist
compresses
Sitz baths
Warm soaks