NR224 Study Guide Exam 2

NR224 Study Guide Exam 2 Chapter 48 Skin Integrity and Wound Care Skin: Two layers-epidermis and dermis -Separated by membrane, referred to as dermal epidermal junction -Epidermis: top layer, several layers -Dermis: inner layer of skin, provides tensile strength, mechanical support, and protection to the underlying muscles, bones, and organs. (Contains mostly connective tissue and few skin cells) Collagen: tough, fibrous protein Pressure Ulcers -Pressure sore, decubitus ulcer, and bedsore -Localized injury to the skin and other underlying tissue, usually over a bony prominence -Result of pressure or pressure in combination with shear and/or friction -Decreased mobility, decreased sensory perception, fecal or urinary incontinence, and/or poor nutrition are at risk for PU development. Cause of PU -Tissue receive oxygen/nutrients and eliminate metabolic wastes via the blood. -Interference of blood flow disrupts cellular metabolism and function/life of cells. -Prolonged pressure affects cellular metabolism by decreasing or obliterating blood flow, results in tissue ischemia and ultimately tissue death. Pathogenesis of Pressure Ulcers -Three pressure-related factors contribute to PU development -Pressure intensity: pressure applied over a capillary exceeds the normal capillary pressure, vessel is occluded for prolonged period of time, tissue ischemia can occur. Leads to tissue death if patient cannot respond to discomfort. -Pressure duration: Low pressure over prolong period and high-intensity pressure over short period of time are two concerns related to duration of pressure. Check affected areas for blanching. -Tissue intolerance: ability of tissue to endure pressure depends on integrity of tissue and supporting structures. Shear, friction, and moisture affect ability of skin to tolerate pressure. Greater the degree to which factors shear, friction, and moisture, more susceptible skin will be to damage. -Underlying skin structures (blood vessels, collagen) assist in redistributing pressure. Systemic factors such as poor nutrition, increased aging, hydration status, and low blood pressure affect tolerance of the tissue to externally applied pressure. Blanching: occurs when normal red tones of the light-skinned patient are absent Blanching Hyperemia: if an affected area blanches (turns light in color) and the erythema returns when you remove your finger, hyperemi