Skin Anatomy
- Epidermis
- Keratinocytes
- Melanocytes
- Dendritic Cells
- Merkel Cells
- Dermis
- Sweat Glands
- Hair Follicles
- Sebaceous Glands
- Hypodermis
Skin Functions
- Thermoregulation
- Protection
- Innate Immune Protection
- Synthesize Vitamin D
- Water and Salt Excretion
- Dilated Capillaries are a Blood Reservoir
Braden Scale
- Sensory Perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction and Shear
Interventions for Impaired Skin Integrity
- Signs of Skin Breakdown
- Pain
- Redness
- Decreased Skin Turgor
- Bleeding
- Bony Prominences
- Reposition Q2H
- Pressure Relief
- Maintain Clean and Dry Skin
- Adequate Nutrition and Hydration
Pressure Ulcers
- Stage 1 - Non-Blanchable Redness
- Stage 2 - Partial Thickness
- Stage 3 - Full Thickness Skin Loss
- Stage 4 - Full Thickness Tissue Loss
- Unstageable
- Possible Deep Tissue Injury
- Skin Color Alterations
- Remove Necrotic Tissue Before Staging
Types of Wound Healing
- Acute
- Chronic
- Primary Intention
- Approximated Edges
- Secondary Intention
- Edges Not Approximated
- Tertiary Intention
- Delayed Closure due to Infection and Necrosis
Wound Drainage Types and Devices
- Serous
- Serosanguineous
- Sanguineous
- Purulent
- T-tube
- Penrose
- Jackson-Pratt (JP)
- Hemovac
- Record Drainage Amounts
- Check Device Function
R.I.C.E. (Treating Soft Tissue Injury)
- Rest
- Ice
- Compression
- Elevation