Ch 32 Wound Care Concepts Flashcards
Functions of the Skin
protection, temp regulation, psychosocial sensation, vitamin D production, immunologic, absorption and elimination
Factors Affecting Skin Integrity
integrity, resistance to injury (age, amount of underlying tissues, and illness conditions). adequately nourished and hydrated body cells, and adequate circulation
Developmental condiderations
Children younger than 2 (skin is thinner and weaker)
Infants skin and mucous membranes are easily injured and infected, childs skin becomes increasingly resistant to injury and infection, structure of skin changes as age. (older adults thin, easily damaged skin)
State of Health Affecting Skin
very thin and obese people tend to be more susceptible, fluid loss through fever, vomiting and diarrhea, excessive moisture, jaundice, and diseases of the skin.
wound classification
- partial thickness
- full thickness
- unstageable
Wound Repair
- primary intention (well approximated, minimal tissue loss)
- secondary intention (not well approximated edges, large open wounds (burns or major trauma) require more time and tissue replacement, commonly contaminated, more scar tissue)
- Tertiary intention (delayed primary closure)- wounds that are left open for several days to allow edema or infection to resolve or drain, and then are closed.
Vitamins Necessary for wound healing
A- for collagen and epithelialization
B- cofactor of enzyme reactions for healing
C- collagen synthesis, capilary formation, and resistance to infection.
K- synthesis of prothrombin
Zinc, copper, iron assist in collagen synthesis.
Manganese- enzyme activator
Phases of Wound healing:
hemostasis, inflammation, proliferation , and maturation
Hemostasis phase:
immediately after initial injury. blood vessels constrict, blood clotting begins. capillary permeability increases, forming exudate. swelling and pain. heat and redness.
Inflammatory Phase:
2-3 days. WBC (leukocytes and macrophages) move to the wound. leukocytes ingest bacteria and debris. macrophages are essential. they release growth factor necessary for the growth of epithelial cells and new blood vessels. attracts fibroblasts to help fill in the wound.
Proliferation Phase
fibroblastic, regenerative, or connective tissue phase. several weeks. new tissue is built. capillaries grow across the wound, fibroblasts form fibrin that stretches through the clot. new tissue (granulation tissue) forms the foundation for scar tissue. highly vascular, red and bleeds easily. nutrition, oxygenation, and prevention of strain on the suture line is highly important
Maturation Phase
begins abt 3 weeks after injury. collagen that was deposited is remodeled, making the healed wound stronger and more like adjacent tissue. the scar is formed, strength is less than normal tissue and never fully restored.
Factors affecting wound healing
Local factors, pressure, desiccation, maceration, trauma, edema, infection, , excessive bleeding, necrosis , biofilm.
Systemic Factors: age, circulation and oxygenation, nutritional status, wound etiology, medications and health status, immunosuppression, adherence to treatment plan,
Necrotic Tissue
Appears:
slough: moist, yellow, stringy
Eschar: dry, black, leathery tissue
Wound Complications
- Infection
- Hemorrhage
- dehiscence
- evisceration
- fistula
Factors in Pressure Injury Development
External pressure that compresses blood vessels, and friction and shearing forces that tear and injure blood vessels and abrade the top layer of skin
risks for Pressure injury development
immobility, nutrition and hydration, skin moisture, mental status, and age , poor skin hygiene, diabetes mellitus, diminished sensory perception, fractures, history of corticosteroid therapy, immunosuppression, increased body temperature, microvascular dysfunction, multiple organ dysfunction syndrome, previous pressure injuries, significant obesity or thinness, terminal illness/end of life/dying process,
Staging Pressure Injuries
Stage 1: visible blanching , area may be painful, firm, soft, warner, or cooler to adjacent
Stage 2: partial thickness loss of dermis and presents as a shallow, open ulcer or a ruptured/intact serum-filled blister
Stage3: full thickness tissue loss. subC tissue may be visible, and epibole may occur. slough and/or eschar may be present do not obscure the depth of tissue loss. may include undermining and tunneling.
Stage 4: full thickness loss with exposed or palpable bone, cartilage, tendon, fascia, muscle. slough or eschar may be presend, epibole, undermining and or tunneling often occur.
Unstageable: unable to visualize the extent of damage due to slough or eschar.
Suspected deep tissue injury: persistent, nonblanchable purple or maroon discoloration of intact or nonintact skin, or separation of the epidermis that revels a dark wound bed or blood filled blister. painful, firm, mushy, boggy, warmer, or cooler. from intense or prolonged pressure and shearing.
Physiologic Effects of Wounds and Pressure Injuries
pain, anxiety and fear, activities of daily living, changes in body image,
Focussed Assessment of the skin
the appearance, recent changes, activity/mobility, nutrition, pain, elimination
Wound Assessment
sight and smell, appearance, drainage, odor, and pain.
identify barriers to the healing process and signs of complications.
Appearance of the Wound:
note location, and described in relation to the nearest anatomic landmark.
note the size: length, width, and depth
not the edges, color of wound and surrounding area.
Skill: measuring the wound
draw the shape and describe it, measure it.
depth. gloves, sterile flexible applicator at 90 degrees and insert, mark the deepest point. for tunneling. note the depth. note the direction of tunneling in relation to a clock/
When to note odor of a wound:
only after it has been cleaned
