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
RYB Wound Classification
R: Red: protect. normal. gentle cleansing, moist dressings, change of dressing only when necessary.
Y: Yellow: Cleanse. exudate, slough, clean it. often accompanied by purulent drainage. color can be whitish yellow, creamy yellow, yellowish green, or beige. wound cleanser and irrigating the wound.
B: Black: Debride: eschar, can be brown, gray or tan. often needed to be done by advanced practice nurses. after debridement, the wound is treated as yellow, then red.
Risk Assessment for Pressure Injuries
Norton Scale: physical and mental conditions, activity, mobility, and incontinence
Waterlow Scale: age and gender, build and weight, continence, skin type, mobility, nutrition, and special population specific risks.
Braden Scale: mental status, continence, mobility, activity and nutrition.
Braden Scale:
19-23 no risk, 15-18 mild risk, 13-14 moderate risk, 10-12 high risk, 9 or lower, very high risk
Diagnosing
Disturbed body image, deficient knowledge related to wound are, impaired tissue integrity, imparied skin integrity, risk for impaired skin integrity, risk for infection , readiness for enhanced health management,
Wound Care/Management
no dressing: heals slower bc of drying produces a dried eschar or scab
Closed care: keeps wound moist and promotes healing. the best environment.
Purpose of wound dressings:
provide physical, psychological and aesthetic comfort, prevent eliminate, or control infection; absorb drainage, maintain moisture balance of the wound, protect the wound from further injury, protect the skin surrounding the wound, debride (remove damaged/necrotic tissue) if appropriate; stimulate and/or optimize the healing response; consider ease of use and cost effectiveness.
types of wound dressings
those that maintain moisture, those that absorb moisture, and those that add moisture.
Autolytic debridement
uses occlusive dressings (hydrocolloids) or transparent films, and uses the bodys own enzymes and defense mechanisms to loosen and liquify necrotic tissue.
Enzymatic Debridement
application of commercially prepared enzymes to speed up the body’s autolytic process
Mechanical debridement
external physical force to dislodge and remove debris and necrotic tissue. could be achieved by wound irrigation with pulsed pressure lavage, whirlpool therapy, ultrasound or laser treatment, or with surgical debridement.
Bandages: Figuration to use with each body part
Spiral Turn: wrist, fingers, and trunk
Figure of eight: joints: knees , elbow, ankle, and wrist /
Recurrent Bandages: figure eight turn to finish, used for fingers, head, and for a residual limb
T binders
Used to secure a dressing on the rectum, perineum and groin. single t are used for females. double t is used for males.
Nursing Dx for Heat or Cold
acute pain, ineffective tissue perfusion, chronic pain, risk for injury
Applying Heat
Dry heat: hot water bag, electric heating pads, aquathermia pads, hot packs
Moist heat
warm moist compress, sitz bath, warm socks,
Applying Cold: Dry Cold
Ice bags, cold packs
Applying Cold: Moist Cold
cold compress, usually used for injured eye, headache, tooth extraction, sometimes hemorrhoids
