CH 33/55 Skin Integrity and wound care Flashcards
Wounds are the results of
injury to the skin
Although there are many different methods and degrees of wound injury
the basic phases of healing are essentially the same for most wounds
A pressure injury is
a specific type of tissue injury from unrelieved pressure usually over bony prominences that results in ischemia and damage to the underlying tissue
stages of wound heal thing
Inflammatory stage, proliferative stage, maturation or remodeling stage
Inflammatory stage(1)
Begins with injury and last 3 to 6 days
Proliferative Stage(2)
last 3-24 days replacing lost tissues resurfacing new epithelial cells
Maturation or remodeling stage (3)
occurs on about day 21 and involves the strengthening of the collage scar it can take more than 1 year to complete
Primary Intention
little to no tissue loss, edges approximated with surgical incision. heals rapidly, low infection risk, minimal scarring
Example of primary intention
closed surgical incision with staples. sutures, or liquid glue
Secondary intention
loss of tissue, wound edges separated, longer healing, increase infection risk, scarring, heals by granualation
Secondary intention example
pressure injury left open to heal
Tertiary intention
widely separated, deep, risk of infection, closed later,
Tertiary Intention example
abdominal wound initially left open until infection is resolved and then closes
Factos affecting wound healing
age, overall wellness, decrease leukocyte count, infection, meds such as anti-inflammatory and antineoplastic. malnourshed clients, tissue perfusion, low hgb levels, obesity, chronic diseases, smoking, wound stress
Note the appearance of
open wounds
red wound
healthy regeneration of tissuey
yellow wound
present of purulent drainage and slough
black wound
present of eschar that hinders healing and requires removal
USE RYB color code guide for wound care
red-cover
yellow-clean
black-deride, remove necrotic tissue
closed wounds
skin edges should be well approximated
drainage
aka exudate
drainage (exudate)
A result of the healing process and accumales during the inflammatory and proliferative phases
Note the amount, color, consistency of wound
drainage
For an accurate measurement of drainage weigh the dressing
1g=1ml of drainage
Serous drainage
the portion of the blood that is watery and clear or slightly yellow In color
example of serous drainage
drainage from blisters
Sanguineous drainage
contains serum and red blood cells. thick and appears reddish. brighter drainage indicated bleeding, darker indicated older bleeding
serosangueneous drainage
contains both serumm and blood. water and pale and pink due to a mix of red and clear fluid
purulent drainage
result of infection. thick and contains white blood cells, tissue debris, and bacteria. maybe could odor and its color yellow, tan, green, brown reflect the type of organic,
purosanguineous
a mixed drainage of pus and blood (newly infected wound)
Ensure adequate hydrate
2,500 ml of fluid a day if no heart and kidney issues
Educate about good protein sources
meat, poultry, eggs, dairy, beans, nuts, whole grains
for clean wounds such as a surgical incision clean
from least contaminated (the incision) toward the most contaminated ( the skin)
Do not use cotton balls or other fibers that shed
to clean wounds
wound dressings
woven gauze, nonadherant, damp to damp, self adhesive transparent film, hydrocolloid, hydrogel, alginates, collagen
Woven gauze drssing
absorbs exudate from wound
nonadherant material
does not stick to the wound bed
damp to damp dressing
used to mechanically debride a wound until granulation tissue starts to form must keep moist
self adhesive transparent film
a temporary second skin ideal for small superficial wounds
hydrocolloid
an occlusive dressing that swells in the presence of exudate,
hydrogel
mostly water felt after contact with exudate , moist wound bed
alginates
non adherent dressing conform to wound shape and absorb exudate packs wound supports debridement
collage
powders pastees granules sheets, hells, helps stops bleeding, promotes healing
vacuum assisted closure system
use of foam strips laid into the wound bed with a sealed drape applies and suction tubing placed speeds tissue generation and decrease swelling
Dehiscent
a partial or Toal rupture separation of a sutured round
evisceration
a dehiscent that involves the protrusion of visceral organs through a wound opening
Deep tissue pressure injury
persistent non blanchable, deep red, maroon, or purple discoloration
stage 1 pressure injury
non blancahble erythema of intact skin
stage 2 pressure injury
partial thickness skim loss with exposed dermis, involves epidermis and dermis. Wound bed is viable with reddish-pinikish bed without slough, eschar, granulaiton or adipose tissue. it can appear as an intact or ruptured blister
stage 3 pressure injury
full thinkness ki loss, visible adipose tissue and possible granulation tissue. wound edges appear roller under, slough, eschar present. no exposed muscle tendons ligaments cartilage or bones. possible tunneling
stage 4 pressure injury
full thickness skin and tissue loss with cartilage bone fascia, muscle tendon exposed.un
unstageable press injury
obscured, full thickness skin and tissue loss. No determination of stage because escharor slough obscures the wound bed.
To avoid pressure injuries keep bed
at or below 30 degrees
to avoid pressure injuries
reposition client in bed every 1-2 hours
Keep an eye on _____ levels for skin
albumin 3.5
Pressure injury stage 1 treatment
relieve pressure, turning, keep clean
pressure injury stage 2 treatment
moist healing environment,hydrocolloid dressing
stage 3 pressure injury treaten=ment
clean or deride
stage 4 pressure injury treatment
clear or deride- non ahdheran dressing changes every 12 hours, skin grafts
