Class 7 - Nursing Interventions Chronic Illness and Chronic Wound Management Flashcards
factors that can predispose the older adult to skin breakdown are
- age
- nutrition (fluid and food intake)
- genetics
- immobility
- chronic illnesses
- polypharmacy
- cognitive impairment
what is a primary intention wound
- Wound surfaces are approximated (to bring
together the cut edges) closed and no or
minimal tissue loss (i.e. surgical wound) - heals from the top down
- Healing occurs within the connective tissue
what is a secondary intention wound
- Wound is open, involves considerable tissue
loss – edges can not be approximated
- heals from the bottom up
- Healing occurs through granulation
pressure ulcerwhat is a tertiary intention wound
- Wound is left open initially (3-5 days), then
edges are approximated - reasons for delay due to, edema or infection
to resolve or exudate to drain - closed with staples, sutures, or adhesive skin
- healing occurs both from the bottom and the
top
partial vs full thickness wound repair
partial:
- shallow, involves loss of epidermis and partial
dermis
- heals by regeneration (ex: surgical wounds)
full
- extend beyond the dermis
- heals by scar formation - deeper structures do
not regenerate (ex: pressure ulcers)
what are the stages of wound healing
- inflammatory phase
- immediate repsonse occurs (redness,
swelling, throbbing, heat and pain)
- lasts 3-6 days - proliferation phase
- lasts 3-24 days
- this is the rebuilding stage of the wound with
granulation tissue - maturation phase
- begins about day 21 can take up to 2 yrs
- remodelling occurs
what are some types of chronic wounds
- pressure ulcers
- venous and arterial wounds
- diabetic ulcers
- fungating wounds (cancer wounds)
what is a skin tear
a wound that is caused by shear, friction and or blunt force resulting in the separation of skin layers
what are some causes of skin tears
- blunt trauma
- shearing or friction
- removing tape
- removing stockings
- banging into furniture
who is at risk for skin tears
- older adults over the age of 85
- females
- immobilized persons
- polypharmacy
- dehydration
- poor nutrition
- cognitive impairments
what can be done to prevent skin tears
- skin hygiene
- hydration
- proper transferring
- avoid using adhesive products on frail skin
- avoid antiseptics, chemicals and heavy soaps
- proper clothing (long sleeves, long pants)
what are the three things to do for a skin tear to treat it
- control bleeding
- approximate edges
- dressing
what are venous wounds
- caused by poor blood return
- result of weak veins, decreased ability of the
calf muscle to pump blood back up to the
heart (d/t limited ROM)
what are the signs and symptoms of venous wounds
- edema
- pain (constant or intermittent)
- discoloration of the skin
- hardening of the skin around the ulcer
- itching, heaviness and aching
what causes venous wounds
- obesity
- blood clots
- varicose veins
- immobility
- diabetes
how can you treat a venous wound
- absorbent dressings
- compression bandages or stockings to
support the valves in the veins to improve
blood flow
what are arterial wounds
- these are ischemic ulcers (arterial
insuficiency). Build up of fatty substances in
the wall of the artery
- they are commonly caused by peripheral artery disease (PAD).
what causes arterial wounds
- poor blood supply
- vasculitis
- diabetes
- renal failure
- high blood pressure
- trauma
what are the signs and symptoms of arterial wounds
- painful
- pale or necrotic wound bed
- they often appear on the distal lateral
extremity - the effected extremity is usually cool, absent
of hair growth, has diminished pulses and
thickened toenails
what can you do to treat arterial wounds
- urgent treatment
- DO NOT use compression bandages (this can
reduce blood supply further) - surgery may be indicated to clear the blocked
artery
what are some of the general treatments recommended for arterial wounds (not surgery oriented)
- clean the wound
- treat any infections with antibiotics
- manage pain
- rest feet to prevent damage to the wound
and to help speed healing - prevent them
- careful ongoing assessment, documentation
and prompt treatment
what should you do to prevent diabetic ulcers
- check feet daily
- check color of legs and feet for swelling/
redness - wash and dry feet daily
- trim nails straight across
- wear good fitting supportive shoes
what should you not do in regards to diabetic ulcers
- do not cut your own corns or calluses
- do not soak your feet
- do not take really hot baths
- do not put lotion btw your toes
- do not walk barefoot outside or inside
- do not sit for long periods of time
what are fungating wounds
these are cancer tumors
- very painful
- strong odour
- they will not heal
what can be done to treat a fungating wound
- often charcoal dressings are used to absorb
the odour - can use silver or antimicrobial dressings
- never use adhesive dressing or tapes
they increase the trauma to the wound
where do pressure sores come from
they result in prolonged pressure on an area; usually over bony prominences
what risk factors exist for the elderly regarding pressure sores
- age related changes
*reduced elasticity of the skin
*thinning of underlying muscle and tissues
*reduced collagen formation - chronic medical conditions such as
cardiovascular disease and diabetes - reduced nutritional status
there are three things in the development of pressure sores, what are they
- pressure intensity: the amount pf pressure
exerted to collpse a capillary results in tissue
ischemia - pressure duration: takes less than 2 hours
for redness to show up (this is stage 1) - tissue tolerance: depends on the integrity of
the tissue and supporting structures;
external factors such as friction and shear;
internal factors such as nutrition and age.
what is the Braden scale
it a measurement tool to determine the risk that a patient has for pressure sores
what is on the braden scale
- moisture
- activity
- nutrition
- friction/ shear
- mobility
- sensory
what is the purpose of a dressing
- protect from microbial contamination
- protect from mechanical injury
- maintain moist wound healing
- absorbs drainage
- provides thermal insulation
what are the four stages of pressure ulcers
stage 1 - skin intact
stage 2- partial thickness skin loss
stage 3 - full thickness tissue loss fat maybe
visible
stage 4 - full thickness tissue loss with exposed
bone and tendon and muscle
define abrasion
scraping or wearing away
define debridement
removal of damaged tissue or foreign objects from a wound
define eschar
dark scab or falling away of dead skin
define exudate
material composed of serum, fibrin and WBCs that escapes form blood vessels into an area of inflammation
define granulation tissue
new tissue in granular form on the healing surface of a wound
define indurated
hardened or has a ridge around the edges of a wound
define laceration
deeps cuts or tear
define macerated
softened by soaking in a liquid
define sloughing
shed or remove
define necrotic tisue
dead cells
define serous
a pale yellow transparent fluid that fills the inside of body cavities
define serosanguinous
fluid containing both blood and serum
define sanguinous
fluid containing blood
define purulent
containing pus
what is the cleanser of choice for wounds
isotonic saline or lactated ringers
do wounds heal better in moist or dry environments
moist
why are antibiotics not given to patients even though they may have a few bacteria in the chronic wound
b/c prolonged use of antibiotics can make a person susceptible to wound infection by resistant organisms
signs and symptoms of a wound infection are
- redness
- swelling
- heat
- throbbing pain
- tenderness
- foul odour
- fever
what are you looking for when assessing a wound
- wound size
- be specific and use medical terminology when appropriate
- measure, do not guess
- depth includes tunneling if
noted – use a sterile q-tip to
measure if needed
- signs of infection
- redness
- warmth
- swelling
- pain
- odour
- exudate (note colour)
- blanching
- surrounding skin color and
temperature- reddened, pale
- cool to touch, warm to touch
- wound edges- macerated or
any induration - wound bed - necrosis, slough
or granulation - wound location
