Exam 4 Flashcards
Risk factors that impair skin integrity/forming of pressure ulcers
decreased mental status, decreased skin elasticity, shearing and friction, immobility, fecal and urinary incontinence, inadequate nutrition
-greatest risk= spinal cord injuries, hospitalized and long term care facilities
Prevention of skin breakdown/pressure ulcers
turn Q2 hours
Stages of pressure ulcers
stage 1-stage 4 (goes from ok, to bad), unstageable, susceptible deep tissue injury
Stage one of pressure ulcer
nonblanchable erythema of intact skin signaling potential ulceration, doesn’t turn white, no immediate cap refill
Stage two of pressure ulcer
partial-thickness skin loss involving epidermis and possibly dermis; open blister, shallow crater
Stage three of pressure ulcer
full-thickness skin loss, involving damage or necrosis of subcutaneous tissue- not all the way to the bone
Stage four of pressure ulcer
full-thickness skin loss with extensive destruction, with tissue necrosis or damage to muscle, bone, or supporting structures- all the way to the bone
Unstageable pressure ulcer
eschar present, has black thick tissue over the top, escarp.–unable to assess depth, undermining
Susceptive deep soft tissue injury; pressure ulcer
appears as a bruise, but you can’t determine how much damage lies underneath the tissues
Surgery for pressure ulcer; debridement
if eschar has formed or autolytic debridement or larval therapy
Nonpharmacological therapy
- minimize direct pressure; turn q2 hours
- clean pressure ulcer at dressing change
- use surgical asepsis
- provide ROM exercises and mobility
Prevention of pressure ulcers
- maintaining skin hygiene
- avoiding skin trauma
- keep head of bead at or below 30 degrees
- bathe with tepid water (not hot) and minimal scrubbing
- keep skin clean, dry, and intact
- keep clients from sliding down in bed (lift, not pull)
- do not massage bony prominences
Assessment of pressure ulcers
- inspect->palpate->document
- risk assessment tools
Risk assessment tools for pressure ulcers
- braden scale for predicting pressure sore risk. #below 18 at risk
- norton scale, #below 15 or 16 indicators of pressure ulcer development
Implementation for maintaining skin integrity
- clean skin when soiled
- avoid massage over bony prominences
- minimize skin exposure to moisture
- minimize skin injury due to friction, shearing
- place client on pressure reducing device
Nursing Diagnosis for pressure ulcers
- risk for impaired skin integrity
- impaired skin integrity
- risk for infection
- imbalanced nutrition: less than body requirements
- risk for compromised human dignity
- situational low self-esteem
Types of wound healing
primary intention, secondary intention, tertiary intention
Types of wound healing: primary intention
-surgical incision
characteristics=little/no tissue loss, edges approximated (surgical incision)
wound type= heals rapidly, low infection risk, no/minimal scarring
Types of wound healing: secondary intention
-wound that heals from inside out
characteristics= tissue loss, wound edges widely separated (pressure ulcers, open burn areas)
wound type= longer healing time, increased infection risk, scarring
Types of wound healing: third intention
-delayed wound healing
characteristics= widely separated, deep, spontaneous opening of a previously closed wound, infection risk
wound type= closed later, extensive drainage and tissue debris, long healing time
Phases of wound healing
inflammatory stage, proliferative stage, maturation/remodeling stage
Phases of wound healing: inflammatory stage
-begins with the injury and lasts 3-6 days, happens immediately after injury occurs
Care involves:
- controlling bleeding- hemostasis (bleeding stops)
- delivering oxygen, WBC’s and nutrients to the area
Phases of wound healing: Proliferative stage
-lasts the next 6-21 days
Effects to the wound include:
- replacing lost tissue with connective/ granulated tissue
- contracting the wound’s edges
- resurfacing of new epithelial cells
- collage synthesis
Phases of wound healing: maturation/remodeling stage->
- 21+ days- can take more than 1 year to complete
- involves strengthening of the collagen scare and the restoration of a more normal appearance
Types of wound exudate
serous, sanguineous, purulent, serosanguineous, purosanguinous
Types of wound exudate: serous
-portion of the blood (serum) that is watery and clear/slightly yellow, contains few RBC’s- blister fluid from burn
Types of wound exudate: Sanguineous
-contains serum and large number of RBC’s thick and reddish
- brighter=fresh bleeding, darker= older drainage
- damage to capillary= good indicator
- good indicator that there was severe damage of the capillaries
- fresh open wounds
Types of wound exudate: purulent
- puss- result of infection
- thick and contains WBCs, tissue debris, and bacteria, may have foul odor, and its color reflects the type of organism present. ***Appear anywhere from thick milky white to yellow or green (ex: green for pseudomonas aeruginosa)=puss
Types of wound exudate: Mixed purosanguinous
mixed, blood tinged but thick in appearance
Types of wound exudate: mixed serosanguineous
mixed, contains both serum and blood, watery and appears blood-streaked or blood-tinged. Blood tinged appearance but mostly clear- pinkish color
Complications of wound healing
dehiscence, evisceration, infection, hemorrhage
Complications of wound healing: dehiscence
partial/total rupture (separation) of a sutured wound-> wound that opened back up. “popping” or “giving way” in wound area
-requires emergency treatment: call for help, cover wound, position client supine with hips and knees bent, watch for signs of shock
Complications of wound healing: evisceration
- involves the protrusion of visceral organs through a wound opening
- requires emergency treatment: call for help, cover wound, position client supine with hips and knees bent, watch for signs of shock
Complications of wound healing: infection
-S/S (3-11 days after injury/surgery): purulent drainage, pain, redness, edema, fever, chills, increased HR, RR, WBC count
Complications of wound healing: Hemorrhage
-excessive bleeding, dislodged clots, erosions of blood vessels
Appearance of wounds: color
red- healthy (protect)
yellow- presence of purulent/puss drainage (cleanse)
black- presence of eschar
