Fund 50 - week 7 - integumentary Flashcards
Skin is largest
organ in body: Covers the entire body and continuous with mucous membrane
skin outer to inner
epidermis, dermis, subq.
Epidermis
Thin, barrier layer
Made of by epithelial cells
Keratinocytes provide strength and elasticity
Melanocytes gives skin pigment
Langerhan cells phagocytize foreign material and trigger immune response
Dermis (dermis has everything and sailing into the sun)
Contains collagen: elastic connective tissue to provide structural integrity
Blood vessels
Sweat and oil glands, hair follicle, sensory receptor
function of skin (skin IS TEPAD)
protection, thermoregulation, elimination, storage Vitamin D
Absorption
Sensation
Body image
Protection (the skin keeps what low for protection)
Physical barrier from infection
Low pH (4-6.8), inhibit microbes
Sebum on skin contains antimicrobials
Provides immunity
Epidermis: Langerhan cells
Dermis: macrophages and mast cell
Prevents excess fluid loss
Thermoregulation through (think sweating VV)
vasoconstriction
vasodilatation
perspiration
Elimination through (just think sweat)
sweat: it’s certain byproducts
electrolytes
water
Storage (skin is all blood and water)
stores 15% body’s water
stores 1/3 of the body’s blood supply
Synthesis of Vitamin D
when exposed to UV sunlight
Sensation and absorption
pain, pressure, temperature
absorb certain drugs
Definition of wound:
any break in the normal integrity of the skin and tissues
Classifications of wounds (was that wound intentional?)
Intentional vs Unintentional
Closed vs Open
Acute vs Chronic
Pressure injury stages
Intentional wounds:
Planned procedures
Surgeries, interventional radiology therapies, paracentesis, etc.
Done under sterile field
Wound edges clean and bleeding usually under control
Infection minimal and healing facilitated
Unintentional wounds
Accidental
Unexpected trauma (accidental cuts, stabbing, gunshot, burns)
Contamination of wound likely d/t unsterile environment
Bleeding may be uncontrolled
High risk of infection and longer healing time
Open wound through intentional or unintentional
means
Risk of infection dependent on intention (if intentional, its surgery so it’s sterile)
Closed wound
skin remains intact
Blunt force trauma: Falls, internal injury from a car accident, assault
Contusion, hematomas, ecchymosis
Acute wounds - how long to heal? (and ex. - the surgery was a cute one)
Heal within days to week
Progresses through the normal healing process Ex: surgical incision
Risk of infection < chronic
Chronic wounds - how long is healing? (and ex. of chronic wounds)
Healing is delayed >30 days
Healing stalled d/t infection, ischemia, continued pressure, or edema
Ex: diabetes ulcers, PVD, PI
Wound healing is a
process of tissue repair by physiological mechanisms that regenerate functioning cells and replace connective tissue with scar tissue.
phases of wound healing (it’s a BIPR remodel)
bleeding, inflammatory, proliferative, remodeling
phases of wound healing - hemostasis (hemo = blood)
Occurs immediately after tissue injury
Vasoconstriction and blood clotting via platelet and fibrin aggregation
Inflammation (followed by what?) The flame became white and macros attracted the growth
(main point - redness, heat, pain)
Followed by vasodilation (heat and redness) → ↑capillary permeability leaking of plasma→ exudate→ swelling→ loss of function
Chemicals on tissues attract WBCs
WBC and macrophages migrate to injured site
Macrophages also attract growth factors for regeneration of epithelial cells and fibroblasts to fill in wound
Inflammation is a NON-SPECIFIC
reaction
Not the same as infection; although infections may trigger inflammation
Intended to neutralize, control or eliminate offending agent
Chemical Response during inflammation (Local symptoms) which one causes the inflammation? (and also PKH)
the cytokines are what cause inflammation. Chemicals mediators such as histamine, kinins, prostaglandins released at site of injury also responsible for early stage vasodilation
Kinins attract neutrophils to area
Systemic Response during inflammation - and who is responsible for unleashing?
Fever*** caused by endogenous pyrogens released by neutrophils and macrophages
Chills occur in fevers d/t resetting of hypothalamic thermostat control
5 cardinal signs of inflammation***(flaming cardinals swap roles - SWP RL)
Redness, warmth, swelling, pain, loss of function
Proliferation - how long does it last? (it’s been a proliferative several weeks since granny is connecting with the blast)
(Granulation, fibroblastic, connective tissue)
Lasts several weeks
Maturation (Remodeling) when does it start? (the remodel will take about 3 weeks after we breakdown the collagen)
Begins 3 weeks after injury
Initial collagen broken down and remodeled into scar tissue to add strength to wound
Scar tissue is avascular, no sweat gland follicles or tan in sunlight
Contraction of wound
Level of contamination*** (clean to contaminated)
(contamination does not equal infection)***
Clean
Clean-contaminated
Contaminated
Infected wounds
>100,000 organisms per gram of tissue
Organisms present BEFORE procedure
signs of infection - when do they start? (infection 28 days later)
Usually occurs 2-7 days after injury or surgery
Contaminated wounds more likely to get infected
signs and symptoms of infection - think of abcesses (and don’t forget color)
Erythema, warmth and edema around the wound
Foul odor
Fever, malaise, ↑ WBC
Increased pain, delayed wound healing
Increased drainage esp purulent (yellow pus)
Changes in wound color (slough, eschar)
pressure injury
“A PRESSURE INJURY is a localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device”
The injury can present as intact skin or an open ulcer.
pressure injuries are a huge….(and how much pressure to cause one?
and growing problem in health care expenditures
Increases morbidity & mortality
Capillary pressure over bony prominences is only ~20 mm Hg-very low pressure
Excess pressure disrupts blood flow and causes ischemia
2 hours is max tissue can tolerate ischemia before tissue begins to die
stages of a pressure injury
STAGE 1
STAGE 2
STAGE 3
STAGE 4
SUSPECTED DEEP TISSUE INJURY
UNSTAGEABLE PRESSURE INJURY
Devices Related PI That Can Be Staged (my ears, nose and throat on stage)
Behind ears from nasal cannula
Nasogastric tubes
Endotracheal tubes
devices related to PI - Mucosal Membrane Pressure Injury - can or cannot be staged?
Found on mucous membranes with a history of medical device at location of injury
Due to the anatomy of the tissue these injuries cannot be stage
pressure injury stage I (and what about the temp?)
skin is intact
Non-blanchable erythema
Not maroon or purple (Deep tissue injury)
Skin intact
Over bony prominence or device related
Area may be painful
Warmth or firmness compared to adjacent area
Difficult or assess in patients with dark skin tone or areas of hyperpigmentation
PI stage 2 (color and what level of skin is exposed?)
Partial thickness skin loss with exposed dermis
Wound bed viable, shallow, pink or red and moist
Intact serum filled or ruptured blister
No adipose tissue, granulation tissue, slough or eschar
May be mistakenly used to describe skin tears, burns, maceration, excoriation, incontinence associated dermatitis or, abrasions
PI stage 3 (there are 3 stages for a fat granny, but fascists, muscle, and bone tend to be elsewhere)
Full thickness skin loss
Adipose and granulation tissue visible in the ulcer
Fascia, muscle, tendon, bone not visible
PI stage 4 (everyone is on stage at 4, even ebola - BUT one isn’t completely covering)
Full thickness tissue loss
Exposed bone, tendon, muscle, tendons, ligaments
Epibole (rolled around edges) undermining and/or tunneling common
Slough or eschar may be present but does not completely obscure wound bed
May cause osteomyelitis if bone exposed
pressure injury healing stage 4 (4 stages of my scar)
Healing Stage 4 filled with Scar Tissue – made of protein/collagen tightly woven together
DIFFERENT from original tissue– will always be a Stage 4
(Chart as a Healing Stage 4 – Not a Stage 2 !!! No reverse staging)
pressure injury - Stage 4 PI reopened
though shallow, it is not called stage 2 (no dermis, fat or muscle inside) chart it as “reopened Stage 4”
PI unstageable**
UNSTAGEABLE PRESSURE INJURY
Obscured full-thickness tissue loss
Extent of tissue damage cannot be terminated d/t obscurity from slough or eschar
If slough or eschar removed (black stuff) from unstageable, it always reveals stage 3 or 4 PI
pressure injury - deep tissue***(deep tissue deep purple)
Persistent nonblanchable deep red, maroon, or purple discoloration
Result of intense, prolonged pressure and shearing at bony prominence
May rapidly reveal the actual extent of tissue injury or resolve without tissue loss
Difficult to detect in dark skin tones (compared to adjacent tissue, may be painful and firm)
at risk PI (slakin and fresh)
Friction:
May be caused by wrinkled sheets, when patients drag their elbows, heels when repositioning themselves
Shear:
When one layer of tissue slides over another layer of tissue
Causes the skin to separate from its underlying layers
Blood vessels and capillaries damaged → impaired circulation
When patient partially sitting up in bed and person sliding down toward foot of bed; skin sticks to sheet
at risk PI immobility
Generalize weakness, chronic illness
Paralysis, neurological disorders, cognitive dysfunction
Bed or chair bound from spinal cord injuries
Pain
Sedated and comatose patient
Age related factors- Skin regenerates slowly, vulnerable to damage, cognitive impairment, nutrition, etc.
Hypoperfusion - impaired circulation
Extreme low weight – Less cushioning
Poor nutrition and hydration
factors that affect wound healing PI -local factors
Pressure and edema? (too swollen for blood flow)
interferes blood flow
biofilm and wound healing
Biofilm may contain multiple species of bacteria that shield against the immune system and antimicrobial agents
A reservoir for infection
factors that affect wound healing - nutrition - vitamins
Nutrition - wound healing requires adequate protein, carbohydrates, fats, vitamins and minerals, fluid intake
Fat (20-30% of intake): provides energy, protein sparing, vit A absorption
Adequate circulation - to carry oxygen and nutrients to wound
Fever affects wound healing how? (think sweating and bmr)
Wounds heal slower BECAUSE Increases BMR → increased O2/nutrient requirements
Diaphoresis on skin → maceration
factors that affect wound healing - Medication and Overall health (steroids and overweight)
Overly thin and obese people more susceptible to skin irritation and injury
Corticosteroids decrease the inflammatory process
Anemia - Add iron supplements
Smoking - provide smoking cessation program
Hypothermia - causes vasoconstriction
Impaired immune function and chronic illness: chemo agents, DM, prolonged abx, immunocompromised
obesity and wound healing (hiss at obese ppl)
Higher risk for dehiscence (when wounds opens up) d/t increased tension on skin
More vulnerable to pressure ulcers
Many obese people are actually malnourished despite their weight
diabetes and wound healing - how does hyperglycemia affect wound healing?
Hyperglycemia impairs wound healing and leads to higher risk of infection
Stress of wound increases blood sugar level
Peripheral arterial disease (perry art is thin and dead)
Limits activity d/t pain and leads to muscle atrophy
Thin tissue that is prone to ischemia and necrosis
Need to restore arterial blood perfusion for wound healing
Chronic venous disease (veins get edema)
Results in engorged tissue with high levels of waste products resulting in edema, ulceration, and breakdown
Contamination - it can spread from surrounding skin, that’s it
Wounds may get colonized from surrounding skin and local skin organisms
Internal sources like mucous membranes of GI tract and chronic wounds also colonized with bacteria
Subtle signs of contamination (bacteria has not invaded tissue)
Infection
Bacteria invades tissue → systemic response
Contamination - signs (this contamination is causing odor in the tunnel, and granny isn’t here.
When is it critically colonized?
include:
new foul odor, ↑drainage, new tunneling of wound, absent or friable granulation tissue, change in color of wound bed
No active infection until critically colonized (>100K per gram of tissue)
age related skin changes - what about sweat and why do they get cold?
Diminished activity of sebaceous and sweat glands→xerosis (itchy, red, dry, cracked, or fissured skin)
Epidermis and dermis thins and atrophies
Less effective thermoregulation d/t loss of lean body mass and subcutaneous tissue
age related skin changes - collagen
Changes in collagen/elastin fibers decreases elasticity and integrity → prone to tearing
Regeneration of healthy skin takes twice as long in an 80 year old vs 30 year old
Impaired tactile sensitivity
Blood vessels thinner and more fragile-bruise easily
nursing care plan - just look, that’s it
Skin Integrity – each time you change pt’s position, look for redness, swelling, heat, and break in the skin, especially over bony prominences.
nursing care plan interview (think paraplegic)
Inquire about skin/existing skin condition, mobility, nutrition, pain, elimination continence
nursing care plan - inspect where? ***and what is most important thing patient should do?
Under medical devices: oxygen delivery devices, catheters, orthopedic braces, casts, airway or ventilator tubing/tape, NG tube, cervical collars, chest tubes, bony prominence
If wound present: appearance, drainage, size, closed or open, odor
unhealthy), biofilm
Educate patient to report any changes or new onset of pain
wound assessment - what to measure and the q-tip
Measure dimensions
L X W X D
Assess for presence of tunneling/undermining using moistened Q-tip
Length-greatest length in cm (measure from head to toes)
Width-greatest width side to side
Depth-mark with Q-tip at deepest point and hold to ruler
wound assessment undermining (it’s literally just a mine)
Erosion under the wound edges, resulting in a large wound with a small opening
May have multiple directions
wound assessment - tunneling (the tunnels destroy fascists w/ abscesses)
Destruction of the fascial planes which results in a narrow passageway
Potential for abscess formation
Usually one direction
wound assessment - approximated (approximately together)
edges come together.
can be rolled or calloused
wound assessment - location
Describe location using anatomical terms
Non-healing wounds on feet usually d/t diabetes or PVD (peripheral vascular disease)
wound assessment odor
Odor - Foul smelling wounds indicate infection
wound characteristics and amount - drainage (SSSPP) seriously sang w/ blood, serosang, pur, and pursang.
Presence of biofilm
Exudate/drainage:
Serous
Sanguineous-bloody
Serosanguineous
Purulence
Purosanguineous-thick
wound assessment - palpate
Pain, discomfort over bony prominences/pressure points (sacrum, ischium, trochanters, heels, elbows, and the back of the head. Don’t forget to look between the toes)
Changes in temperature
Texture of skin
planning and implementation - best practices (pillows on heels, nutrition, moisture barrier)
Suspend heels – pressure off
Keep head of bed (HOB) at <30 degrees if no contraindication
Inspect skin every shift and at every turn
Nutrition and hydration
Apply moisture barrier if incontinent
Vigilant skin care and moisture
Encourage mobility
planning - just transferring and get wrinkles out
Use transfer and lifting devices (trapeze, draw sheet, hover mat) to decrease friction and shear
Straighten bed linens to remove wrinkles; use incontinence pads or chux whenever possible.
planning and implement wound care - moisture
Promote moisture environment
Moist environment provide optimal conditions for wound healing → increases rate of epithelialization and proliferation
healing exudate-vital proteins, cytokines, and growth factors which facilitate autolytic debridement
Inadequate moisture impedes cellular activities and promotes eschar formation → poor healing
wound care (DMD GP didn’t do wound care)d
Remove wound debris gently with normal saline
Maintain moist (not dry or wet) environment
Soften necrotic tissue with wet to damp dressing (autolytic debridement)
Always fluff gauze before packing wound
Use absorbing dressings to remove excess exudate
Protect periwound
Maintain aseptic technique to reduce the risk of contamination and infection
Manage pain
Medihoney (the honey does osmosis)
contains osmotic agent to draw out moisture from deeper tissue
helps to lower pH of wound
Hydrogel
moist environment
enhances autolytic debridement
Silver-based dressings (bacteria that are resistant to heavy metals)
Antimicrobial
Xeroform-occlusive
bacteriostatic - chest tube - use this to wrap around tube
Jackson Pratt (JP)
Pockets of fluid (you know this)
Placed during surgery or interventional radiology to remove fluid collection
Can help in healing process and remove infected pockets of fluid
Debridement
Debridement is just the Removal of non-viable.
Eliminates source of infection
Helps to visualize wound bed
Promotes healthy tissue to regenerate
Types of debridement (maggot bride - AESMM)
Autolytic
Enzymatic
Surgical
Mechanical
Maggot
wound care device (wound vac)
Applies negative pressure to the wound to remove excessive drainage (blood, exudate and infectious materials)
Provides direct and complete wound bed contact
Reduces edema
Promotes perfusion and granulation tissue formation by facilitating cell migration and proliferation
skin graft - and how quickly does the donor site heal?
Taking skin from another part of the body to protect/fill in defect
Can take full thickness in areas with extra skin like buttocks, groin, thigh
This “donor site” heals in 7-10 days
skin graft split/partial
Split/Partial thickness skin graft
removes skin but leaves deeper structures with sweat glands and hair follicles
evaluation - how often to evaluate wound after treatment?
Assess the effectiveness of treatment at minimum once per week with measurements/observations
Reevaluate treatment if not healing in timely manner
Regenerative/Epithelial healing (the top layers regenerate bc they’re partially thick. and what type of wound?)
Wound only involves epidermis and dermis
New tissue cannot be distinguished from intact skin
No scar formation
E.g. Partial-thickness wounds
Primary Intention - wound healing
(just bringing the edges together) Wound involves minimal or no tissue loss
Edges approximated (sutures, staples, or surgical glue touching/closed)
Minimal scarring (However scar tissue still only 80% as strong as original tissue)
Eg. Clean surgical incision
Secondary Intention - wound healing (the second you can’t close it)
Extensive tissue loss that prevents edges from approximating or because wound intentionally left open d/t contaminated/infected tissue/blood clot
Wound debrided or infection resolved then allowed to heal from inner layer to surface with beefy red granulation tissue (a type of connective tissue)
Tertiary Intention - wound healing (tersh needs to wait)
Tertiary Intention (Delayed primary closure):
Initially wound healed by secondary intention
When there is no evidence of edema or infection, granulation tissue pulled together and wound edges sutured
Requires strict aseptic technique to prevent infection
Infection-> 100K
Infection-> 100K bacteria/gram tissue or beta strep in any wound
Assess and monitor
Culture wound
Scarring (my adhesions are to keloid and hypertrophy)
Hypertrophic scar -
Scar stays within boundaries of wound
Keloid-scar - outgrows border of injury; acts like a tumor
Adhesions: bands of scar tissue that form between or around organs e.g intestinal adhesions may lead to bowel obstructions
scarring - Excessive contraction results in…
deformity; shortens muscle or scar tissue, especially over joints, results from excessive fibrous tissue formation
Hemorrhage - and how long to monitor after?
Result from ruptured suture, accidental arterial puncture, fistulas, dislodged clot
Monitor surgical wound and drains frequently for bleeding for first 48hrs
Apply pressure dressing if needed
Report uncontrolled and excessive bleeding
wound complications***(ED break it open)
Dehiscence and Evisceration
Most serious post-op complication
Dehiscence - partial or total separation of a wound
Evisceration - Complication of a dehisced wound with protrusion of viscera (internal organ)
Prevention and nursing intervention:
Splint wound when cough/sneezing, getting out of bed
Use abdominal binder
wound complications - fistula
abnormal passage of an organ or vessel to the outside of the body or from an internal organ or vessel to another
Examples:
Carotid-cavernous fistula - abnormal connection between the carotid artery to a large vein
Rectovaginal fistula - abnormal connection between rectum and vaginal
Enterocutaneous fistula - abnormal connection between intestine and skin
is a surgical incision acute or chronic?
acute
**inflammation can occur in 2 places (and examples)
Occurs at tissue level: e.g. result of trauma, surgery, insect bites, sore throat
Occurs at cellular level: e.g. stroke, DVT, myocardial infarctions
your capillaries dilate when you get a pin prick because..
they are opening up to release the wbcs (leuocytes)
if any beta-hemolytic…***
is present in any number, it indicates an infected wound
ex of chronic wounds (chronically VAD)
venous ulcer, aterial ulcer, diabetic ulcer
only stage 2 if
its over a bony prominence or some device was involved
when inspecting the skin, use the pneumonic MEASURE (drainage, appearance, suffering, undermine, re-eval, edges)
MEASURE
M=Measure size of wound
E=Exudate amount
A=Appearance of base: necrotic (black), fibrin (firm yellow), slough (soft yellow – viscous and opaque), granulation tissue (beefy and healthy or red and friable-unhealthy), biofilm
S=Suffering (Pain)
U=Undermining
R=Re-evaluate treatment
E=Edges
what labs assess nutrition? ***(albinos need to assess their nutrition)
remember these labs - Albumin (normal 3.2-5 g/dL)
Half life 20-22 days
Prealbumin (Transthyretin) (normal 2—42 g/DL
Half life 2-4 days
Better indicator of current nutrition*
Transferrin 170 to 370 mg/dl
Transport protein to carry iron
Exudate/drainage:
Serous (you’re seriously clean)
typical of clean wounds, clear watery with little cells=straw colored serum
Exudate/drainage:
Sanguineous-bloody (and what colors?) (I sang w/ bloody capillaries)
Sanguineous-bloody; if bright red blood =bleeding active; if red-brown and darker probably indicates capillary damage
Exudate/drainage:
Purulence
thick, often malodorous (Pus-WBC’s, bacteria, and cellular debris
Clean (and what is not involved with a clean wound?)
Uninfected wound with minimal inflammation
Respiratory, GI, GU tracts not involved
Clean-contaminated (still clean, but…)
Surgical incisions that enter the respiratory, GI, or GU tract
Higher risk of infection but no obvious infection
Contaminated
Open, traumatic wounds or surgical incision in which there is a bridge in asepsis
High risk of infection
Excess sugars (as with diabetes) increase (glyco nation decreases collagen and leads to hypoxia. Hypoxia leads to free radicals. Watch out T cells.
Excess sugars increase glycation → inhibit collagen and elastin regeneration.
Impaired circulation leads to hypoxia (foot ulcers, chronic pressure related wounds)
Free radicals from hypoxia further prolong injury
Impaired immune function-T cells, phagocytosis, bactericidal ability etc.
who should get special attention during nursing care plan?
Pay special attention to:
Critical care patients
Fresh Post-op patients
Patients who are homeless or from SNF
Diapers should be a
avoided
Use pressure-relieving mattresses for patients at
high risk
Reposition chair or wheelchair bound patients how often? (The reposition is every hour. and how often to shift weight?)
every hour. If they are able, teach them to shift their weight every 15 minutes.
Avoid using (waffles are better than donuts)
donut-type devices; use waffle cushion instead
planning and implement wound care - inadequate moisture
impedes cellular activities and promotes eschar formation → poor healing
Dry dressings may disrupt healing when removed; fresh tissue gets removed during dressing change
planning and implement wound care - excessive moisture leads to…(moisture is mace)
maceration and increases likelihood of skin breakdown
Creates supportive environment for bacterial growth
debridement - Autolytic
gel that helps the body use own enzymes
debridement - Enzymatic
products that contain enzymes
debridement - Surgical
more invasive
debridement - Mechanical
wet to dry
debridement - Maggot
clean wounds
Expected trajectory/path for wound healing time (when you do evaluation) - the percentage
the wound should be 20% smaller at week 2 and 40-50% at week 4 to heal in 12 weeks
how long is inflammation phase? (my flame only lasted the weekend)
(2-3 days)
how proliferation works (proliferative fireworks)
Fibroblasts (connective tissue cells) form collagen and produce growth factors to form blood vessels
Blood vessels carry oxygen nutrients to cont’n healing
Results in granulation tissue formation –highly vascular, red and bleeds easily
Granulation tissue is the foundation for scar formation
appearance of base - colors - necrotic
black
appearance of base - colors - fibrin (fibrin is firm)
firm yellow
appearance of base - colors - slough (slough is soft)
soft yellow – viscous and opaque
appearance of base - colors - granulation tissue
beefy and healthy or red and friable-unhealthy
exude - Serosanguineous (sarah and sang are pink)
most commonly seen in new wounds lighter pink, combination of serous and sanguineous drainage-
at risk for PI - wet and dry?
Maceration (moisture, pee) or dessication (overly dry) – prone to impaired skin integrity
medical conditions that are prone to PI
circulatory compromise (DM, vascular disease, anemia, smoking, etc.)
what is epibole and what stage would you see it? (the ebola rolled in at 3)
rolled wound edges common - stage 3
CERTAIN AREAS: NOSE, EARS, OCCIPUT ARE SHALLOW ULCERS BUT
CAN BE STAGE III OR WORSE
what might occur during stage 3? (mining the tunnels at 3 p.m.)
Undermining and tunneling may occur
stage 3 - Slough and or eschar (slough almost there at 3, but might not make it)
may be visible but if they obscure the extent of tissue loss, PI wound be considered unstageable
Acute inflammation leads to (just a description of inflammation basically)
erythema, pain, warmth and systemic response including fever and leukocytosis
what phase do macrophages appear?
Inflammation. Macrophages engulf bacteria (phagocytosis) and clear debris
chronic wounds remain in what phase?
**Wound remains in inflammatory phase of healing
deep tissue wound - intact or not?
Intact or non-intact skin revealing dark wound bed or blood filled blister (if it’s bloodfilled, it’s deep tissue. if it’s clear, it’s stage 2 PI, like a blister*
problem w/ obesity and hormones (adin is obese)
Low adinopectin (hormone that protects against insulin resistance) impairs angiogenesis (blood vessel formation) leading to micro-abnormalities that causes a persistent state of mild inflammation
obese more vulnerable bc
Venous insufficiency cardiovascular disease
Vit A and C essential for (why do you put it on your face)
epithelialization and collagen synthesis
Zinc promotes (zinc in my cells)
proliferation of cells
Protein essential for
for cell and tissue growth (1-2.5 g/kg/day of protein to prevent tissue catabolism)
Carbohydrates
(50% of intake) - cellular metabolism; protein sparing
30-45 kcal/kg/day to maintain + nitrogen balance
Fluid intake -
Fluid intake - Maintain fluid intake to 1ml/Kcal/day (ex: 2500 Kcal =2500mL/day)
in obese ppl, Wound tension increases tissue pressure, then what happens?
it reduces microperfusion and O2 availability
in obese ppl, Impaired (karin, pro, and mig)
proliferation and migration (critical step in re-epithelialization)
Wound assessment - open vs closed
sutures, staples, surgical glue
would assessment - Periwound skin (just the skin around the wound) (BI MEN periwound)
indurated (hard), erythematous, macerated (moisture), bruised, normal
slough (slough off the dead skin)
dead tissue, usually cream or yellow in color
eschar
dry, black, hard necrotic tissue
Bacteria compete with granulation for what?
nutrition
should you remove eschar on unstageable wound?
stable, dry, adherent, intact without erythema, and on on heel or limb should not be softened or removed. Provides natural barrier to cover wound
how does biofilm delay healing? (biofilm on fire, granny delayed w/ epi and kerin)
Delays healing through chronic inflammation, delayed granulation tissue formation, and delayed epithelial migration
Impairs migration and proliferation of keratinocytes
Hematomas (and can cause what?)
localized mass of blood that could cause tissue ischemia
what to do if evisceration occurs? (evisceration is a looooowww blow)
place patient in low fowler and immediately cover exposed organ with moistened sterile saline gauze**
*Contact provider immediately and stay with patient
what is the PRIMARY CAUSE OF WOUND CHRONICITY (biofilms are chronic)
biofilm, found in 60% of chronic wounds
local factors that affect healing - dessication?
Dehydrated cells die. Moist environment promotes epithelialization
local factors - maceration?
overhydration actually changes pH of skin and promotes bacterial growth → infection
local factors - trauma?
Repeated trauma delays wound healing
local factors - excessive bleeding results in what?
clots that interfere w/oxygen diffusion
local factors - can epitheliazation occur with necrosis?
no, it must be debrided
local factors - biofilm?
A protective matrix of bacterial that ↓ the effectiveness of abx and normal immune response
how does secondary heal fast or slow? And how is the scarring?
more slowly and more scarring
how often to reposition a patient?
Reposition at least every 2 hours
does secondary intentional or tertiary have more scarring?
secondary, as long as it’s intentional secondary
Purosanguineous - (one step beyond)
thick red-tinged pus indicating blood in infected wound
contamination equals infection - T or F?
F - contamination does NOT equal infection
arterial ulcers are what color?
pale bc blood can’t get to it
diabetic ulcers are venous or artery?
venous ulcers
stage 1 pressure injury - and what color?
non-blanchable erythema - NOT purple or maroon
fat in diet
should be 20 - 30% - helps spare protein
would you see slough or eschar with arterial vascular disease? (art has a black heart)
black eschar
where are the sores located with venous ulcers?
the ankles
softening necrotic tissue with wet to damp dressing is what type of debridement?
it’s mechanical
flaps
blood supply stays attached to flaps
ex. of Primary Intention - wound healing
clean surgical incision
how long to monitor surgical wound and drains? (wounds in the first 48)
48 hours
