Integumentary System Pt. 2 (Exam 3) Flashcards
PROF COURTNEY WOUND CONTENT
TESTABLE MATERIAL
Factors that Affect wound Healing
-Age
-Loss of turgor
-Skin fragility
-Decreased circulation and oxygenation
-Slower tissue regeneration
-Decreased absorption of nutrients
-Decrease in collagen
-Impaired immune functions
-Dehydration
-Decrease WBC count
-Infection
-Medications (Chemo/ Steriods)
-Low hemoglobin levels
-Obesity, smoking, and chronic disease
Three key components of wound management
- Assessment
- Cleansing
- Protection
Wound Assessment: Appearance
Red: Good (want beefy)
Yellow: (Slough- dead cells accumulate in wound exudate) (Could mean we are staying in inflammatory stage)
Black: Eschar (Dead tissue) (needs to be removed)
Wound Assessment: Length, Width, and Depth
-Track progression (pictures)
-Can tell if it is worsening
-Use sterile q-tip to see if it tunneling
Wound Assessment: Closed Wounds
-Skin edges should be well approximated (Back together)
-Note drains tubes
-Note pain
Wound Measurement
-Made in CM
-First measurement: Head to toe
-Second measurement: side to side
-Third measurement: Depth
Note: tunneling and undermining on clock position
12 O-clock is at patients head.
Wound Drainage
-Results of the healing process: can be normal or abnormal
-Accumulates during the inflammatory and proliferative phases of healing
Wound Drainage: Document/note
-Amount of drainage, oder, consistency, and color of drainage from drain or on the dressing
-Note integrity of the surrounding skin
For accurate Measurement
Weigh the dressing
-1g = 1 ml of drainage
-Often just say : scant, moderate, large, copious
Wound Drainage: Exudate
-Serous: Portion of blood (serum) that is watery and clean or slightly yellow
-Sanguineous: Serum and red blood cells. Thick and appears reddish. Brighter indicates active bleeding. Darker indicates older bleeding.
-Serousanguinous- contains serum and blood. watery, looks pale/pink
-Purulent: Result of infection; thick, contains, WBC’s, tissue debris, and bacteria (foul smelling)
Nursing interventions: Patients with wounds
-Adequate hydration and nutrition
-High protein, carbohydrates and vitamins
-Monitor albumin and pre-albumin levels
Nursing interventions for Patients with wounds
-Remove sutures and staples as ordered (7x-10 days)
-Administer analgesics and monitor for pain
-Administer antimicrobials as order and monitor effectiveness
-Document well
Wound Dressings: Woven Gauze (Sponges)
-Absorb and pull exudate from wound
Wound Dressing: Non-adherent material
-Doesn’t stick
-Use if changing frequently
-Good because doesnt hurt skin around wound
Wound dressings: Wet-to-dry
-Used to mechanically debride a wound until granulation tissue starts to form
-4x4’s
-Moist wound bed is a good thing (If clean)
Wound dressing: Self adhesive / transparent
-Tegaderm
-Be weary: Can cause more damage than good
Wound dressing: Hydrocolloid
-Occlusive dressing that swells in presence of exudate (Duoderm)
-Maintain moist environment and pull off to much drainage
-Stay in place for 3 days and do need to be changed if there is to much exudate
Wound Dressings: Hydrogel
Mostly water, gels after contact with exudate, promotes autolytic debridement, rehydrates and fells dead space
-May need a secondary occlusive dressing
-For infected, deep wounds or necrotic tissue
-Not for wounds that are draining a lot
-Provides moist wound bed and can reduce pain and prevent skin breakdown in high pressure areas
Wound Dressing: Alginate
Non adherent dressing that conform to wound shape and absorb exudate
Wound dressing: Collagen
-Powder, pastes, granules, gels, and pastes
-Stop bleeding and promote healing
Vacuum-Assisted Closure System: Wound Vacs
-Use of foam strips into the wound bed with occlusive dressing – Creates negative pressure to occur once the tubing is connected
-Helps with tissue generation, decrease swelling, and enhance healing in moist, protective environment
Surgical Wound Problem: Hemorrhage
-Greatest risk 24-48
-Can be caused by clot dislodgment, slipped culture, or blood vessel damage
-Internal bleeding may present with swelling, distention in area and may cause sanguineous drainage (subtle change in VS)
-Hematoma is a local area of blood collection that appears as red or blue bruise
-Wound hemorrhage can be an emergency –> apply pressure dressing, notify provider and monitor vital signs
Surgical Wound Problems: Dehiscence
-Partial or total rupture of a sutured wound, usually with a separation of underlying skin layers
-3-11 days after surgery
-Small wet-to-dry dressing
Surgical Wound Problem: Eviscertaion
-A dehiscence that involves the protrusion of visceral organs through wound opening
Evisceration Manifestations
-Significant increase in flow of serosanguionus fluid on the wound dressing
-Immediate history of sudden straining
-Patient reports of a sudden change or popping or giving way in wound area
-Visualization of viscera
Risk factors for Dehiscence and Evisceration
-Chronic disease
-Advanced age
-Obesity
-Invasive cancer
-Vomiiting
-Dehydration
-Ineffective suturing
-Abdominal surgery
-Infection
Dehiscence/Eviisceration: Nursing Management
-Notify provider immediately due to need for surgical intervention
-Stay with the patient
-Cover wound and any protruding organ with sterile towels or sterile dressing (gauze) soaked with sterile normal saline. (Do not reinsert organs)
-Postion patient supine with hips and knees bent
-Maintain calm environment
-Keep patient NPO in prep for returning to surgery
Infection and Surgical Wounds: Manifestation
-2-11 days after injury or surgery
-Pain
-Redness, edema, and purulent drainage
-Fever and chills
-Odor
-Increased pulse and respiratory rate
-Increase WBC
