POD 2 Flashcards
3 layers of skin
- epidermis
-dermis - subcutaneous
epidermis
outermost layer of skin on your body. It protects your body from harm, keeps your body hydrated, produces new skin cells and contains melanin
dermis
middle layer of skin in your body. It has many different purposes, including protecting your body from harm, supporting your epidermis, feeling different sensations and producing sweat and hair.
hypodermis
storing energy, connecting the dermis layer of your skin to your muscles and bones, insulating your body and protecting your body from harm
wound is
- disruption of integrity and function of tissue in body
- causes cells that would normally be connected to become separated (not all equal & therefore treatment varies)
wound healing is
complex and ordered sequence of biochemical events that occur in response to tissue injury and leads to tissue repair
tissue layers involved & their capacity for regeneration determine the mechanism of repair of any wound
2 types of wound healing
- primary intention
- secondary intention
primary intention is
tissue edges are brought together (approximated) or closed with sutures, staples, or steri-strips & minimal or no tissue loss
does primary intention have minimal granulation tissue or scarring
YES
primary intention has minimal risk of
infection or deficits
with primary intention does healing occur quickly or slowly
QUICK
examples of primary intention
lacerations, punctures, thermal burns, blisters, surgical incisions
secondary intention is
wound edges are unable to be approximated & involves loss of tissue
with secondary intention, how does the wound heal
it is left open until it fills with scar tissue & occurs from bottom up & from outer edges toward the centre
secondary intention there is an increase in
infection & more likely to scar
secondary intention examples
pressure ulcers
wound healing is divided into 3 phases
inflammatory phase, proliferative phase, maturation phase
inflammatory phase
- commences as soon as tissue integrity is disrupted by injury; this begins the coagulation cascade to limit bleeding
duration of inflammatory phase
0-14 days
wounds closed by primary intention = lasts 4 days
inflammatory phase is characterized by
erythema, edema, pain
proliferative phase
begins as the cells that migrate to site of injury (fibroblasts, epithelial cells, vascular endothelial cells)
fibroblas proliferation stimulated by macrophage-released growth factors
during the proliferative phase, what kind of tissue is started
granulation
duration of proliferative phase
4-42 days
maturation phase
collagen degradation, and collagen remodeling
duration of maturation phase
24 days -18months
scar tissue formation occurs during which stage
maturation
what is the #1 enemy of surgical wound
INFECTION
local symptoms of infection
- redness
-induration - swelling
- pain
change in exudate
systemic symptoms of infection
- fever
- elevated WBC
- diaphoresis
- decreased energy
internal hemorrhage
presenting as distention, swelling, pallor, diaphoresis combined with tachycardia & low BP
external hemorrhage
copious amounts of sanguineous drainage on dressings, into drains or out of orifices combined with tachycardia, and low BP
what do you need to do with hemorrhage
assess vital signs
apply pressure dressings
inform dr STAT
hematoma
localized collection of blood underneath tissues
hematoma appears as
swelling, change in colour, change in sensation or warmth or as mass with blue colour
hematomas should be monitored for
increasing size & outlined with pen for observation
hematomas may ne reabsorbed by body or drained by dr
TRUE
dehiscence
partial or total separation of would layers
monitor for dehiscence by ..
looking at wound approximation & increased serosanguinous drainage
to prevent dehiscence, teach pateints how to
splint when doing deep breathing & coughing exercises to help stabilize incisions
evisceration
protrusion of internal viscera through incision
requires emergent surgical erpair
nursing responsibilities for evisceration
place sterile over organs (abdo pads soaked in warmed normal saline & notify the dr STAT)
fistulas are
abnormal passages between 2 organs or between an organ and outside of body
most fistulas form as a result of
poor wound healing or complications of disease
fistulas are difficult to treat surgically due to
increased risk of developing further fistulas
treatment for fistulas are
resting the gut (NPO), IV nutrition (TPN), surgery
intrinsic factors that affect healing
diabetes, cancer, renal disease, liver disease, obesity, impaired immune system, age of the patient
extrinsic factors that affect healing
malnutrition, tobacco use, inappropriate use of dressings, stress, medication use (systemic steriod use)
assessment: type of wounds
- pressure ulcers
- diabetic/neuropathic ulcers
- venous stasis ulcers
- arterial / ischemic ulcers
- surgical wounds
- atypical wounds
- fungating / malignant wounds
- burns
assessment: location
- sacral region
- sacroiliac region
- buttock
- coccyx
- hip
- thigh
- ischial tuberosity
- posterior thigh
assessment: wound measurement
- allows the nurse to assess wound healing & adjust treatment plans
when measuring wounds it is essential to measure the wounds:
length, width, depth
undermining is
a separation of tissue from the surface under the edge of wound
accurate measurement of undermining allows the nurse to
treat the wound to optimize healing
undermined areas must
packed appropriately, healing occur from “ground” up (wound bed)
documentation: describing the wound
appearance of wound bed (percentage of granulation tissue visible)
granulation tissue in documentation
red or pink colour with cobblestone like appearance (healing, filling in)
necrotic/non-viable in documentation
slough-yellow, tan dead tissue
eschar-black/brown necrotic tissue, can be hard or soft
serous
clear watery plasma
purulent
thick yellow green tan or brown
serosanguineous
pale red watery, mixture of clear and red fluid
sanguineous
bright red, indicates active bleeding
what else do we document
- exudate
- amount (scant, small, moderate, large, saturated)
- type (serous, sanguineous, purulent)
- odor
- measurements (length, width, depth)
- presence of sutures, staples
- wound approximation
- drains
- condition of surrounding skin (red swelling)
- pain!!
what to do to assess odor of wound
be sure to clean wound well first before assessing odour
dressing changes
- common to reinforce surgical dressings within the first 24hr after surgery to reduce incidences of infections
only sterile objects may be placed on a sterile field
TRUE
a sterile object out of range of vision or below waist level is
considered contaminated
when a sterile surface comes into contact with a wet substance the field is
considered comtaminated
how to do a dressing change
- verify order
- gather equipment
- verify pt
- explain procedure to pt
- assess pt for need of analgesia (admin 30 mins prior)
- set up work space
- open sterile dressing kit by pulling back (furthest away from you) open first
- add sterile items to your sterile field using drop technique
- gloves & remove dressing
- inspect wound (redness, edema, ecchymosis, drainage, approximation)
- cleanse wound from top to bottom & center to outside (clean to dirty) (dry wound with gauze)
- dress wound as per protocol
