Skin Integrity And Wound Care Flashcards
Classification of pressure ulcers
Stage one non-blanchable redness of intact skin. Stage two partial thickness skin loss or blister. Stage III full thickness skin loss, fat visible. Stage for full thickness tissue loss, muscle or bone visible. Unstageable or unclassified is full thickness skin or tissue loss, depth unknown. Suspected deep tissue injury is depth unknown.
Granulation tissue
Red, moist tissue composed of new blood cells, the presence of which indicates progression toward healing.
Slough
Soft yellow or white tissue is characteristic of this. Stringy substance attached to wound bed. Must be removed by skilled clinician before the wound is able to heal.
Eschar
Black or brown necrotic tissue. Needs to be removed before healing can proceed.
How to measure wound depth
Measure by using a cotton tipped applicator are in the wound bed
Exudate (wound)
Should describe the amount, color, consistency, and order of wound drainage and is part of the wound assessment
Wound classification
Primary intention, is a wound that is closed, such as a surgical incision. Risk of infection is low, healing occurs quickly with minimal scar formation.
Secondary intention, is a wound with edges not approximated, such as a pressure ulcer. Wound is left open until it becomes filled by scar tissue. It takes longer for a wound to heal, that’s the chance of infection is greater.
Partial-thickness wound
Shallow wounds involving loss of epidermis and possibly partial loss of dermis. Heal by regeneration.
Full-thickness wounds
Extend into dermis and heal by scar formation. Do not regenerate.
Partial thickness wound repair steps
- Inflammatory response
- Epithelial proliferation
- Migration
- Re establishment of the epidermal layers
Full thickness wound repair steps
- Hemostasis
- Inflammatory
- Proliferative
- Remodeling
Acute wound
Proceeds through an orderly and timely repair to process that results in sustained restoration of anatomical in functional integrity
Chronic wound
Fails to proceed through in orderly and timely process to produce anatomical and functional integrity
Complications of wound healing
- hemorrhage
- infection
- dehiscence
- evisceration
Hemorrhage
Bleeding from a wound site, although normal during and immediately after initial trauma, can also occur after hemostasis, either externally or internally.
Wound infection
The second most common healthcare associated infection. It wound is infected if purulent material drains from it.
Dehiscence
The partial or total separation of wound layers, this most commonly occurs before collagen formation.
Evisceration
Protrusion of visceral organs through a wound opening, causing total separation of wound layers.
Considerations for the Braden scale.
Sensory perception, moisture, activity, mobility, nutrition, friction and shear.
Factors influencing pressure ulcer formation and wound healing
Sheer force, friction, moisture, nutrition, tissue perfusion, infection, and age.
Risk factors for pressure ulcer development
In paired sensory perception, impaired mobility, alteration in level of consciousness, shear, friction, and moisture.
