skin integrity and wound healing Flashcards
wound categories
tissue loss: burns, ulcers, lacerations
no tissue loss: surgical incision
primary intention
edges are approximated
low risk of infection
minimal scarring
secondary intention
- edges not approx.
- ulcers
- burns
- high risk of infection
- tissue loss
- severe scarring
tertiary intention
- delayed approx.
- purposely delaying closure to observe for infection or get rid of infection
- let heal from bottom up
- cleaning out
partial thickness wound
- involves epidermis & portions of dermis
- inflammatory for 24 hrs
- moist wound: ab 4 days heal
- dry wound: 6-7 days heal
- thin layer of epithel. slowly reestablishes
full thickness
- destroys all layers of dermis
- vasoconstriction in mins/hrs
- inflammation
- takes days-months to heal
- fibroblasts with granulation tissue to heal
- remodeling: scar tissue healing (can take months to years)
dehiscence
the opening of a previously approximated wound
- at high risk 3-11 days after injury or surgery
hemorrhage
bleeding of a wound
- hematoma: collection of a clot and blood under the skin that causes a solid swollen area
- ecchymosis
evisceration
wound opens and organs come out
- abdominal most common
- call MD stat
- sterile towels soaked in saline to keep moist
fistula formation
- abnormal connections (anastomosis) between a hollow organ and the skin of another hollow organ
- classified according to location
- low output: <200mL/24 hr
- high output: >500mL/24 hr
serous drainage
clear watery plasma
sanguinous drainage
bright red, active bleeding
serosanguinous drainage
mixture of clear plasma fluid and blood (pale pink and watery)
purulent drainage
thick, yellow, green, tan, or brown, odorous
pressure injury
a localized injury to the skin and other underlying tissue usually over a bony prominence as as a result of pressure or pressure in combination with sheet and or friction
two problems causing pressure injury
- no oxygen delivered
- no cellular waste removed
pressure related factors
- intensity
- duration
- tissue tolerance
- skin response to pressure
skin response to pressure
- normal reactive hyperemia
- abnormal: non blanching erythema
- darker skinned patients are exception for no blanching
braden scale
6-23
- low score= high risk
- hiher than 18= low risk
- ability to feel pain and pressure
- moisture
- activity
- mobility
- nutrition
- sheering forces combined with friction
define friction and sheer
friction: the resistance of skin rubbing on sheets
sheer: two things sliding against each other
age related risk factors
- reduced skin elasticity
- decreased amount of collagen
- polypharmacy
- decreased inflammatory response
- malnutrition
pressure injury sites
sacrum
greater trochanters
ischial tuberosities
lateral malleolus
tuberosity of calcaneus
olecranon
tunneling
channel or pathway that extends in any direction from the wound through subq tissue
- use sterile 9” q tip to measure
undermining
tissue destruction underlying the intact skin along the wound margins
slough
- dead non-viable tissue
- yellow, green, or gray
- light, thin, wet, stringy
- remove
eschar
- dead, non-viable
- usually black, brown, or gray
- dark, thick, hard
- leave in place, similar to scab
granulation tissue
- live, viable, good
- beefy red color
epithelial tissue
- live, viable
- deep to pearly pink
- dry
muscle
- highly vascularized
- pink to dark red, striated
periwound skin
skin around the wound
maceration
lighter color of moist skin (technical name for grape fingers)
erythema
redness
cyanosis
poor blood flow
when are wounds staged
once at admission
stage 1
- no blanching erythema of intact skin
- no tissue loss
stage 2
- partial thickness skin loss with exposed dermis
- shallow open ulcer– intact or ruptured blister
- red-pink wound bed
stage 3
- full thickness skin loss
- not seeing bone, tendon, or muscle
- may see epibole
- possible slough, escar, undermining, or tunneling
stage 4
- full thickness skin and tissue loss
- seeing muscle and bone
- often includes epibole, undermining, tunneling
- may include slough or eschar
unstageable/unclassified
- full thickness skin/tissue loss
- unknown depth
- base of wound not visualized d/t slough and eschar
suspected deep tissue injury
- depth unknown
- purple or maroon area of intact skin or blood filled blister
wound vac
assistant in wound closure by applying negative pressure to draw the edges of the wound together
can black foam touch healthy skin?
no, it will cause tissue death
debridement
- the removal of dead, non-viable tissue
mechanical debridement
- wet to dry dressings
- irrigation
- whirlpool
autolytic debridement
- patients own enzymes self digest eschar
- transparent dressing over wound to seal
chemical debridement
- topical enzymes
- dakins solution
- maggot therapy
surgical debridement
sharp instrument used to cut away necrotic tissue
proteins role in wound repair
- growth and repair
most common way to test protein level
serum albumin level
BEST measure of overall nutritional status
prealbumin
vitamin A’s role in wound repair
- helps reduce the negative effects of steroids on wound healing
- carrots are good source
vitamin C’s role in wound repair
- helps synthesize collagen
zinc’s role in wound repair
- epithelialization
- helps synthesize collagen
- nuts are good source
copper’s role in wound repair
- good for collagen fiber linking
- seafood is good source
fluid with highest risk for skin breakdown
GI drainage
fluid with moderate risk for skin breakdown
bile
stool
urine
purulent exudate
fluid with low risk for skin breakdown
slava
serosanguinous drainage
barrier cream
preventative measure for pressure injuries
reposition pt…
- q2h
- lift, dont drag
teach mobile pts to …
reposition q 15 minutes
30 degree lateral position
support surfaces for pressure injury prevention
specialty beds
waffle mattress
mepilex
pressure injury preventative dressing
- piece of foam w sticky dressing
gold standard for wound cultures
tissue biopsy
when collecting specimens for wound cultures…
- clean wound first
- never collect old drainage
benefits of heat therapy
- vasodilation
- helps decrease muscle tension
benefits of cold therapy
- vasoconstriction
- blood vessels take up less space, therefore less pressure
- decrease muscle tension
when to not use hot/cold therapy
if pt cannot feel pain
types of heat therapy
- warm, moist compress
- warm soak
- sitz bath
- hot pack
- heat lamps
warm soak temp range
105-110 degrees F
sitz bath
- for perineal area
- done for 20 minutes
heat lamps
- leave on for about 10 minutes
- should be an arms length away from pt
cold therapy
cold soak
- 59 degrees F
- 20 mins
cold compress
- 20 mins
ice bag or collar
- 30 mins
dressing change: check orders for…
- type of dressing
- cleaning solution
- wound specifics
clean dressing changes
- done with a clean technique
- put on gloves
- remove old dressing
- clean and assess site
- apply new dressing
wound assessment
- OREEDA
- closure
drainage assessment
CCOAL
Color
Consistency
Odor
Amount
Location
types of closures
- sutures
- staples
- steri strips
