tissue integrity and wound care Flashcards
impaired tissue integrity
- reduced perfusion
- pain
- infection
primary intention
tissue/skin is closed
- wound edges are approximated and uncomplicated
secondary intention
wound left open to heal by itself to fill in and close naturally
- left open and wound heals from bottom up
hemostasis
first step of inflammation
process of blood clot formation at the site of injury
inflammatory phase
second step of inflammation
immediate response to trauma; damaged cells and pathogens removed from wound are
- days 0-3
proliferation phase
thirs step of inflammation
wound rebuilt with new granulation tissue composed of collagen and extracellular maxtrix
- days 3-21
maturation phase
fourth step of inflammation
ongoing collagen synthesis to rebuild and strengthen tissue
- day 21 - 2 years
asepsis
keeping microorganisms away; practices that keep area free from microorganisms
- sterile gloves and field, use clean dedicated area
clean technique
medical asepsis; can use non-sterile gloves
most common sites of infection
- wounds
- urinary tract
- respiratory tract
- bloodstream
signs of systemic infection
hypotension, tachycardia, tachypnea, SOB, shivering, diaphoresis
interventions for tissue/wound integrity
- medical treatment for infetion
- lab tests
- collecting specimens
- administer meds
- surgery
hypovolemic shock
decrease in blood volume leading to inadequate filling of vasculature and decreased CO
- d/t hemorrhage, trauma, low intake, vomitting
s/s of hypovolemic shock
- tachycardia
- thirst
- cool peripheries
- hypotension
- low RR
- irritable
complications of hypovolemic shock
- metabolic acidosis
- GI ischemia
- ARDS
cardiogenic shock
ineffective pumping of heart to meet body demands
- low CO, low SBP, hypoperfusion, hypoxia
- may be caused by MI, STEMI
septic shock
due to infection
- severe hypotension, decreased LOC, rapid shallow breathing
superficial burn
- epidermis
- no blister
- painful, dry, red
partial thickness burn
- epidermis and dermis
- blisters
- painful, red, weeping
- can be waxy
full thickness burn
- dermis and subcutaneous tissues
- no blister
- waxy appearance
- no pain or sensation
burn treatment
- cool water for 20 min
- cool compresses
- analgesia
- protect with loose sterile gauze
- hydration
complications with burns
- edema
- hypovolemia
- clotting
- infection
- hypoxia
fat embolism syndrome
complication of fracture; rare; onset in 24-72 hr
- most common in long bone fractures (femur and pelvis)
- fat from marrow enters blood stream
fat embolism s/s and treatment
- dyspnea, hypoxemia, tachypnea, seizure risk, confusion, petechial rash
- treat with supportive care (O2, intubation, fluids)
petechial rash
small red and purple dots clustered
DVT diagnosis
ultrasound
- can use compression stockings to prevent
PE diagnosis
CT
compartment syndrome
increased pressure in enclosed compartment which compromises circulation; fascia unable to stretch
- occurs in soft tissue injuries and fractures
- necrosis can occur after 4 hours
- elevate to level of heart, NOT higher
6 P’s of compartment syndrome
- pain out of proportion to injury (hallmark sign)
- parathesia
- pallor
- pulseless
- paralysis
- temp
stage 1 ulcer
- intact skin
- redness to localized area
- discoloration, warmth, hard
stage 2 ulcer
- partial thickness; shallow open wound bed that is red/pink
- no slough
stage 3 ulcer
- full thickness; subcu fat visible
- some slough present
- tunneling
- usually located on buttocks
stage 4 ulcer
- tissue loss
- exposed bone or tendon
- slough with underminning and/or tunneling
hydrocolloid dressings
minimal-moderate drainage absorption and maintain moist wound envrionment
- provide cushioning
- used for partial/full thickness wounds, stage 2-3 pressure injuries, dry necrosis, dry slough, dry granulation
- do NOT use for infected wounds
hydrogel wound dressings
maintain a moist environment with minimal drainage absorption; do not adhere to wound and require secondary dressing to secure’
- used for partial-full thickness wounds, stage 2-4 pressure injuries, infected and non-infected wounds, dry necrosis, dry slough, dry and deep granulation, epithelializing, first and second degree burns, dry wounds
alginate wound dressings
absorb exudate and maintain moist envrionment; require secondary dressing to secure
- used for wet necrosis, wet slough, wet granulation, partial/full thickness wounds, stage3-4 pressure, infected and non infected, moderate-heavy exudate, tunneling wounds, do NOT use for minimal drainage wounds
foam wound dressings
maintain a moist environment to insulate wound and are highly absorbant
- used for wet necrosis, wet/shallow slough, wet granulation, partial/full thickness wounds, stage 2-4 injuries, surgical wounds, around tubes and drains
antimicrobial wound dressings
anibacterial action to prevent infection and can be highly absorbant
- use for burns, partial/full thickness, stage 2-4 injuries, nonhealing wounds, acute and chronic
