Tissue Integrity Part 2 Flashcards
what is convection
transfer of heat
what is primary intention
wound margins are well approximated (opposing edges are together)
laceration and surgical incision
has most rapid healing
what is secondary intention
infected wounds or wound margins are not well approximated
larger wound area requires formation of granulation tissue to fill gap
longer time to heal
what is tertiary intention
associated w/ large infected and contaminated wounds
how do you treat a primary intention wound
edges brought together by sutures
no granulation tissue seen w/ healing
short healing period w/ minimal tissue loss
clean wound
how do you treat a secondary intention wound
packed w/ gauze
surgical wound left open to heal by scar formation
primary intention is not possible due to tissue damage/loss (trauma)
wound is allowed to granulate
what is needed for a wound to heal
o2 and nutrients
what is thrid intention used for
manages heavily infected or contaminated wounds
left open
granulation tissue
what are the 3 phases of wound healing
inflammatory phase
granulation phase
maturation phase
what happens in the inflammatory phase
lasts 3-5 days
homeostatis develops- macrophages remove debris
what happens in the granulation phase
lasts 5-21 days
new bvs and tissue are formed
what happens in the maturation phase
lasts for months
collagen fiber is remodeled- scar formation and contraction occur
what populations are at higher risk for impaired tissue integrity
infants
children
older adults
what does macerated mean
excess moisture- wrinkly skin after shower
what is cleansing
removal of debris and exudate
what do you use to irrigate
normal saline
if you have drainage what dressing do you apply
absorbant dressing
why do diabetic foot uclers occur
sensory neuropathy
peri vascular disease (poor circulation)
immunocompromised (hyperglycemia impairs ability for leukocytes to destroy bacteria)
what is the developemnt of diabetic foot ulcers
soft tissue injury- skin breakdown btwn toes, areas of dry skin, or formation of callus
unable to feel pain- injuries from cutting nails, foreign objects, or ill-fitting shoes
cant feel temp
unaware of pressure
what are the clinical signs of diabetic foot ulcer
drainage
swelling
redness of leg
gangrene
what is the treatment for diabetic foot ulcers
keep pt off of feet
control bgl
antibiotics
debridement
what are some risk factors for diabetic foot ulcers
diabetes for more than 5 years
age over 40
smoking
decreased peripheral pulses
decreased sensation
anatomic deformities or pressure areas
hx of foot ulcers or amputations
how do you manage diabetic foot ulcers
feet examined at least once a yr
assess for neuropathy
pressure areas (calluses or thick toenails) treated by podiatrist
routine nail trimming by podiatrist
monitoring and managing bgl
what are nursing management for diabetic foot ulcers
foot assessment at each encounter
educating on well fitting shoes, wearing same shoes for no more than 2 days in a row, never go barefoot, check feet daily, no lotion btwn toes, check bath water w/ hands
