TOPIC 4 Flashcards
pressure ulcers
a localized injury to the skin and underlying tissue, usually over a bony prominence. It results from pressure in combination with shear and/or friction.
what are some other names for a pressure ulcer?
Pressure sore, decubitus ulcer, or bed sore
what are the three major elements that cause a pressure ulcer?
pressure intensity (tissue ischemia & blanching)
pressure duration
tissue tolerance
tissue ischemia
If pressure applied over a capillary exceeds normal capillary pressure and the vessel is occluded for a prolonged time
blanching
Blanching occurs when the normal red tones of skin are absent.
pressure duration
Pressure duration assesses low and extended pressures. Low pressures over a prolonged time can cause tissue damage. Extended pressure occludes blood flow and nutrients and contributes to cell death.
tissue tolerance
The ability of tissue to endure pressure depends on the integrity of the tissue and supporting structures.
what assessment is included for a pressure ulcer?
-wound location
-depth of tissue involvement (staging)
-type and approximate percentage of tissue in wound bed
-wound dimensions (if present include sinus tracts and tunneling)
-exudate description (if present odor)
-condition of surrounding skin.
what are the risk factors for a pressure ulcer
-Impaired sensory perception
-Impaired mobility
-Alteration in LOC
-Shear
-Friction
-Moisture
stage I
o Intact skin with nonblanchable redness of a localized area usually over a bony prominence
-Discoloration of the skin, warmth, edema, hardness, or pain may also be present.
stage II
o Partial-thickness skin loss involving epidermis, dermis, or both
-Presenting as a shallow open ulcer with a red pink wound bed, without slough.
-May also present as an intact or open/ruptured serum-filled or serosanguineous filled blister.
-Presents as a shiny or dry shallow ulcer without slough or bruising. Bruising indicates deep tissue injury.
stage III
o Full-thickness tissue loss with visible fat but bone, tendon, or muscle are not exposed.
stage IV
o Full-thickness tissue loss with exposed bone, muscle, or tendon
partial thickness wound
Involves the epidermis and the dermis but does not extend through the dermis to the subcutaneous layer
full thickness wound
the dermis, epidermis, and subcutaneous tissue are penetrated; muscle and bone may be involved
Primary intention wound healing
intentional wounds with minimal tissue loss and well approximated edges. low risk for infection (ex: surgical incision)
secondary intention wound healing
a wound involving loss of tissue, is allowed to remain open and heal by granulation, epithelialization, and contraction - used for dirty wounds, o/w abscess can form, greater risk for infection
Tertiary intention wound healing
o Wound that is left open for several days, then wound edges are approximated
granulation tissue
The tissue that normally forms during the healing of a wound
slough
stringy substance attached to wound bed
eschar
black or brown necrotic tissue
exudate
fluid, such as pus, that leaks out of an infected wound
black wound
o black or brown necrotic tissue is eschar, which also needs to be removed before healing can proceed.
yellow wound
soft yellow or white tissue is characteristic of slough (stringy substance attached to the wound bed), and it must be removed by a skilled clinician before the wound is able to heal
red wound
o Recall that granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates; progression toward healing
wound
a disruption of the integrity and function of tissues in the body.
a partial thickness wound heals by
regeneration
a full thickness wound heals by
forming new tissue (scar)
what are the three components of the partial thickness healing process?
inflammatory response
epithelial proliferation and migration
establishment of the epidermal layers
inflammatory response (partial thickness)
nonspecific defense against infection, characterized by redness, heat, swelling, and pain (generally limited to the next 24 hours)
epithelial proliferation and migration (partial thickness)
Epithelial cells begin to migrate across wound bed soon after wound occurs. Wound left open to air: resurface 6-7 days. Moist wound: resurface 4 days.
reestablishment of the epidermal layers (partial thickness)
The cells slowly reestablish normal thickness and appear as dry, pink tissue.
what are the four phases of the full thickness healing process?
hemostasis
inflammatory
proliferative
maturation
hemostasis (full thickness)
injured blood vessels constrict, and platelets gather to stop bleeding. Clots form a fibrin matrix that later provides a framework for cellular repair
inflammatory (full thickness)
damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and movement/migration of serum and WBCs into the damage tissues
proliferative phase (full thickness)
o Begins with the appearance of new blood vessels as reconstruction progresses and lasts from 3 to 24 days. The main activities during this phase are the filling of the wound with granulation tissue, contraction of the wound, and the resurfacing of the wound by epithelialization
maturation phase (full thickness)
o The final stage of healing, sometimes takes place for more than a year, depending on the depth and extent of the wound. The collagen scar continues to reorganize and gain strength for several months. However, a healed wound usually does not have the tensile strength of the tissue it replaces.
hemorrhage
excessive/profuse Bleeding from a wound site, is normal during and immediately after initial trauma. (Hemorrhage occurs externally or internally.)
hematoma
A localized collection of blood underneath the tissues. It appears as a swelling, change in color, sensation, or warmth that often takes on a bluish discoloration.
wound infection
Infection is present when the microorganisms invade the wound tissues. (Signs of inflammation often present)
dehiscence
partial or total separation of wound layers
Evisceration
With total separation of wound layers, evisceration or protrusion of visceral organs through a wound opening occurs
evisceration is an emergency, so what needs to be done?
Immediately place damp sterile gauze over site, contact the surgical team, do not allow the patient anything by mouth (NPO), observe for signs and symptoms of shock, and prepare the patient for emergency surgery.
What are the s/s of a wound infection?
-Contaminated or traumatic wounds: 2-3 days
-Post op surgical wound: 4-5 days
-Fever, tenderness and pain at wound site
-Elevated WBC count
-Wound edges appear inflamed
-Drainage may be present: odorous and purulent (yellow, green, or brown)
What is the Braden Scale used for?
used to assess pressure ulcer risk
braden scale
Developed based on risk factors in a nursing home population and is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
-lower total score indicates a higher risk for pressure ulcer development.
what are the economic consequences of pressure ulcers
Medicare and Medicaid: no additional reimbursement for care related to stage III and stage IV pressure ulcers that occur during the hospitalization
what are some factors that influence pressure ulcer formation and wound healing?
nutrition
tissue perfusion
infection
age
how many calories a day does a patient need for maintenance of skin and wound healing
1500kcal/day
what nutritional interventions are recommended for wound healing
vitamin A
vitamin C
calories
protein
what is the effect of age on wound healing
increased age affects all phases of wound healing
with in _____ days a normal healing wound resurfaces with epithelial cells and edge close
7-10
what needs to be notes about the character of wound drainage
amount
color
odor
consistency of drainage
serous
clear, watery plasma
sanguineous
bloody drainage
serosanguineous
Pale, red, watery: mixture of clear and red fluid
purulent
producing or containing pus
Hemovac and Jackson-Pratt
exert a constant low pressure as long as the suction device is fully compressed. to as self-suction.
braden scale score
o 9 or less = Very high risk
o 10 - 12 = High risk
o 13 - 14 = Moderate risk
o 15 - 18 = Mild risk
o 19 - 23 = Generally not at risk
o Lower numerical scores on the Braden scale indicate that a patient is at high risk for skin breakdown
what are the three major areas of nursing interventions for prevention of pressure ulcers
· (1) skin care and management of incontinence
· (2) mechanical loading and support devices, which include proper positioning and the use of therapeutic surfaces
· (3) education.
When should skin assessments be conducted
on admission and at least every day (high risk patients need to be checked more often)
what are positioning interventions for
to redistribute pressure and shearing force to the skin
what bed position decreases the chance of pressure ulcer development from shearing forces
30 degrees or less
how often should a client be repositioned
at least every 2 hours
debridement
· removal of nonviable, necrotic tissue. this is necessary to rid the wound of a source of infection, enable visualization wound bed, clean base necessary for healing
Autolytic debridement
uses synthetic dressings wound to allow the eschar to be self-digested e action of enzymes that are present in wound fluids.
Chemical debridement
may use topical enzymes used to changes in the substrate resulting in the breakdown of necrotic tissue.
Surgical debridement
is the removal of devitalized tissue by using a scalpel, scissors, or other sharp instrument.
In an emergency setting, use first aid measures for wound care, they include
stabilizing cardiopulmonary function, promoting hemostasis, cleaning the wound, and protecting it from further injury.
How do you control bleeding?
Control bleeding by applying direct pressure on it with a sterile or clean dressing such as a washcloth.
when a patient has a puncture wound you want to…
allow the puncture wound to bleed (to remove dirt and other contaminants)
When a penetrating object such as a knife blade is present…
do not remove the object. The presence of the object provides pressure and controls some bleeding.
when cleaning a wound
clean from least to most contaminated
use separate swab for each stroke
glean gently and often with normal saline
Intermittent suturing
the surgeon ties each individual suture made in the skin.
Continuous suturing
a series of sutures with only two knots, one at the beginning and one at the end of the suture line.
retention sutures
are placed more deeply than skin sutures, and nurses may or may not remove them, depending on agency policy. The manner in which the suture crosses and penetrates the skin determines the method for removal.
effects of heat application
Improving blood flow to an injured part. Periodic removal and reapplication of local heat restores vasodilation.
effects of cold application
The application of cold initially diminishes swelling and pain. Prolonged exposure of the skin to cold results in a reflex vasodilation.
Warm, moist compresses
improve circulation, relieve edema, and promote consolidation of purulent drainage.
what are the purposes of dressings
-Protects from microorganisms
-Promote homeostasis
-Promotes healing by absorbing drainage or debriding a wound
-Supports wound site
-Promotes thermal insulation
-Provides a moist environment
when applying tape to a wound…
ensure that it adheres to several inches of skin on both sides of the dressing and that it is placed across the middle of the dressing. When securing the dressing, press the tape gently, making sure to exert pressure away from the wound.
what is the first step in packing a wound
assess its size, depth, and shape
negative pressure wound therapy
o NPWT is the application of subatmospheric (negative) pressure to a wound through suction to facilitate healing and collect wound fluid.
o supports wound healing by edema reduction and fluid removal, macro deformation and wound contraction, and micro deformation and mechanical stretch perfusion
gauze
They are absorbent and are especially useful in wounds to wick away wound exudate.
transparent film
This type of dressing traps moisture over a wound, providing a moist environment.
hydrocolloid
They are adhesive and occlusive. The wound contact layer of this dressing forms a gel as wound exudate is absorbed and maintains a moist healing environment.
hydrogel
Hydrogel dressings are gauze or sheet dressings impregnated with water or glycerin-based amorphous gel. This type of dressing hydrates wounds and absorbs small amounts of exudate.
foam dressings
are for wounds with large amounts of exudate and those that need packing.
composite dressings
combine two different dressing types into one dressing
when should analgesic medications be administered before a dressing change
30 to 60 minutes before
wound irrigation
o to flush the area with a constant low-pressure flow of solution. (this will cleanse a wound of exudate and debris.)
oMake sure that fluid flows directly into the wound and not over a contaminated area before entering the wound.(least to most contaminated)
drainage evacuation
Constant, low-pressure vacuum to remove and collect drainage
bandages and binders
Functions: create pressure, immobilize and/or support a wound, reduce or prevent edema, secure a splint, secure dressings
lacerations
a deep cut or tear in skin or flesh.
abrasions
the process of scraping or wearing away.
contusions
A region of injured tissue or skin in which blood capillaries have been ruptured; a bruise
penetrating wounds
Trauma is usually by a sharp and pointed instruments like needles, sticks, pencils, knives, arrows, pens, glass and any object with sharp edges
