Week 1 Wound Flashcards
Blood changing from a liquid to a gel
Hemostasis
Phases of Healing
Vascular
Contraction of the smooth muscle produces vasoconstriction
Formation of the Platelet Plug
Lesion of the endothelium exposes the collagen fibers platelet adhesion is triggered
Platelets release mediators which further enhance platelet aggregation platelet plug is formed
Coagulation
Fibrin Filaments polymarize red and white blood cells get trapped and blood clot is formed
Inflammation
Response to cellular injury marked by capillary dilatation, leukocytic infiltration, redness, heat, and pain and that serves as a mechanism of initiating the elimination of noxious agents and damaged tissue.
Stages of healing
Mast Cells Histamine
Initiation- Prostaglandins - Leukotrienes- Class switching Lipoxins- Termination
Proliferation
Rapid increase in reproduction of new cells
Granulation
Formation of new connective tissue and blood vessels on surface of a wound = result proliferation
Phases of Healing
Hemostasis
Blood Clot
Inflammatory
Fibroblasts
Macrophages
Proliferative
Fibroblasts proliferating
Subcutaneous Fat
Remodeling
Freshly healed epidermis and dermis
Pressure Injury
Localized Damage to the skin and underlying soft tissue
Usually over a bony prominence or related to a medical or other device
Injury can be present as intact skin or as open ulcer
May be painful
Common places for pressure ulcers
Head
Shoulder
Sacrum
Heel
Pressure sore forms when pressure forces a bony prominence to compress underlying soft tissue.
Stage 1
Area is reddish and may be hard and warm
No skin lost
Stage 2
Sore extends into, but not through the skin layers. Skin partially lost.
Stage 3
Skin Layers are completely lost. Necrosis of subcutaneous tissue may extend to but not through the fascia.
Stage 4
Necrosis beyond the fascia causing extensive damage to muscle and bone
Pressure and Shear is affected by what?
Microclimate
Nutrition
Perfusion
Co morbidities
Condition of soft tissue
Which agency has elements for pressure ulcers?
JACO
Use nursing skills and judgement and write care plan to prevent them as well.
Blanchable Redness
Not staged or considered a pressure ulcer
Warning sign to stage 1
Pressing on reddened area and skin becomes white for at least a brief period of time
Stage 1
Non blanchable erythema of intact skin
Intact skin with a localized area of non blanchable erythema. May be different in darker pigmented skin
Presence on blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes.
Color changes do NOT include purple or maroon discoloration; these may indicate deep tissue pressure injury
Stage 2
Pressure injury. Partial Thickness skin loss with exposed dermis
Wound bed is viable pink or red with blisters. Adipose not visible and deeper tissues are not visible.
No granulation eschar and slough
Injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel
Stage 2 should not be used to describe what?
MASD
IAD
ITD
MARSI
Traumatic Wounds- Skin tears, burns, and abrasions
Stage 3
Full Thickness loss
Adipose visible
and granulation and epibole is present are often present
epibole is rolled wound edges
Depth of tissue damage depends on anatomical position
Muscle or bone not exposed
If slough and eschar obscures the extent of tissue loss this is…
Unstageable Pressure Injury
Stage 4
Full Thickness skin and tissue Loss
Exposed bone muscle tendon or cartilage
Slough and eschar may be visible
Rolled edges and tunneling often occur
Slough obscures the extent of the tissue loss this is unstageable injury
Unstageable
Slough and eschar are covering the stages of 3 and 4
Obscured full thickness and tissue loss
Stable Eschar
Dry adherent intact without erythema or flatulence on the heel or ischemic limb should not be softened or removed
DTI
Deep Tissue Pressure Injury
Persistent nonblanch deep red, maroon or purple discoloration
Blood filled blister with deep red or purple color
Pain and temperature often precede skin color changes
Injury results from intense or prolonged pressure and shear forces at the bone muscle interface.
Wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss
If necrotic tissue, subq, granulation, fascia, muscle, or other underlying tissues indicates what?
Unstageable Stage 3 or 4
Do not use DTPI to describe vascular, traumatic, neuropathic, or derm conditions
Tunneling
Patient head = 12 oclock
Sanguineous
Thin, bright, red
Serosanguineous
Thin, watery, clear pale red to pink
Serous
Thin, watery clear
Purulent
Thick, opaque tan to yellow
Foul Purulent
Thick opaque yellow to green with offensive odor
Amount of Wound- None
Wound Tissues dry
Scant
Wound tissues very moist, drainage
25% dressing
Small = wound tissues wet, drainage
Less than 25%
Moderate
Wound tissues wet, drainage involves 25 to 75% dressing
Large = Wound tissues filled with
Fluids above 75%
Nonadherent
Easily separated from wound base; loosely adherent = pulls away from wound, but attached to the wound base.
Firmly Adherent
Does not pull away from wound
Slough
usually lighter in color, thinner and stringy in consistency can be yellow, gray, white, green, and brown
Eschar
Usually darker in color, thicker and hard consistency black or brown color.
Granulation Tissue
Beefy Red, granular, bubbly in appearance should be differentiated from a smooth red wound bed color of tissue or full dusky
Epithelialization
Appear as deep pink, then pearly/ pink and light purple from the edges in full thickness wound or may form islands in the wound base with superficial wounds
Foreign Bodies
Wound Edges
Defined or undefined edges attachment
Rolled under
Epibole
Macerated softened by liquid
Fibrotic
Fibrous connective tissue present
Callused Hardened
Border round shaped, square, and irregular
Surrounding Tissue
Color
edema
Firmness
Intact
Induration
Pallor
lesions
texture
scar
rash staining
mositure
Indicators of Infection
Fever
streaking
redness
Increased drainage
odor
warmth
elevated WBC
induration
malaise
edema
weeping
Increased pain
Discoloration
Tubes or Drains
NC NG tube Foley Catheter Rrectal Tube ET tube PEG Tube
Wound Management
Nursing Assessment
Evaluate Mobility
Evaluate Circulatory Status
Evaluate Neurologic status
Evaluate Nutrition, hydration
Braden Scale
What are risk Factors for developing pressure ulcers?
Immobility
Impaired sensory perception or cognition
Decreased tissue perfusion
Decreased nutritional status
Friction, shear
Increased moisture
Braden Scale
Scores patient by:
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction and Shear
Lower the score means higher chance of developing a pressure sore
6 is lowest.
20 is highest
Braden Risk Assessment Scale
6 to 23
Lower score - Higher risk
Higher score- Less risk
Wound Healing
Nursing Interventions
Mobilize the client
Nutrition
Hydrate
Hygiene
Monitor Skin
Dressing Changes
Irrigation
Use of solution to provide turbulence to wound to promote hydration, removal of deep debris and allow for visualization of wound.
Debridement
Removal of unhealthy tissue from a wound to promote healing
Surgical and Santyl - Enzyme Debridement
Dressing
Sterile covering to promote wound healing by protecting the wound from further harm
Hydrocolloid
Used for burns
Light to moderate draining wounds , necrotic wounds, under comprrssion wraps, pressue ulcers, and venous ulcers
Hydrogel
Used for wounds with little to no excess of fluids, painful wounds, necrotic wounds, pressure ulcers, donor sites
2nd degree or higher burns and infected wounds
Aliginate used for moderate to high amounts of wound drainage, venous ulcers, packing wounds, and pressure ulcers in stage 3 or 4.
True
Collagen
Used for chronic or stalled wounds, ulcers, bed sores, transplant sites, surgical wounds, second degree or higher burns and wounds with large surface areas
Negative Pressure Wound Therapy
Using vacuum dressing to enhance and promote wound healing
Use of Foam Dressing
Used for first and second degree burns, chronic wounds, diabetic, venous, arterial and pressure ulcers, wounds suffering excessive drainage, acute or surgical wounds at risk for suffering isolation
Name of Different Wound Therapies
Foam Dressing with Negative Pressure
Compression Dressing
Pressure Dressings
Optimal Nutrition
Royal Jelly
Probiotics
Skin Grafts
Maggots
Hyperbaric Oxygen Therapy
Acupuncture
Hydrogels
Wound Therapy Experimentations
Nanoparticle Therapy
Laser
Silk Wound Care Mats
Self Repairing Material
Bamboo Wound Care Dressings
Q Peptide Scar Reducing Compound
Nanofiber Devices
Stem Cells
Dehiscence
Wound Rupture along surgical incision
Caused by poor stitching, diabetes, obesity, Ehlers- Danlos syndrome, picking at surgical incision
Evisceration
Ejection or exposure of viscera (internal organs)
Ways to Prevent Ulcers
Improve Nutrition
Improve mobility
Improve Sensory Perception
Improve Tissue Perfusion
Reduce pressure, friction, and shear
Repositioning
Minimize Moisture
Nursing Diagnosis
Acute Pain
Impaired Skin Integrity
Disturbed Body Image
Deficient Fluid Volume
Deficient Knowledge
Superficial
Epidermis layer
Dry Red and blanches to touch
3-6 days healing
None
Superficial Partial Thickness
Epidermis and upper portion of dermis
Moist blisters, blanches to touch
7-20 days
Potential pigment changes
Deep Partial Thickness
Epidermis and most dermis, blood capillaries are destroyed; most hair follicles and nerves remain intact
Blisters; wet or waxy dry, variable colors does not blanch with pressure
More than 21 days
Scarring, risk for contractures
Full Thickness
Epidermis, subcutaneous, and dermis
Waxy, charred or translucent color
Pain due to adjacent areas
Will not heal if more than 2% off body surface is affected
Severe scarring, high risk for contracture
Rules of Nines
Measurement of % of affected surface area
Assists in determining fluid replacement
Face/ Scalp or Back of Head
4.5
Ant RUE and Post LUE
4.5
Abdomen or Buttocks
9
ANT RLE LLE or Post LLE RLE
9
Parkland Formula
LR
4ml/ kg/ %TBSA Burn
Treatment
Pain Management
Fluid and Electrolyte Replacement
Antimicrobial Ointments
Silver Compounds
Wound Debridement Skin Grafts
Psychosocial Support
Brooke
LR
1.5 ml/ kg/ % TBSA BURN
Colloid
0.5 ml/ kg/% TBSA BURN
