Week 9 - Integumentary Health Flashcards
Inflammation
- Inflammation: a protective biological response to injury or infection
- Goal: eliminate the initial cause of cell injury, clear out damaged cells & tissues, & initiate repair
- Required to maintain homeostasis & prevent further damage
Signs and Symptoms of Inflammation
Local Manifestations
- Redness (rubor)
- Heat
- Swelling
- Pain
- Loss of function
- Exudate
Systemic Manifestations
- Malaise
- Increased HR & RR
- Fever
- Nausea
Vascular VS. Cellular Response Inflammatory Process
Vascular Response
→ Vasodilation: Increases blood flow to the affected area
redness, heat
→ Increased Permeability: Allows immune cells, proteins, nutrients to enter the tissue swelling
Cellular Response
→ Leukocyte activation (white blood cells)
→ Neutrophils: First responders, phagocytize pathogens & debris
→ Macrophages: Continue
phagocytosis, release cytokines to recruit additional immune cells
→ Lymphocytes: T cells kill infected cells, B cells make antibodies, long term immunity
Chemical Mediators of Inflammation
Histamine:
→ Released by mast cells, causes vasodilation & increased vascular permeability
Prostaglandins:
→ Produced by various cells, contribute to vasodilation, pain, & fever
Cytokines:
→ Such as interleukins & tumor necrosis factor (TNF), modulate the activity of immune cells & promote inflammation
Types of Inflammation
Acute
→ Rapid onset, short duration (minutes to days)
→ Characterized by classic signs of inflammation
→ Usually resolves once the harmful stimulus is removed
Chronic
→ Prolonged duration (weeks to years)
→ Often involves ongoing tissue destruction & repair
→ Can lead to conditions such as fibrosis & granuloma formation
Outcomes of Acute Inflammation
→ Resolution: Complete healing without any residual damage
→ Fibrosis: Scar formation
→ Chronic Inflammation: Persistent inflammation leading to tissue damage
→ Outcome depends on severity of injury, effectiveness of inflammatory response, & ability of tissue to regenerate
What is a Wound?
- A break or disruption in the integrity of the skin & underlying tissues
Classified by:
→ Cause (Surgical, Traumatic/non-surgical)
→ Underlying pathology (vascular, pressure, diabetes-related)
→ Duration (acute, chronic)
→ Depth (Superficial, Partial Thickness, Full Thickness)
Wound Classification
Primary Intention
→ Healing when the wound edge is well approximated
Secondary Intention
→ Wounds with wider wound margins that cannot be approximated
→ Slower to heal and greater risk of infection
→ Eg pressure ulcers
Tertiary Intention
→ AKA delyaed primary intention
→ Wound intentionally left open and later closed surgically
→ Eg wounds with infection, edema and poor circulation
Factors Affecting Wound Healing
Local factors
→ Oxygenation
→ Infection
→ Moistire
Systemic Factors
→ Age
→ Nutrition
→ Chromic diseases
Patient related factors
→ Smoking
→ Medication
→ Stress
Phases of Wound Healing
1) Inflammatory (Initial) Phase
2) Proliferative (Granulation) Phase
3) Maturation Phase
Inflammatory Phase
- Lasts 3-5 days
- Platelets begin the process of controlling bleeding + clot formation
- Removal of debris & pathogens from wound site
- Immune cells, such as neutrophils & macrophages, recruited to area to perform
phagocytosis & release cytokines that promote inflammation & attract additional immune cells - Crucial for preventing infection & setting stage for tissue repair
Proliferative Phase
- Lasts from 5 days to 3 weeks
- New tissue forms, angiogenesis occurs to restore blood supply to wound
- Fibroblasts produce collagen & extracellular matrix granulation tissue
- Granulation tissue fills wound, provides foundation for new tissue growth
- Formation of new blood vessels to supply nutrients & oxygen to healing tissue
- Epithelial cells cover the wound
Maturation Phase
- Takes months to years
- Remodelling & scar contraction occur
- A mature scar will be essentially avascular & pale
Healing by Secondary or Tertiary Intention
- Heal from base (bottom) up & inward
What is the big risk with these types of wounds?
Wound Assessment
Primary
- Anatomical location & type
- Size (length, width, depth)
- Shape (round, etc.)
- Exudate (serous, sanguinous,
serosanguinous, purulent) - Surrounding skin/peri-wound
(intact, edema, temperature,
discolouration) - Signs/symptoms of infection
(swelling, new/worse drainage,
fever, leukocytosis)
Secondary
- Wound bed (granulation,
slough, eschar)
- Odour
- Undermining/tunneling
- Necrosis
- Discomfort (pain)
Types of Exudate
Serous
→ Results from fluid that has low cell and protein content; seen in early stages of inflammation or when injury is mild
→ ex. Skin blisters
Serosanguinous
→Found during the midpoint in healing after surgery or tissue injury
→Composed of RBCs &
serous fluid, which is semi-clear pink and may
have red streaks.
→ex. A few days post-op
from major surgery
Sanguinous
→ Fresh blood that leaks from a wound, often seen
in deeper wounds.
→It can be a normal part of the inflammatory stage but may indicate trauma if it
appears outside of this stage
→ex. Deep cut, immediate
post-op surgery
Purulent (Pus)
→ Consists of WBCs, microorganisms (dead and
alive), liquefied dead cells, other debris
ex. Abscess, infection
What is observed in a wound bed?
1) granulation - ew, healthy pink or red tissue with bumpy, cobblestone-like appearance
2) necrosis - dead tissue
3) slough - yellowish, moist, stringy, or thick, dead tissue
Why is a thorough wound assessment important?
- Monitor Healing process
- Identify complications early
- Adjust treatment plans as needed
- Develop an effective wound care plan
What would you assess to determine if a wound is healing as expected?
Primary intention
→ Minimal redness and swelling
→ Reduction in the amount of draignage
→ Drainage is becoming more serious
→ Wound edges are well approximated
→ Minimal pain/ decreasing
Secondary intention
→ Granulation tissue formation
→ Reduction in wound size
→ Minmal exudate
→ Epithelialization
→ No signs of infection (ex redness, swelling)
What changes in a wound would a nurse report?
Concerning Finding
1) Redness, swelling, purulent drainage, fever and persistent or increased pain
→ due to infection
2) red streaks extending outward from wound
→ due to lymphagitis
3) wound rmeians unchanged over time
→ due to delayed healing
4) new or worsening sanginous drainage
→ due to bleeding/hemmorrhage
5) visible seperation of wound edges
→ dehiscence
Sterile vs. Clean Dressings
Sterile Dressings
→ Requires a completely sterile
environment
→ Ex. Surgical wounds, wounds with exposed bone, central line dressings, burns
Clean Dressings
→ Used for less critical wounds
→ Approach emphasizes
cleanliness but does not require a completely sterile environment
→ Ex. Diabetic foot ulcers, some pressure ulcers, minor cuts & abrasions, skin tears
General Principles of Wound Management: Primary Intention
- Remove the old dressing as per order
→ Initial dressing often left in place & reinforced for first 48 hours post-op - Assess wound closure & closure devices (sutures, staples, etc.)
→ Count #, look at wound approximation - Gently clean the wound and periwound (as ordered)
→ Often with sterile normal saline - Apply a simple protective dressing to keep wound clean & dry (as ordered)
→ Often gauze & tape - Monitor for complications
Dressing Types and Their Uses
Gauze Dressings:
→ Versatile, used for packing or covering wounds
→ Minimal absorption
Nonadherent Dressings:
→ Minimally absorbent; used in minor wounds and skin tears
→ Ex. Adaptic, Inadine
Transparent film
→ Semipermeable, minimal
absorption, used for dry wounds with minimal drainage
→ Ex. Tegaderm
Hydrocolloid Dressings:
→ Provide a moist environment,
suitable for wounds with
minimal to moderate exudate
→ Ex. Tegasorb
Foam Dressings:
→ Highly absorbent, used for
wounds with moderate to
heavy exudate
→ Ex. Tegaderm Foam
General Principles of Wound Management: Secondary
Intention
- Remove the old dressing as ordered
- Assess wound bed & tissue type
- Gently clean the wound & periwound skin (as ordered)
→ Often with sterile normal saline
→ May require irrigation of the wound bed or debridement of dead tissue
(advanced skill) - Pack the wound (as ordered) & apply a protective dressing
→ Wound is typically packed with moist gauze & covered with a simple dressing – however, this depends on the type of wound - Monitor for complications
Packing A Wound
- Use the correct material to pack
(often gauze) - Fill the entire wound depth
- Pack loosely
- Maintain moisture balance
Wound Management
- Red’ Wound (granulation tissue)
- ‘Yellow’ Wound (slough tissue)
- ‘Black’ Wound (eschar tissue)
Debridement
Debridement:
→ Removal of necrotic tissue
→ Surgical, mechanical, autolytic, enzymatic
→ Wound debridement is an advanced skill that requires
additional training
Moisture Balance:
→ Moist wound bed & dry periwound
→ Prevent desiccation or maceration
Negative Pressure Wound Therapy (NPWT)
- Uses a vacuum to promote wound healing by removing exudate and reducing edema
Proper Wound Management
- Complete a detailed assessment of the wound & interpret whether findings are expected (appropriate) or indicative of a potential
complication - Cleaning the wound with the ordered solution (often, sterile saline)
- Choosing the appropriate dressings based on the wound’s characteristics
→ The type of dressing is often ordered – nurses need to make sure this is still appropriate based on their wound assessment - Address underlying factors affecting healing
Drainage Evacuation
Closed Drains
→ JP drains
→ Hemovac Drains
Open Drains
→ Penrose
Nursing Role: Drain Assessment & Management
Drain Assessment
→ Type of Drain
→ Insertion site (look for proper securement & signs of infection)
→ Dressing dry and intact (if present)
→ Patency (not kinked, blocked, or dislodged)
→ Suction is properly engaged (closed drain)
Drain Management
→ Measure the volume of drainage hourly immediately post op, then as ordered
→ Record output on fluid balance record
→ Assess drainage for colour, consistency, amount, odour
Patient Education to Promote Wound Healing
Nutrition
→ Proteins, vitamins A, C, zinc, iron important for tissue repair & immune function
→ Recommendations: Encourage a balanced diet with plenty of fruits, vegetables, lean proteins, & whole grains (eggs, nuts,
chicken, broccoli, fish)
Smoking
→ Smoking impairs blood flow, reduces oxygen delivery to tissues, delays wound healing
→ Advice: Encourage smoking cessation to improve healing. Even quitting for a few weeks before & after surgery can significantly reduce complications.
Hydration
→ Proper hydration supports cellular function & nutrient transport
→ Encourage drinking at least 8-10 cups of water daily and consuming water-rich foods like fruits & vegetables
Deep Breathing & Coughing
→ Help clear the lungs, reduce the risk of pneumonia, improve oxygenation, which is vital for healing
→ Perform DB&C exercises regularly, especially after surgery splint the wound to reduce pain & support incision
Mobility
→ Movement improves circulation & reduces pressure on wounds
→ Encourage gentle, regular movement and physical therapy as appropriate. Avoid prolonged immobility
Complications of Wound Healing
1) Infection
Nursing Interventions:
2) Sepsis
Nursing Interventions:
3) Dehiscence
Nursing Interventions:
Other Complications of Wound Healing
Hypertrophic Scars & Keloids
→ Hypertrophic scars remain
within the boundaries of the
original wound
→ Keloids extend beyond the
wound edges
Hemorrhage
→Caused by suture failure, clotting abnormalities, infection, or erosion of a blood vessel
Fistula Formation
→ An abnormal passage that forms between 2 organs or vessels, or between an organ & the skin
Pressure Injuries
- A localized injury to the skin or underlying soft tissue, usually over a bony
prominence, as a result of excessive or prolonged pressure, shear, & tissue
deformation - Common sites: sacrum, heels, elbows, hips
- Prevention & Early detection/intervention are important
Risk Factors for Pressure Injuries
1) Immobility
2) Poor Nutrition
3) Moisture
4) Decreases Sensation
5) Advanced Age
6) Additional Factors; chronic illness, friction, shear
Stages of Pressure Injuries
Stage 1: Non-blanchable erythema
→ Characteristics: Redness that does not fade when pressed
Stage 2: Partial-thickness skin loss
→ Characteristics: Blistering or open sore
Stage 3: Full-thickness skin loss
→ Characteristics: Deep crater, may see fat
Stage 4: Full-thickness tissue loss
→ Characteristics: Exposed bone, tendon, or muscle
→ Unstageable and Deep Tissue Injury
Pressure Injury Prevention
- Reposition every 2 hrs
- Offload heels
- Reduce friction and shearing
- Ambulate
- Hydration
- Diet rich in proteins
Braden Scale - For Predicting Pressure Sore Risk
6 subscales:
1. Sensory perception
2. Moisture
3. Activity
4. Mobility
5. Nutrition
6. Shear and friction
Score indicates risk:
- Less than 13 = high risk
- 13 to 14 = moderate risk
-n 15 to 18 = mild risk
