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91 Cards in this Set

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Wounds
Introduction
Overview of Integumentary System
Content
Critical Knowledge Application
Summary
Review of Integumentary System
Largest organ
Protective barrier
Sensory organ
Thermoregulation
Synthesizes Vit D
First line of defense
Injury poses risks
Body's Defense Mechanisms
Primary
Secondary
Specific
Nonspecific
Causes of Injury
Physical injury or trauma
Irritants
Trauma/Surgical Intervention
Oxygen or nutrient deprivation
Genetic or Immune defects
Microorganisms
Inflammation
The response of the tissues of the body to injury, an adaptive mechanism invoked to:
-destroy injurious agents
-confine injurious agents
-stimulate immune response
-promote healing
Inflammatory Response
More than 2 weeks = chronic
The inflammatory response can be divided into a vascular response, a cellular response, formation of exudate, and healing
Types of Inflammation
Acute
Chronic
Local
Systemic
Acute Inflammation
Occurs immediately usually within seconds of injury
Chronic Inflammation
Lasts for weeks, months, or even years. The injurious agent persists or repeatedly injures tissue. The predominant cell types present at the site of inflammation are lymphocytes and macrophages. Examples of chronic inflammation include rheumatoid arthritis and tuberculosis
Localized symptoms
Local response to inflammation includes the manifestations of redness-heat, pain, swelling, and loss of function.
Systemic symptoms
Systemic manifestations of inflammation include leukocytosis with a shift to the left, malaise, nausea and anorexia, increased pulse and respiratory rate, and fever.
Phases of Tissue Repair/Wound Healing
Inflammatory
Proliferative
Maturation/Remodeling
Inflammatory Phase - Redness, Swelling, Warmth, Pain
Begins immediately and lasts about 3 days
Vasoconstriction and clot formation
Phagocytosis
Formation of exudate
Proliferative Phase - day 4-24 post injury
appearance of new blood vessels
wounds heal from edges in (contraction)
collagen-strength and structural integrity
Reconstruction
Collagen deposition (main component of scar tissue)
Granulation tissue
Wound contraction
Epithelialization
Proliferative Phase
The main activities during this phase are the filling of the wound with granulation tissue, contraction of the wound (healing from the edges in) and the resurfacing of the wound by epithelialization
Remodeling Phase/Maturation Phase (day 24 up to 2 years)
Scar is remodeled
Capillaries disappear
Scar regains 2/3 of original strength
Remodeling Phase/Maturation Phase (day 24 up to 2 years)
Scar tissue 70/30 rule 70% of original strength (tensile strength) contains fewer pigmented cells (melanocytes). Scarred areas increased risk of skin breakdown. Scar will always be weaker than the surrounding skin, lighter in color than normal skin.
Remodeling Phase/Maturation Phase (day 24 up to 2 years)
The final stage of healing, may take 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.
Two types of wounds
1. those with tissue loss
2. those without tissue loss
A clean surgical incision is an example of a wound with little tissue loss
Wound Healing Intention
Wounds are said to heal by either first or second intention
-Primary intention
-Secondary intention
-Tertiary intention
Wounds that heal by primary intention
-Surgical wound, edges are approximated (closed) with tape or staples (Nurses can remove staples if there is an order)
-Low infection risk
-Generally resurfaced between 4-7 days
Wounds that heal by secondary intention
Wound is open
Healing takes longer
Greater chance for infection
More scar formation
Contraction (wounds heal from the edges in) a shrinking or a reduction in size
Wounds that heal by tertiary intention
Delayed primary intention = Tertiary intention
-Contaminated wound that could have been closed by primary intention
-High risk for infection
-Closed when clean of debris
Factors that influence wound healing
Major factor
-The less the injury, the more rapid the healing process
Other factors that influence wound healing: Age
-The very old
-The very young (don't have mature systems)
Other factors that influence wound healing: Nutrition
-Protein
-Vitamins
-Zinc
Nutrition is very important for Proliferative Phase
Collagen - amino acids from ingested protein
Open wounds can lose 50 grams of protein/day
1-8 grams/kg per day for wound healing
Steroids have negative affect on wound healing, vitamin A helps with this
Other factors that influence wound healing: Obesity
Fatty tissue lacks blood supply needed
Impaired oxygenation
Any factor that reduces oxygen to the tissue impairs tissue repair
Alters synthesis of collagen and formation of epithelial cells
Smoking
-Decreases tissue oxygenation
-Increases platelet aggregation reduces amount of functional hemoglobin in blood
Medications
Some medications will reduce the inflammatory response and slow collagen formation (specifically steroids)
Diabetes
Tissue perfusion impaired
Hyperglycemia affects leukocytosis to perform phagocytosis
Complications associated with wound healing: Hemorrhage
Increased risk within 48 hours post-op
May occur 6-7 days post-op
Hemorrhage, or bleeding from a wound site is normal during and immediately after the initial trauma. Hemostasis occurs within several minutes unless large blood vessels are involved or the client has poor clotting function
Complications associated with wound healing: Hemorrhage
The nurse can detect internal bleeding by looking for distention or swelling of the affected body part, a change in the type and amount of drainage from a surgical drain, or signs of hypovolemic shock.
Complications associated with wound healing: Signs of hypovolemic shock
tachycardia
tachypnea
hypotension
cool, clammy or cyanotic skin
Hypovolemic shock
A decreased blood volume that may be caused by internal or external bleeding, fluid losses, or inadequate fluid intake
Infection
Most common surgical complication
Infection - Signs and Symptoms
fever
tenderness and pain at the wound sight
elevated WBC count
edges of wound may appear inflammed
Dehiscence
partial or total separation of wound layers
Sudden sero-sanguinous drainage
"Letting go"
Evisceration
medical emergency!
wound separation protruding organs
cover with sterile towels soaked with sterile saline
pt. NPO going back to OR
Fistula Formation
Abnormal passage between 2 organs or between organ and outside of body
Fistula Formation
Most fistulas form as a result of poor wound healing or as a complication of disease, such as Crohn's disease
Fistula Formation
Trauma, infection, radiation exposure, and diseases such as cancer can prevent tissue layers from closing properly and allow the fistula tract to form.
Fistula Formation
Fistulas increase the risk of infection, fluid and electrolyte imbalances from fluid loss
Keloid
-Raised scar extending beyond original boundaries of wound
-Can be surgically removed but likely to recur
-Caused by excessive collagen production
Hypertrophic Scar
-Scar raised above suture line but remains in original wound boundaries
-Can be painful and itchy
-Regress with time
-Caused by excessive production of collagen
Types of Wounds
Wound classification
2 categories of wounds:
-Surgical
-Traumatic
Surgical Closed Wound/Clean
-Intentional incision made under aseptic conditions
-Edges smooth & approximated
-Potential risk for infection low
Surgical Closed Wound/Clean-Contaminated
-Surgery in areas of high bacterial population
-No signs of infection
-No break in aseptic technique
-Potential risk for infection greater than clean wound
Open Wound/Contaminated
-Incision has not been sutured
-Edges not approximated
-Break in asepsis
-High risk of infection
Infected
-Clinical signs of infection (redness, swelling, pain and fever)
-Purulent drainage
-Spilling of drainage from one organ to another organ
Colonized
-Contains microorganisms (multiple)
-Chronic wound (always colonized)
-Healing is slow
-High risk for infection
Closed Traumatic Wound
-Tissue damage without break in skin
-Risk of internal hemorrhage
-Function of body part affected
Closed Traumatic Wound: Contusion
-No break in the skin, but damage to underlying tissue
-Can occur as a result of a blow from a blunt instrument
-A bruise
Closed Traumatic Wound: Hematoma
-Localized collection of blood in tissue
-Blood can become trapped in the tissue of the skin or organ
-Incomplete homeostasis
Closed Traumatic Wound: Ecchymosis
-A blotchy area or discoloration of skin caused by blood that escapes or is forced out into subcutaneous tissue
Open Traumatic Wound
-Break in skin or mucous membranes
-May be clean or contaminated
Open Traumatic Wound: Abrasion
Superficial wound
Caused by scraping skin over a fixed surface
Painful
Open Traumatic Wound: Penetrating Wounds
Instrument that causes injury passes through skin into deeper tissues or into an organ
Involves epidermis, dermis, deep tissues, and organs
High risk for infection
Open Traumatic Wound: Perforating Wounds
Foreign external object or instrument
Enters and EXITS from an internal organ making a hole
High risk of infection
Open Traumatic Wound: Puncture
Stab produced by sharp pointed object piercing deep tissues
Seals itself quickly
Decubitus (Pressure) Ulcers
Impaired skin integrity r/t unrelieved, prolonged pressure
Soft tissue compressed between bony prominence and external surface for a prolonged period
Pressure intensity, pressure duration and tissue tolerance contribute to pressure ulcer formation
Risk Assessment for Decubitus
There are several instruments for assessing clients at risk for developing a pressure ulcer
-Norton Scale (lower the score the higher the risk)
-Braden Scale
Common sites of Decubitus
Most common sites
-Coccyx
-Elbows
-Head (back of head)
-Heels
-Hips
-Knees
-Ankles
-Scapula
Predisposing Factors - Decubitus
Age
Decreased mobility
Impaired sensory perception
Alterations in level of consciousness
Poor nutrition
Predisposing Factors - Albumin
Albumin is a frequently measured variable used to evaluate the client's protein status. A client with a serum albumin level below 3g/100mL is at greater risk for pressure ulcer. In addition, low albumin levels are associated with poor wound healing.
Pathological Processes
Anemia
Diabetes
Edema
Infection
Malnutrition
Obesity
PVD
Mechanical Irritants
Friction (dragging pt. over sheets)
Shearing (gravity)
Wrinkles in bed linen
Presence of bandages, casts, restraints, splints, tapes, and so on
Chemical Irritants
Incontinence
Perspiration (antifungal powders better than creams)
Soap
Solutions (cleanse wounds can be very caustic)
Wound drainage
Stages of Decubitus
Stage I
Stage II
Stage III
Stage IV
Stages of Decubitus: Stage I
An observable pressure-related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following:
Skin temperature (warmth or coolness)
Tissue consistency (firm or boggy feel) and/or Sensation (pain, itching)
Stages of Decubitus: Stage I
The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue or purple hues.
Stages of Decubitus: Stage II
Partial thickness loss of skin involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
Stages of Decubitus: Stage III
Full-thickness tissue loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
Stages of Decubitus: Stage IV
Full-thickness tissue loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures (e.g. tendon, joint capsule).
Undermining and sinus tracts also may be associated with Stage IV pressure ulcers.
Prevention of Decubitus Ulcers
BEST TREATMENT IS PREVENTION!
Early identification of high risk clients
Positioning q2 hrs.
Topical skin care
Support surfaces
Nursing Care of Decubitus Ulcers
Remove all pressure from area
Maintain cleanliness
Dressing based on stage of ulcer
Application of moist heat or cold as ordered (you don't see this in acute care)
Assessing Wounds
Cannot reverse stage wounds
Care of Wounds
The care of the wound varies with the:
type of wound
size of wound
amount of exudate
location
whether it is a closed or open wound
physician preference
presence of complicating factors
Care of Wounds: Open Method of Care
Exposing the wound to air produces drying
Used in wounds without drainage
Common in surgical wounds healing by primary intention
Care of Wounds: Closed Method of Care
Dressings have the following advantages:
-create an environment of optimum wound healing (moist environment speeds up epithelialization)
-protect the wound from contamination
-concealing unpleasant disfigurements
-can assist in approximating wound edges
-provides compression/pressure
-support and immobilize
-removal of necrotic tissue (wet to dry dressing)
-vehicle for giving medications (medicated gauzes)
Types of Dressings: Primary
Covers incision or wound
Types of Dressings: Secondary
On top of primary, usually thicker, this is what you apply your adhesive to
Types of Dressings: General Dressings
Occlusive
Non-occlusive
Non-adhering telfa
Medicated
Wet to Dry
Self-adhesive
Hydrocolloid
Hydrogel
Drains - Types
Simple (penrose) - capillary action
Closed (foley) - drainage directly through tube
Suction (Jackson-Pratt, Hemovac) - closed system exerts a constant low pressure
Debridement
Removal of non-viable, necrotic tissue
4 types:
-mechanical
-autolytic (synthetic dressing over wound moist environment enzymes within wound debride
-chemical (specific for necrotic tissue)
-sharp/surgical
Negative Pressure therapy
Wound VAC (vacuum assisted closure)
-stimulates granulation
-improves circulation
-removes fluid from surrounding area
-changing schedule varies
-should not be off for more than 2 hrs./day
Nursing Diagnosis
Impaired skin integrity
Risk for infection
Imbalanced nutrition: less than body requirements
Acute or chronic pain
Impaired physical mobility
Ineffective tissue perfusion
Impaired tissue integrity
Planning
Common expected outcome to see wound improvement within 2 week period
Higher percentage of granulation tissue in wound base
No further skin breakdown in any body location
Increase in caloric intake by 10%
Implementation
Assess client for risk factors (obesity, incontinence, elderly, immobility) for pressure ulcer development
Provide pressure reduction or relief surface
Use moisture barrier ointment
Reposition client using drawsheet
Establish and post turning schedule
Limit HOB elevation to 30 degrees unless contraindicated
Provide adequate nutritional and fluid intake
Implementation
Assess wound for location, stage, size, tissue type and amount, exudate, and surrounding skin condition
Change dressings as needed using appropriate type and technique
Avoid use of adhesive tape
Avoid use of doughnut ring
Teach principles of good hygiene and assist as needed
Evaluation
Determine client's response to therapies and if goals were met
Nursing interventions must be individualized to meet the specific risk factors
Care of the client with wounds requires a multidisciplinary team approach