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91 Cards in this Set
- Front
- Back
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Wounds
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Introduction
Overview of Integumentary System Content Critical Knowledge Application Summary |
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Review of Integumentary System
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Largest organ
Protective barrier Sensory organ Thermoregulation Synthesizes Vit D First line of defense Injury poses risks |
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Body's Defense Mechanisms
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Primary
Secondary Specific Nonspecific |
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Causes of Injury
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Physical injury or trauma
Irritants Trauma/Surgical Intervention Oxygen or nutrient deprivation Genetic or Immune defects Microorganisms |
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Inflammation
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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 |
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Inflammatory Response
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More than 2 weeks = chronic
The inflammatory response can be divided into a vascular response, a cellular response, formation of exudate, and healing |
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Types of Inflammation
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Acute
Chronic Local Systemic |
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Acute Inflammation
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Occurs immediately usually within seconds of injury
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Chronic Inflammation
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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
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Localized symptoms
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Local response to inflammation includes the manifestations of redness-heat, pain, swelling, and loss of function.
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Systemic symptoms
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Systemic manifestations of inflammation include leukocytosis with a shift to the left, malaise, nausea and anorexia, increased pulse and respiratory rate, and fever.
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Phases of Tissue Repair/Wound Healing
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Inflammatory
Proliferative Maturation/Remodeling |
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Inflammatory Phase - Redness, Swelling, Warmth, Pain
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Begins immediately and lasts about 3 days
Vasoconstriction and clot formation Phagocytosis Formation of exudate |
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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 |
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Proliferative Phase
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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
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Remodeling Phase/Maturation Phase (day 24 up to 2 years)
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Scar is remodeled
Capillaries disappear Scar regains 2/3 of original strength |
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Remodeling Phase/Maturation Phase (day 24 up to 2 years)
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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.
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Remodeling Phase/Maturation Phase (day 24 up to 2 years)
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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.
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Two types of wounds
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1. those with tissue loss
2. those without tissue loss A clean surgical incision is an example of a wound with little tissue loss |
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Wound Healing Intention
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Wounds are said to heal by either first or second intention
-Primary intention -Secondary intention -Tertiary intention |
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Wounds that heal by primary intention
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-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 |
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Wounds that heal by secondary intention
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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 |
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Wounds that heal by tertiary intention
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Delayed primary intention = Tertiary intention
-Contaminated wound that could have been closed by primary intention -High risk for infection -Closed when clean of debris |
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Factors that influence wound healing
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Major factor
-The less the injury, the more rapid the healing process |
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Other factors that influence wound healing: Age
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-The very old
-The very young (don't have mature systems) |
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Other factors that influence wound healing: Nutrition
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-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 |
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Other factors that influence wound healing: Obesity
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Fatty tissue lacks blood supply needed
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Impaired oxygenation
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Any factor that reduces oxygen to the tissue impairs tissue repair
Alters synthesis of collagen and formation of epithelial cells |
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Smoking
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-Decreases tissue oxygenation
-Increases platelet aggregation reduces amount of functional hemoglobin in blood |
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Medications
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Some medications will reduce the inflammatory response and slow collagen formation (specifically steroids)
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Diabetes
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Tissue perfusion impaired
Hyperglycemia affects leukocytosis to perform phagocytosis |
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Complications associated with wound healing: Hemorrhage
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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 |
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Complications associated with wound healing: Hemorrhage
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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.
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Complications associated with wound healing: Signs of hypovolemic shock
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tachycardia
tachypnea hypotension cool, clammy or cyanotic skin |
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Hypovolemic shock
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A decreased blood volume that may be caused by internal or external bleeding, fluid losses, or inadequate fluid intake
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Infection
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Most common surgical complication
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Infection - Signs and Symptoms
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fever
tenderness and pain at the wound sight elevated WBC count edges of wound may appear inflammed |
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Dehiscence
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partial or total separation of wound layers
Sudden sero-sanguinous drainage "Letting go" |
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Evisceration
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medical emergency!
wound separation protruding organs cover with sterile towels soaked with sterile saline pt. NPO going back to OR |
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Fistula Formation
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Abnormal passage between 2 organs or between organ and outside of body
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Fistula Formation
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Most fistulas form as a result of poor wound healing or as a complication of disease, such as Crohn's disease
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Fistula Formation
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Trauma, infection, radiation exposure, and diseases such as cancer can prevent tissue layers from closing properly and allow the fistula tract to form.
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Fistula Formation
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Fistulas increase the risk of infection, fluid and electrolyte imbalances from fluid loss
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Keloid
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-Raised scar extending beyond original boundaries of wound
-Can be surgically removed but likely to recur -Caused by excessive collagen production |
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Hypertrophic Scar
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-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 |
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Types of Wounds
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Wound classification
2 categories of wounds: -Surgical -Traumatic |
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Surgical Closed Wound/Clean
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-Intentional incision made under aseptic conditions
-Edges smooth & approximated -Potential risk for infection low |
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Surgical Closed Wound/Clean-Contaminated
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-Surgery in areas of high bacterial population
-No signs of infection -No break in aseptic technique -Potential risk for infection greater than clean wound |
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Open Wound/Contaminated
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-Incision has not been sutured
-Edges not approximated -Break in asepsis -High risk of infection |
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Infected
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-Clinical signs of infection (redness, swelling, pain and fever)
-Purulent drainage -Spilling of drainage from one organ to another organ |
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Colonized
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-Contains microorganisms (multiple)
-Chronic wound (always colonized) -Healing is slow -High risk for infection |
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Closed Traumatic Wound
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-Tissue damage without break in skin
-Risk of internal hemorrhage -Function of body part affected |
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Closed Traumatic Wound: Contusion
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-No break in the skin, but damage to underlying tissue
-Can occur as a result of a blow from a blunt instrument -A bruise |
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Closed Traumatic Wound: Hematoma
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-Localized collection of blood in tissue
-Blood can become trapped in the tissue of the skin or organ -Incomplete homeostasis |
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Closed Traumatic Wound: Ecchymosis
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-A blotchy area or discoloration of skin caused by blood that escapes or is forced out into subcutaneous tissue
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Open Traumatic Wound
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-Break in skin or mucous membranes
-May be clean or contaminated |
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Open Traumatic Wound: Abrasion
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Superficial wound
Caused by scraping skin over a fixed surface Painful |
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Open Traumatic Wound: Penetrating Wounds
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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 |
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Open Traumatic Wound: Perforating Wounds
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Foreign external object or instrument
Enters and EXITS from an internal organ making a hole High risk of infection |
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Open Traumatic Wound: Puncture
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Stab produced by sharp pointed object piercing deep tissues
Seals itself quickly |
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Decubitus (Pressure) Ulcers
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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 |
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Risk Assessment for Decubitus
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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 |
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Common sites of Decubitus
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Most common sites
-Coccyx -Elbows -Head (back of head) -Heels -Hips -Knees -Ankles -Scapula |
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Predisposing Factors - Decubitus
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Age
Decreased mobility Impaired sensory perception Alterations in level of consciousness Poor nutrition |
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Predisposing Factors - Albumin
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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.
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Pathological Processes
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Anemia
Diabetes Edema Infection Malnutrition Obesity PVD |
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Mechanical Irritants
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Friction (dragging pt. over sheets)
Shearing (gravity) Wrinkles in bed linen Presence of bandages, casts, restraints, splints, tapes, and so on |
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Chemical Irritants
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Incontinence
Perspiration (antifungal powders better than creams) Soap Solutions (cleanse wounds can be very caustic) Wound drainage |
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Stages of Decubitus
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Stage I
Stage II Stage III Stage IV |
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Stages of Decubitus: Stage I
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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) |
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Stages of Decubitus: Stage I
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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.
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Stages of Decubitus: Stage II
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Partial thickness loss of skin involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
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Stages of Decubitus: Stage III
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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.
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Stages of Decubitus: Stage IV
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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. |
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Prevention of Decubitus Ulcers
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BEST TREATMENT IS PREVENTION!
Early identification of high risk clients Positioning q2 hrs. Topical skin care Support surfaces |
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Nursing Care of Decubitus Ulcers
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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) |
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Assessing Wounds
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Cannot reverse stage wounds
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Care of Wounds
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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 |
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Care of Wounds: Open Method of Care
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Exposing the wound to air produces drying
Used in wounds without drainage Common in surgical wounds healing by primary intention |
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Care of Wounds: Closed Method of Care
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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) |
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Types of Dressings: Primary
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Covers incision or wound
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Types of Dressings: Secondary
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On top of primary, usually thicker, this is what you apply your adhesive to
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Types of Dressings: General Dressings
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Occlusive
Non-occlusive Non-adhering telfa Medicated Wet to Dry Self-adhesive Hydrocolloid Hydrogel |
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Drains - Types
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Simple (penrose) - capillary action
Closed (foley) - drainage directly through tube Suction (Jackson-Pratt, Hemovac) - closed system exerts a constant low pressure |
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Debridement
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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 |
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Negative Pressure therapy
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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 |
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Nursing Diagnosis
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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 |
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Planning
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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% |
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Implementation
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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 |
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Implementation
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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 |
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Evaluation
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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 |
