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129 Cards in this Set
- Front
- Back
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Functions of Skin
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The skin provides multiple functions, protection, immunological, psychosocial, sensation, vit D production, Temperature, absorption and elimation
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Body's Defense Mechanisms
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Primary and Secondary, Specific and nonspecific
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Primary
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are external barriers to keep forgein bodies out(this is intacted skin and digestive respiratory and geno urinary sytem and mucous membrane)
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Secondary
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kick in immediately after inflammation
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Specific
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immune system itself, it must have had prior exposure to the antigen to work.
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Nonspecific
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response immediatelly intacted skin, mucous membrane and proteins produced by the body
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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 Microorganism |
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Physical Injury or Trauma
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once injury has occured the inflammatory system response
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Inflammation
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The response of the tissues of the body to injury, an adaptive mechanism invoked to
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Functions of Skin
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The skin provides multiple functions, protection, immunological, psychosocial, sensation, vit D production, Temperature, absorption and elimation
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Body's Defense Mechanisms
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Primary and Secondary, Specific and nonspecific
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Primary
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are external barriers to keep forgein bodies out(this is intacted skin and digestive respiratory and geno urinary sytem and mucous membrane)
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Secondary
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kick in immediately after inflammation
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Specific
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immune system itself, it must have had prior exposure to the antigen to work.
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Nonspecific
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response immediatelly intacted skin, mucous membrane and proteins produced by the body
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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 Microorganism |
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Physical Injury or Trauma
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once injury has occured the inflammatory system response
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Inflammation
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The response of the tissues of the body to injury, an adaptive mechanism invoked to
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Inflammation
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1.Destroy injurious agents-removes them off the site triggers the immune system and promotes healing
2.Confine injurious agents 3.Stimulates immune response 4.Promotes healing |
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Inflammation(Non-Specfic Response)
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Is what happens when it is triggered and occurs the same way very time. It is self limiting as soon as the threat is gone the inflammation is gone
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Types of Inflammation
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Acute, Exudation, Subacute, chronic, local ,systemic
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Acute
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Vascular Effect- response quickly to artials near site(Vasconstriction)
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Acute
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Usually heal within days to weeks. The wound edges are approximated(edges meet to close skin surface) and the risk for infection is lessened. Acute wounds move through the healing process without difficulty
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Exudation
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at the site occuring immediately cause edema and swelling, Leukocytes move o the area of inflammation, inject bacteria dead cells and cellular debris and removed as pus and loss of function to that area. This may resolve in resolution to the problem and healing should occur and leave no residual damage
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Subacute
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last longer than acute
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Chronic
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Lymphocytes and macrophages are the prodominent cell type(TB, or Rheumtoid arthritis)
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Chronic
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In contrast do not progress through the normal sequence of repair. The healing process is impeded. The wound edges are often not approximated the risk for infection is increased. Chronic wounds remain in the inflammatory phase of healing
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Local
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Pain, reddness, swelling
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Systemic
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Fever
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Neutophils
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Are white blood cells and are the prodominent cell type at the site of inflammation
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Monocytes
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Cleans wound and phagocytosis
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Prolonged Inflammation results in
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Alteration in the immune resonse
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3 Phases of Tissue Repair/ Wound Healing
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Inflammatory
Proliferative Remodeling |
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Inflammatory Phase
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Begins immediately and lasts about 3 days(book says 4-6)
Vasoconstriction and clot formation, Phagocytosis(essentially cleaning the wound) Formation of Exudate Collagen can be found within a few days |
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Book term: Inflammatory
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WBC, Prodominantly Leukocytes and Macrophages, moves to the wound. Leukocytes arrive first to ingest bacteria and cell debris. 24hrs after injury macrophages enter the wound area and remain for an extended period. Macrophages are essential to the healing process. They not only ingest debris, but also release growth factors that are necessary for the growth of epithelial cells and new blood vessels.
The growth factors also attract fibroblasts tha help to fill the the wound which is necessary for the next stage in healing |
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Proliferative Phase
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Reconstruction
Collagen Deposition Granulation Tissue Wound Contraction Epithelialization |
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Proliferative Phase
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Last several weeks, Appreance of new blood vessels reconstruction phase the wound is filled with granulation tissue and the wound contracts and becomes closed and resurfacing of the wound. Collagen provides strength and integrity
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Remodeling Phase
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Scar is remolded
Capilliaries disappear Scar regains 2/3 of original strength Starts about 7 days after trauma may take up to 1yr. New collagen continues to be deposited which compresses the blood vessels in the healing the wound, so the scar and avascular collagen tissue that does not sweat, grow hair or tan in sunlight |
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Wound Healing
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is a process of tissue response to injury. The healing process fills the gap caused by tissue destruction, restoring the structural integrity of the damaged tissue through the orderly release of growth factors and chemical mediators
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Wound Healing Intention (#3)
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Primary, Secondary and Tertiary
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Primary
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well approximated(skin edges tightly togther) Low infection risk generally resurfaces between 4 to 7 days (surgical wound ex:abdomen or lg wounds, retention sutures are stay sutures)
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Secondary
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Have edges that are not will approximated, takes longer to heal and forms more scar tissue and has a greater chance of infection(Ex: burns, pressure ulcers)
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Tertiary
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Wounds are left opened for several days to allow edema or infection to resolve or exudate to drain, then closed(Contaminated wound that could have been closed by primary intention) High risk for infection Ex: surgical wounds
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If a wound is healing by primary intention becomes infected?
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It will heal by secondary intention
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Underminding
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You can put your finger in the wound
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Tunneling
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Going in straight in the wound and with a Qtip just keep going in the edges of the wound
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Factors that Influence Wound Healing- Less injury the more rapid healing process
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1.Age
2.Nutrition 3.Obesity 4.Impaired oxygenation 5.Smoking 6.Medication 7.Diabetes |
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Age
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Alters all ages of wound change, vascular changes, reduce in liver function, cancer patient and mobility
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Nutrition
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Proteins, Vitamins, Zinc patients can lose up to 50 grams of protein in an open wound. Vitamin A & C are essential for reepithelialization and collagen synthesis. Zinc -plays a role in proliferation of cells
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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 O2 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 O2 and increases platelet ct. Smoking reduces functional hemoglobin cause hypocoagulation
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Meds
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Some medications will reduce the inflammatory response and slow collagen formation( Ex: Corticosteroid drugs decrease the inflammatory process)
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Diabetes
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Tissue perfusion impaired, Hyperglycemia->high levels of sugar affects Leukocytes in which affects phagocytosis it also supports and over group of yeast & less O2 to the wound
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Wound Complications
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Infection
Hemorrhage Dehiscence Evisceration |
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Infection-Most common surgical complication
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Increased body temp, Increase WBC, Drainage-purlent(yellow,green,brown and thick) Ther might be pain, reddness and swelling in and around the wound
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Hemorrhage
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Increased risk within 48hrs of post-op, may occur 6-7days post-op but patient on day 2 post-op watch for hemorhage. It is not normal to hemmorrhage after homostasis
Internal hemmorhage or a collection of blood under the tissue is called a Hematoma |
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Dehiscence
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Partial or total separation of wound layers as a result of excessive stress to the wound that are not healed(coughing or sneezing) There will be a sudden Sero-Sanguinous drainage(LETTING GO)
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Evisceration(MEDICAL EMERGENCY)
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The wound completely separates with protrusion of viscera through the incisional area(protruding organs)
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Evisceration Example
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Patient "may say something has suddenly given away" If occurs cover wound area with sterile towels moistened with sterile 0.9%Nacl and notify Dr. The patient should be placed in low flowers postions and the exposed abdominal contents should be covered. Do not leave patient alone
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Fistula
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Abnormal passage between 2 organs or between organ and outside of body. Fistula formation is often the result of infection that has developed into an abscess, which a collection of infected fluid has not drained.
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Hypertrophic Scar
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Scar raised above suture line, but REMAINS IN ORIGINAL WOUND BOUNDARIES
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Keloid
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Raised scar EXTENDING BEYOND ORIGINAL BOUNDARIES OF WOUND-> excess of collagen, can be surgically removed but likely to recur
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Types of Wounds
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Surgical and Nonsurgical
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Surgical closed wound/Clean
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Is the result of planned invasive therapy or treatment(Intentional incision made under aspetic conditions) The wound is intentionally made healing by primary intention-potential risk is low infection-Edges are smooth and approximated(This does not involve GI tract, Resp Tract, Gu Tract and Genitiles)
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Surgical closed wound clean/ Contaminated
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1.Surgery in areas of high bacterial population
2.No signs of infection 3.No break in aseptic tech 4.Potential risk for infection greater than clean wound (ex: Resp, GI,GU Tract all under controlled condition) |
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Opened Wound/Contaminated
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1.Incision has not been sutured
2. Edges are not approximated 3.Breaks in aspesis 4.High risk for infection Wounds left opened and edges not proximated create a high risk for infection |
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Infected
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Purlent drainage may or may not have odor. Will not properly feel growing microorganisms and spilling of drainage from one organ to another
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Colonized
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1.Contains Microorganisms
2.Chronic Wound 3.Healing is slow 4.High risk for infection |
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Colonized
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1.May show signs of infection
2.If cultured may show multiorganisms that can grow into an infection(opened wound harbors bacteria) |
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Closed non-surgical Wound
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Tissue damage w/o break in skin,but soft tissue damage. Risk for internal damage (exampe force, or strain by trauma)
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Closed non-surgical Wound
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1.Contusion
2.Hematoma 3.Ecchymosis |
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Contusion
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Blunt instrument, overlying skin remains intact, with injury to underlying soft tissue, possiblely resulting in bursing or hematoma
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Hematoma
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Localized collection of blood tissue(swelling)Blood can become trapped in tissue of skin or organ, Incomplete homeostasis
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Ecchymosis
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(Alot of Brusing) A blotchy area or discoloration of skin caused by blood that escapes or is forced out into subQ tissue
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Open non-surgical
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1.Break in skin or mucous membranes
2.Maybe clean or contaminated Ex:caused by gun shot wound exposes the body to microorganism, because it was unintentional |
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Open non-surgical
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1.Abrasion
2.Penetrating 3.Perforating 4.Puncture |
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Abrasion
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Superfical wound (depth wise) caused by scraping skin over a fixed surface and painful.
Risk for infection could be an introduction to microorganisms |
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Penetrating
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Instrument entering the skin or mucous membrane and lodges in underlying tissue
Involves the Epidermis,Dermis, Deep Tissue and organs High risk for infection, because whatever causes the wound is not sterile |
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Perforating
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Enters and exits from an internal organ making a hole, it comprises oxygen, abdominal cavity and very high risk
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Puncture
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Sharp instrument puncturing the skin, intentional(vein puncture) or accidential
Amount of bleeding is related to the size of the wound(finger stick) Small risk of infection |
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Red-Yellow-Black system
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Used to classify open wounds based on the color of the wound instead of depth of tissue destruction (pertains to ulcer's alot)
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RED
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We protect
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Yellow
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Cleanse
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Black
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Scrape away make it bleed so the cell will come and migrate
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Cause of Wounds
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Intentional and Unintentional
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Intentional
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Wounds with minimal tissue loss such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention. Wound edges usually smooth and clean Incision made under aseptic techinque
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Unintentional
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Wounds that occurs unexpectedly usually occurs under unsterile conditions, high risk for infection and wounds edges are often jagged
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Pressure Ulcer
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is a wound with localized area of tissue necrosis. Depending on the depth of the ulcer may be an acute wound or chronic wound. The underlying cause is pressure, usually from body weight
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2 Mechanisms contribute to pressure ulcers
EXTERNAL PRESSURE |
External pressure that compresses blood vessels. Pressure ulcers usually occur over bony prominences, where body weight is distributed over small area w/o much subQ tissue to cushion damage skin
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Friction & Shearing
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forces that tear an injure blood vessels and abrade the top layer of skin. This resembles an abrasion.
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Shearing
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separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to tissues under the skin
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Combination of causes
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1.Immobility
2.Nutrition 3.Hydration 4.Skin Moisture 5.Mental Status 6.Age |
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Stages of Pressure Ulcers
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Next Slide
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Stage 1
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Intacted Skin localized area not blanched painfull, more soft warmer(Top Layer)
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Stage 2
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Partial thickness loss involving epidermis. There is no slough and may lood like a blood blister (present as a shiny or dry shallow ulcer)
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Stage 3
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Full thickness loss SubQ fat may be visible but bone tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling
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Stage 4
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Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of wound bed. Often include undermining and tunneling
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Eschar
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is a thick leathery scab or dry crust that is necrotic and must be removed before the stage can be determined accurately
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Suspected Deep Tissue Injury
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Purple or maroon area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and or shearing
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Unstageable
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Full thickness loss in which the base of the ulcer is covered by slough and or eschar
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Stages 3&4 Prevention of Pressure Ulcer
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Best treatment is prevention Do not use donut shaped pillow Special Air Matress Provide passive motion promotes mobilition of excretions
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Nursing Care of Ulcers
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1.Remove all pressure from area
2.maintain cleanliness 3.Dressing based on stage of ulcer 4.Application of moist heat or cold as ordered. Everyone is doing the same thing always use(PUSH TOOL) LxWxD always in CM |
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Assessing wounds
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If you have a stage 4 and it heals it is always a stage 4
Measure in cm and include tunneling if any. |
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Open method of care
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Exposing the wound to air produces drying. Used in wounds w/o drainage.
LOTA-Left open to air Common in surgical wounds healing by primary intention. Remove everyother staple when removing so you can assess wound b/f removing all of them |
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Closed Method of Care
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Frequent dressing changes are important (bacteria likes dark moist places) Protects the wound from contamination can assist in approximating wound edges, provides compression/pressure, support and immobilize, removal of necrotic tissue
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Types of dressing
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Primary and Secondary
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Primary
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Directly covers wound and surrounding skin (2x2)
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Secondary
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outer layer covers primary adhesives
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Types of dressing
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Wet to dry(uses) wet primary then dry
Wet to moist-wet primary vaseline or xeroform Moist to moist-moist primary vaseline xreoform Secondary is covered |
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Transparent Films
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Tegaderm
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Hydrocolloid
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Duoderm Forms a gel as fluid is absorbed and maintains a moist healing environement
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All Dressings use NORMAL SALINE
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Lipping the bottle pour fluids with label up
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Hydrogel
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water or glycerin base gels Impregnated gauze or sheet dsg. Hydrate a dry wound base and can be used in moderate to heavy dressing
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Foam
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Highly absorbent less frequent dressing changes
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Alginates
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heavy to moderate drainage
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Collagen
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wounds must be moist and free of necrotic tissue
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Enzymatic Debriding Agent
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Used in removing necrotic tissue from wound bed. Need a doctor's order. Santyl ointments apply with Acuzyme sterile q-tip to wound bed( thin layer) do not touch healthy tissue
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Drains
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Simple(Penrose)-capillary action
Closed(foley) drainage through tube Suction(jackson pratt Hemovac) Closed system exerts a constant low pressure Clean from dirtiest area first and work way out these keep wounds dry |
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Debridement
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Mechanical
Autolytic Chemical Sharp/Surgical |
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Mechanical
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Basic wet to dry
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Autolytic
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synthetic dressing over wound allowing exudate to be self digested
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Chemical
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Santyl, acuzyme
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Sharp/Surgcial
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surgical quickest method
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Negative Pressure Therapy
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Need Dr. Order-Wound Vac
Stimulates granulation Improves circulation Removes fluid from surroung area Changing schedule varies |
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Hyperbaric oxygen therapy
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burn patients can be in chamber or affected area can be chamber
100% of O2 is delivered at 1.5-3times the norm |
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Nursing Dig
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Look at other factors that may hinder healing, Smoking, diabetic , not enough fluids
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Planning
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should see some improvement by 2 weeks(or decreased by 10%)
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Implemantation
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making sure your positioning correctly and checking for breakdown
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