4) Wounds

Chronic, Acute, or just right wounds 1.Go through healing phase May has a short stalled phase Granulation Infection resolves 2. Stalled Many comorbidities Heavy bioburden Unsuccessful treatments Patient goals 3. Granulation tissue present Causative factors controlled Comorbid conditions optimized Not too wet, not too dry Maximize nutrition

1. Acute 2. Chronic 3. Just right

How to Clean a Wound 1. o Put these in order Lay out materials on clean surface More clean technique involved than sterile a. Use commercial grade wound wash spray or saline in syringe, spray directly onto wound bed and wipe away exudate b. Remove old dressing (note exudate) & discard dressing, remove gloves c. Wash hands & don clean gloves (other PPE may be necessary - goggles, gown. Splash back from big wounds) e. Wash hands f. Remove gloves, wash hands, don new gloves g. Apply provider ordered dressing h. Don clean gloves i. Document findings j. Assess wound characteristics once clean Wound too wet, dry, or just right o 2. ____ → maceration. Put something on to take care of o 3. ____ → not good blood supply, arterial ulcer. Is it acute or chronic o 4. _____ - dog bite o 5. _____ - recurring leg ulcer. Months, why is it not healing

How to Clean a Wound 1. e. Wash hands Lay out materials on clean surface More clean technique involved than sterile h. Don clean gloves b. Remove old dressing (note exudate) & discard dressing, remove gloves c. Wash hands & don clean gloves (other PPE may be necessary - goggles, gown. Splash back from big wounds) a. Use commercial grade wound wash spray or saline in syringe, spray directly onto wound bed and wipe away exudate, f. remove gloves, wash hands, don new gloves j. Assess wound characteristics once clean g. Apply provider ordered dressing i. Document findings E, H, B, C, A, F, J, G, I 2. Wet 3. Too dry 4. Acute 5. Chronic

Wound Assessment 1. Drainage acronym 2. Wound acronym 3. ______ - Pressure ulcer risk predictor score o Most hospitals will use this to see if patient is at risk 4. What is the acronym for this test? 5. What does it stand for? 6. What is the order you would write down a wound assesment? 7. What are holes in wounds called? 8. What are shelves in wounds called?

1. C - Color O - Odor C - Consistency of Drainage A - Amount 2. R - Red E - Ecchymotic E - Edema D - Drainage characteristics A - Approximation of edges 3. Braden Scale 4. NSF MAM 5. Sensory Perception o Spinal cord injury, dementia that can't move self, patient with stroke Moisture o Incontinent? Sweaty, Diaphoretic? Activity Mobility Friction & Shear o When moving them in bed, are their skin staying back then? Nutrition o Where are they at nutritionally 6. BS PEPD Bed, Size, Pain, Etiology (location), Periwound Condition, Drainage 7. Tunneling 8. Undermining

1. What are these? Offers protection Helps with thermoregulation Alerts for sensory changes Metabolizes vitamin D Affects communication and identification 2. ______- macrophages for engulfing bacteria located in the skin. 3.The skin also produces an _____ covering via the hair follicles and sweat glands that makes the pH ____. 4. The epidermis has ____ layers while the dermis has ____ layers. 5. ________ - divides epidermis and dermis

1. Characteristics of the Skin/what it does 2. Langerhans cells 3. oily, acidic 4. Epidermis - 5. Dermis - 2 5. Basement membrane zone

1. _____ - High pressure in the lower leg vessels o Diabetes, heart failure, edema, varicose veins, damages these valves in veins, leading to ulcerations • Decrease venous return • Damage to valves • Vein distension and obstruction Venous stasis 2. What does this lead to? 3. Fix these symptoms of the above answer: a. Upper or Lower limb edema (80% of tine) b. Moist, breaking skin or Dry, scaly skin c. Sensitive skin or tough skin d. no sensation or Itchy skin e. Maceration or gangrene f. Define Hemosiderin staining g. Define Varicosities h. What is the term for bottled neck appearence? i. Wounds located in central or medial limb, gaiter area Bottle neck looking here j. Defined or Irregular wound borders k. Large or small amount of exudate = l. Feet are warm/pink or cold/blue

1. Chronic Venous insufficiency (CVI) 2. Venous Wounds 3a. Upper b. Dry, scaly skin c. Sensitive d. Itchy skin e. Maceration f. RBC breaking down - discoloration (purpleish) g. Varicose veins - twisted, enlarged veins at the surface h. Lipodermatosclerosis i. Medial j. Irregular k. Large l. warm/pink

Fingers and Toes Inspection 1. _______ - copd patients, cystic fibrosis, inability to oxygenate properly. They show this on their fingers. 2. _________- autoimmune or vitamin deficiency 3. ____________Toes- Very contagious; travel nail to nail. Medications are hard systemically on the body 4. What is missing from this list? Types of Wounds 1. _______ - created for therapy o Surgical 2. ______ - resulting from trauma o Fall 3. _____ - skin or mucous membrane is broken 4. ______- tissues are injured but the skin is not broken Wound Pearly pink - 1. ______ Beefy red - 2. ______ Stringy yellow - 3. ______ Black, necrotic tissue - 4. ______ Pus green - 5. ______ Drainage 1. _____ - clear, light yellow, normal. 2. _____ - pinkage o Thin watery drainage that is blood tinged 3. _____ - bloody o Large amount - suspect 4. ______ o Bright drainage - indicates 5. ______ bleeding o Dark drainage - indicates 6. _____ bleeding Purulent - thick opaque white, yellow, green, tan

1. Clubbing 2. Brittle and cracked 3. fungal infection. 4. Cynosis 1. Intentional 2. Unintentional 3. Open wound 4. Closed wound 1. epithelial tissue 2. granulating tissue 3. slough 4. Eschar 5. infected, probably with pseudomonas 1. Serous 2. Serosanguineous 3. Sanguineous 4. hemorrhage 5. fresh 6. older

1. ______ - most dense layer of skin Important for immune health, nutrition, skin repair, heat regulation, maintaining equilibrium o Proteins released from fibroblasts o 2. Two layers: o Most functional unit of skin: building blocks for collagen and elastin. Nerves, sweat glands, hair follicles. When this area is damage: big injure. Important for immune health, nutrition 3. _____ - Layer between skin and structures such as bone, muscle, tendons o Provides protection for the body o Elderly has less → more prone to pressure ulcers o 4. Certain areas offer no subcutaneous tissue. Give 3 examples o 5. Permanent damage → heal by ________ intention o Biggest area on body prone to skin breakdown: pelvic area. Then heels o Insulator o Pressure redistribution

1. Dermis 2. Papillary dermis Reticular dermis 3. Hypodermis (subcutaneous tissue 4. Bridge of nose, top of ears, heels 5. secondary

1. _________- First layer of skin. Constant regenerating. o 2. Has _____ layers o 3. Name them in order a. _________ - Karotynocutes produce granules. Keratohyalin granules - don't actually have keratin, hold other proteins that handles keratin. "Keratin handling proteins" o Releases lamellar bodies - contain a whole bunch of lipids that form a strong lipid layer at top of skin. o Also helps give us an acidic pH of pH b. _______ - Keratinocytes here. Also for horns or hooves. o Very rapid cell division b/c cells are made here o Where we get our skin color - melanocytes. c. _______ - Lucid layer/clear layer. Keratinocytes are dead; zombies. o Lost their nuclei that gave them their color. No granules either d.______ - fourth layer of epidermis Desmosome. Spiney pointy star shells that lost water but are still connected to each other by desmosomes o Immune cells; looks for forgein bodies. Langerhans cells eat the antigens. 3. _______ - dead layer of dead skin. Staked layers of keratinocytes (15-20 layers of these dead flat squamous epithelial cells) Randomly/continously slough off .

1. Epidermis 2. 5 layers 3. Stratum corneim, stratum lucidum, stratum granulosum, stratum spinosum, stratum basale a. Stratum granulosum b. stratum basale c. stratum lucidum d. stratum spinosum e. stratum corneum

1. What are these? Circulation impairment Hyperglycemia Tobacco use Spinal Cord Injury Infections Poor nutrition Dying process 2. What are these? 1st Assess the patient Determine what contributing factors are involved Develop a plan Implement the plan Evaluate effectiveness 5-minute skin assessment: 3. ______, ________, & _______ o Patient & caregivers are your best source of information -o Ask Questions o Find source of the problem for a would o Get vital information o Bony areas for breakdown n 4. 2 largest areas for convern are: ______ & ________ 5. _______ - cracked, scaly, turgor Inflammation, edema, rash, creptis 6. ________- diaphoretic, oily, dry

1. Factors Affecting Wound Healing 2. Nurse's Role 3. Interview, Inspection, and Palpation 4. The Pelvis and the Heel 5. Hydration 6. Moisture

1. Name the 4 phases of wound healing. 2. _______- fibroblast activity. Fibroblasts repair new connective tissue and prepare a wound bed with granulation tissue at the dermal tissue layer of skin. Pulls the wound closed o Collagen for wound strengthing is immature at this phase, but begins to fill in the wound bed. Yellow and black stuff may form, you need to cut that stuff out. o New blood vessel formation is also occurring and vascularity in the wound bed can be seen. o This phase of wound healing in optimal situations occur from day 2a. ___-____ of normal wound healing. 3. _______ - the first phase that occurs after a wound develops. 3a. (____-____days) o Blood vessels constrict in an attempt to stop the wound from bleeding and then triggers a clotting cascade. o During this time, wound healing begins by the initiation of growth factors, cytokines, and fibrin for strengthening. This happens within hours of skin injury. 4. _______- is responsible for preparing a clean wound bed. White blood cells rush to the injury. Neutrophils will be present high initially and are responsible for bacteria clean up. o Monocytes then work to help with macrophage ability and continue to eliminate bacteria and other debris from the wound bed. o Lasts for 4a. ___--___ , however, stalled wounds or comorbid conditions may contribute to the length of inflammatory response (up to 20 days). 5. ______- We call a wound to be closed when no drainage is present or need for a dressing, however if takes much longer for a wound to actually be classified as healed. This phase typical occurs at day 17-25 or greater in optimal healing situations. Collagen continues to build the tissue and add strength to the wound bed. In full-thickness wounds, 80% wound strength will be obtained, and never to full 100%. Wound contraction continues and scar formation present.

1. Hemostasis Inflammation Proliferation/Granulation Remodeling/Maturation 2. Proliferation/Granulation phase 2a. 7-17 3. Hemostasis 3a. 1-3 days 4. Inflammation 4a. 5-7 days 5. Maturation

1. _______ - is a transport system • Helps fight infections and remove toxins • Moves fluid through the veins for reabsorption • Helps maintain homeostasis with fluid management 2. ______ - most commonly caused by trauma to area, radiation, cancer, infection of the vessels o 3. Is usually unilateral/bilateral 4. _____ - Limited or no arterial blood flow feeding lower limb vessels • Major cause is 5. ______ abuse • Other contributing diseases: diabetes, hypertension, Raynauds, other auto immune diseases 6. • ________ - Perfusion impairment contributing to damage of the nerves to extremities • Most common cause - 7. ____ • Other causes - kidney disease, traumatic injury to the spinal cord and nerves, infections, vitamin deficiencies, medications, chemotherapy

1. Lymph System 2. Lymphedema 3. Unilateral 4. Arterial Ulcer 5. Tobacco 6. Lower Extremity Neuropathic Disease (LEND) 7. diabetes

1. What is the NPUAP? 2. Pressure Ulcers are a result of a "__________" injury 3. ______ - nonblanchable area of erythema over bony prominence 4. _______ -full-thickness skin loss, adipose tissue present, nonviable tissue may be present. Supporting structures are not present. May have tunneling or undermining. 5. ______ -partial thickness skin loss with dermis present. Pink/red wound bed or serous filed blister. Fat, granulation, slough, or eschar are not present 6. ______ - full-thickness skin loss with supporting structures present, bone, tendon, muscle, fascia present. 7. ______ - full-thickness wound covered by nonviable slough tissue. 8. ________ - an area of intact or nonintact skin with area of non-blanchable deep red, marroon, or purple discoloration. May also be a blood filled blister.

1. National Pressure Ulcer Advisory Panel serves as the authoritative voice for improved patient outcomes in pressure injury prevention and treatment through public policy, education and research. 2. Bottoms up skin injury 3. Stage I Pressure Injury 4. Stage III Pressure Injury 5. Stage II Pressure Injury 6. Stage IV Pressure Injury 7. Unstageable Pressure Injury 8. Deep Tissue Injury

1. ______ -relieving pain or alleviating a problem without dealing with the underlying cause. 2. What are these? • What is most concerning to the patient • What are the patient/caregivers willing to do • What are the comorbid factors / prognosis involved 3. What does this describe? ♣ Decreased perfusion to the skin ♣ Sudden onset ♣ Decline very quickly ♣ Deep purple/maroon discoloration over dependent area - typically sacrococcygeal / ischium ♣ Butterfly / pear shaped with irregular borders ♣ May progress rapidly ♣ Often an indicator of nearing death 4. _____ - caused by a critically insufficient blood supply (e.g., peripheral vascular disease) or infection. It is associated with diabetes and long-term tobacco smoking. 5. _____ - pressure builds up in small veins in the leg and water from the blood seeps out of the veins and eventually out the skin. Typically the leg will swell up and eventually a clear liquid will start to "weep" out of the area 6. _____ - Also called "fungating lesions"; Cancers that break through the skin ♣ Due to untreated tumor ♣ Can have offensive odor ♣ Often quite painful Drainage can be excessive ♣ Lots of drainage ♣ Very vascular - bleeds easily ♣ In places where its hard to get a dressing to stay

1. Palliative Wound Care 2. Palliative Wound Care goals 3. Kennedy Terminal Ulcer 4. Gangrenous Ulcer 5. Weepy Edema 6. Malignant Lesions

1. Full-thickness wounds can heal in three ways: 2. ______ - a wound is left open to heal with granulation tissue formation and filling in of the wound bed. o Ex: pressure sore is irregular shaped. Try to suture → will probably pop back open so it heals from the bottom up. o Leave open to heal from the bottom up. 3. ______ - suturing or staples are placed to close a wound; Intentionally closing it. o Surgical incision, a laceration 4. ________ - a wound is left open to clean up or stimulate granulation tissue formation in a slow to heal wound, then may be closed later depending on wound characteristics. o Ex: patient came in with emergent surgery on belly and have to leave incision open because it was infected. o Doctors want to wait a couple days to let drainage out before close it. See this in animal bites → bacteria If close too quickly, can pop back open

1. Primary, Secondary, and Tertiary Intension 2. Secondary Intention 3. Primary Intention 4. Tertiary Intention

1. What are these examples of? • Paresthesia • Loss of sensation • Loss of recognition • Loss of balance • Risk of falls 2. What are these examples of? • Foot deformities • Changes in gait 3. What are these examples of? • Sweat grand regulation - cracks, fissures in the skin • Bone changes - osteopenia, fractures Charcot foot • 4. _______ - weakening of the bones in the foot that can occur in people who have significant nerve damage (neuropathy). ...is a very serious condition that can lead to severe deformity, disability and even amputation

1. Sensory Neuropathy 2. Motor Neuropathy 3. Autonomic Neuropathy 4. Charcot foot

1. _______ - are incisions made purposefully by a health care professional and are cut precisely, creating clean edges around the wound. o Are often closed by 2. ______ intention using sutures or skin staples. o Sometimes they are left open to heal by 3. ______ intention and granulation tissue formation, depending on wound characteristics and reason for surgical intervention 4. _____ - uncontaminated. Operating room, sterile environment. 5. ______ -contaminated with bacteria, not yet infected 6. ______ - infected 7. ______ - Inflammation of epidermis from exposure to urine, stool, sweat, wound drainage, over time o Not really wound, but it is a skin condition. o Incontinence or unmanaged moisture of the skin (like diaphoresis) • Skin becomes saturated • Skin is injured • Skin is susceptible

1. Surgical wounds 2. primary intention 3. tertiary 4. Clean surgical wound 5. Contaminated surgical wound 6 .Dirty surgical wound 7. Moisture Associated Skin Damage (MASD)

Which type of Wounds are these? 1. GOAL - control excess drainage, protect periwound tissue 2. GOAL - donate moisture 3. GOAL - clear infection, manage moisture 4. Hydrogel Wound gel Hydrocolloid Honey 5. Primary Dressings Secondary Dressings NPWT 6. ________ - alginate/hydrofibers o Seaweed type material o Put on wound bed and takes up all drainage and looks gummy. 7. ________ - foams, sometimes have to be more creativ o Heart shaped foam. Covers primary dressing o Can also be used as primary dressing NPWT - 8. ________ 9. _______ -type device in sergical settings. Help collect drainage 10. ________ - Help push up some of fluid Silver o Ag. Any type of dressing usually has AG Honey o Pulls fluid from access area Dakins (12. ____ solution), Acetic Acid (13. _____ solution) Iodine Hydrofera Blue Bismuth Tribromophenate

1. Wet wounds 2. Dry wounds 3. Infected wounds 4. Dry wound 5. Wet Wounds 6. Primary dressings 7. Secondary dressings 8. negative pressure wound therapy 9. Vaccume 10. Compression 11. Infected Wound 12. bleach 13. vinegar

Venus or Arterial Ulcers? 1. • In U.S. cost of treating _______ leg ulcers $1.9 - $2.5 billion annually 2. Has a punched out appearence and defined borderes 3. Usually unhealthy wound colors, like yellow, brown and black 4. Often infected with minimal drianage. 5. Account for 80% of all lower limb wounds 6. Pedal pulses are nonpalpable or fain, feet may be dusky and cool to touch, toe nail fungus may be present 7. Lack of hair growth on limbs, necrosis may be present 8. Reccurance rate is high; 60-70% 9. Adherence to plan of care, including lifelong compression, 33-52% 10. Ulcers are painful, intermittent claudation (walking pain) and pain when leg is elevated

1. venous 2. arterial 3. arterial 4. arterial 5. venous 6. arterial 7. arterial 8. Venous 9. Venous 10. arterial