Kozier and Erbs Fundamentals of Nursing Ch 36

Phagocytosis

The process in which macrophages engulf microorganisms and cellular debris.

Proliferative phase

The second phase in healing, extends from day 3 to 4 to about day 21 postinjury; fibroblasts (connective tissue cells) begin to synthesize collagen (whitish protein substance that adds tensile strength to the wound); capillaries grow across the wound increasing blood supply. Then the fibroblast move from the bloodstream depositing fibrin. The tissue then develops into granulation tissue (which is fragile and bleeds easily)

Maceration

Tissue softened by prolonged a wetting or soaking

Tertiary intention

Wounds that are left open for 3 to 5 days to allow edema or infection to resolve or exudate to drain and then closed with sutures , staples or adhesive skin closures heal by tertiary intention. This is also called delayed primary intention.

Hematoma

A localized collection of blood underneath the skin that may appear as a reddish blue swelling (bruise)

Three major types of exudate and 2 mixed types

1. Serous exudate: consists chiefly of serum derived from the blood (the clear portion of the blood) and from the serous membranes of the body. It looks watery and has few cells. (E.g. fluid in a blister from a burn) 2. Purulent exudate is thicker than serous exudate because of the presence of pus; purulent exudates vary in color, some acquiring tinges of blue, green or yellow. 3. Sanguineous exudate consists of large amounts of red blood cells, indicating damage to capillaries that is severe enough to allow the escape of red blood cells from plasma. Frequently seen in open wounds Mixed Types of Exudates are often seen: 4. Serosanguineous exudate: is watery with red blood cells; is commonly seen in surgical incisions. 5. Purosanguineous discharge: consists of pus and blood often seen in a new wound that is infected

Binder

A type of bandage designed for a specific body part, or to support large areas (e.g. arm sling, straight abdominal binder)

Secondary intention healing

A wound that is extensive and involves considerable tissue loss and in which edges cannot be approximated, heals by secondary intention healing. E.g. Pressure ulcer; Secondary intention healing differs from primary intention healing in 3 ways: The repair time is longer, the scarring is greater and the susceptibility to infection is greater; Secondary healing involves wounds that cannot be approximated and that must "heal in." Wounds that are expected to heal by secondary intention heal by "granulating in." In order to support the growth of granulation tissue, the wound bed should be kept moist and oxygen should be kept out of the wound.

What type of syringe should be used to reduce the risk of aspirating drainage

A 30-60 mL syringe with a 19 gauge needle or catheter provides approximately 8 psi - Using piston syringes instead of bulb syringes reduces the risk of aspirating drainage

What does the type of dressing depend on

The location, size, and type of wound; the amount of exudate; whether the wound requires debridement or is infected; and, such considerations as frequency of dressing change, ease of use and cost

Dehiscence

The partial or total rupturing of a sutured wound. Usually involves that abdominal wound in which the layers below the skin also separate.

Suppuration

The process of pus formation

RYB Color Code of Wounds

This concept is based on the color of an open wound - Red, yellow, or black - rather than the depth or size of the wound. On this scheme the goal is to protect/cover Red, cleanse Yellow, and debride Black.

Spiral reverse

Turns are used to Bandage cylindrical parts of the body that are not uniform in circumference; the lower leg or forearm for example

The wound reaches under the skin surface

Undermining

Clean wounds

Uninfected wounds in which there is minimal inflammation and the respiratory, gastrointestinal, genital and urinary tracts are not entered. Clean wounds are primarily closed wounds. (E.g. Breast biopsy, contusions)

Figure 8 turns

Used to bandage and elbow knee or ankle because they permit some movement

recurrent turns (bandages)

Used to cover Distal parts of the body, for example the end of a finger, the skull

Sitz Bath (or Hip Bath)

Used to soak a clients perineal or rectal area

Sharp debridement

Uses a scalpel or scissors to separate and remove dead tissue

Gauze Packing

Using the damp-to-damp technique, has been used to pack wounds that required to debridement

Circular turns

Usually are not applied directly over a wound because of the discomfort the bandage would cause

Factors inhibiting wound healing in older adults

Vascular changes associated with aging can impair blood flow to the wound; collagen tissue is flexible which increases the risk of damage from pressure and friction; scar tissue is elastic; changes in the immune system may reduce the formation of the anti-bodies; nutritional deficiencies may reduce the number of red blood cells and Leukocytes; having diabetes or cardiovascular disease increases the risk of delayed healing due to impaired oxygen delivery to tissues; cell renewal is slower leading to delayed healing

How is the depth of an ulcer obscured by

Slough( yellow tan gray green or brown) or eschar( tan brown black)

Stage I Pressure Ulcer

Stage I pressure ulcers are reddened areas that do not blanch with thumb pressure and that do not clear in the allotted amount of time; Non-blanchable erythemia signaling potential ulceration

Reactive Hyperemia

When pressure is relieved, the pale skin (as a result of compression) takes on a bright red flush, called reactive hyperemia. If the reddened area blanches with thumb pressure and disappears in one-half to three-quarters of the time pressure was on the area, the condition is reactive hyperemia and no damage to the skin and tissues has occurred.

Collagen

Whitish protein substance that adds tensile strength to the wound

Dirty or infected wounds

Wounds containing dead tissue or that has evidence of a clinical infection, such as purulent drainage

Is it important that the client does not see drainage of the wound

Yes

Is sterile technique required for irrigation

Yes

Stage II Pressure Ulcer

Stage II pressure ulcers show partial-thickness skin loss and have the appearance of abrasions, blisters, or shallow craters; Involves the epidermis and possibly the dermis

Stage III Pressure Ulcer

Stage III pressure ulcers demonstrate full-thickness skin loss involving damage 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

Impaired circulation

People with peripheral vascular disease diabetes or congestive heart failure lack the normal ability to dissipate heat via the blood circulation, which puts them at risk for tissue damage with heat and cold applications

Neurosensory impairment

People with sensory impairments are unable to proceive that heat is damaging to tissues and are at risk for burns

Table 36-7

Temperatures for applications

Hemostasis

The cessation of bleeding; results from vasoconstriction of the larger blood vessels in the affected area, retraction (drawing back) of injured blood vessels, deposition of Fibrin (connective tissue), and the formation of blood clots in the area. The blood clots provide a matrix of fibrin that becomes the framework for cell repair. A scab may also form.

Debridement

Removal of necrotic material; May be achieved in four different ways: sharp debridement, mechanical debridement, chemical debridement and autolytic debridement

Prolonged inadequate nutrition

Can cause weight loss muscle atrophy and loss of subcutaneous tissue

Pressure ulcers

Consist of injury to the skin and or underlying tissue usually over a bony prominence; Pressure ulcers are due to localized ischemia; Stage iii or iv and unstageable pressure ulcers are considered a serious reportable event

Braden scale for protecting pressure sore risk (pg 833)

Consists of 6 subscales: Sensory perception, moisture, activity, mobility, nutrition, friction and shear; a total of 23 points is possible and an adult that scores less than 18 is considered at risk. Should be assessed on admission and again when the client's condition changes.

Pus

Consists of leukocytes, liquefied dead tissue debris, and dead and living bacteria

Lewis Hunting Effect

Continued cold causes alternating vasodilation and vasoconstriction

Contusion

Contusions are closed wounds in which the skin is ecchymotic or bruised due to damage of blood vessels. These wounds are treated with ice pack application for the first 24 hours.

Laboratory data

Decreased leukocyte count delay healing; a lower hemoglobin level indicates for oxygen delivery; hypercoagulability

Suspected deep tissue injury

Depth unknown; Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear

Factors affecting wound healing

Developmental considerations (Age), nutrition, lifestyle, medications influence the speed of wound healing

Autolytic debridement

Dressing such as hydrocolloid, and clear absorbent acrylic dressings track the wound drainage against the eschar; the bodies own enzymes in the drainage break down the necrotic tissue; this method takes longer than the other three

Evisceration

Evisceration occurs when an abdominal wound opens and there is protrusion of the internal viscera through the incision. The nurse's first action should be to cover the area with a large saline-soaked dressing to keep the viscera moist.

How many stages of pressure ulcers

Four

Pressure Ulcer Risk Factors

Friction & Shearing, Immobility and Inadequate Nutrition, fecal and urinary incontinence, decreased mental status, diminished sensation, excessive body heat, advanced age, and the presence of certain chronic conditions

friction and shearing

Friction is a force acting parallel to the skin surface while a shearing force is a combination of friction and pressure which damages the blood vessels and tissue in the area

Stage IV Pressure Ulcer

Full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures such as a tendon, or joint capsule; undermining and sinus tracts may also be present

Unstageable or unclassified

Full-thickness skin or tissue loss; the depth is unknown; actual depth of ulcer is completely obscured by slough and/or eschar in the wound bed

red wounds/granulation

Gentle cleansing, protecting; protecting peri-wound skin with alcohol-free film, filling dead space with hydrogel or alignate, covering with appropriate dressing and changing the dressing

As the amount of collagen increases the strength of the wound

Increases

Disadvantage of heat

Increases capillary permeability witch allows extracellular fluid and substances to pass through the walls and may result in edema

Infection

Infection occurs when the microorganisms colonizing a wound multiply excessively or invade tissues; infection can be confirmed by culture of the wound; surgical infection is most likely to become apparent 2 to 11 days postoperatively

Important nursing functions

Maintain skin integrity and promote wound healing

Exudate

Material, such as fluid and cells, that has escaped from blood vessels during inflammation process and is deposited in tissue or on tissue surfaces.

Compress

Moist gauze dressing applied to a wound or injury (can either be cold or warm)

Complications of wound healing

hemorrhage, infection, dehiscence with possible evisceration

basic turns for roller bandages

circular, spiral, spiral reverse, recurrent and figure-eight

Phases of wound healing

inflammatory, proliferative, maturation or remodeling

The nurse must note the following when a pressure ulcer is present

location of the ulcer, size, presence of undermining or sinus tracts, stage of ulcer, color of Wound bed and location of necrosis, condition of wood margins, integrity around skin

Hemorrhage

massive, heavy bleeding. A dislodged clot, a slipped stitch or erosion of a blood vessel may cause severe bleeding. Greatest risk for hemorrhage is 48 hours after surgery and is an emergency.

rebound phenomenon

occurs at the time the maximum therapeutic effect of the hot or cold application is achieved and the opposite effect begins (E.g. Heat produces maximum vasodilation in 20-30 minutes; continuation of the application beyond 30 minutes brings tissue congestion, and the blood vessels then constrict. If the heat application is continued, the client is at risk for burns because the constricted blood vessels are unable to dissipate the heat adequately via the blood circulation. Thermal applications must be halted before the rebound effect begins.

Where should you discharge the dressing

Moisture proof bag

Factors of dehiscence

Obesity, poor nutrition, multiple trauma, failure of suturing, excessive coughing, vomiting, dehydration

Contaminated wounds

Open fresh accidental wounds or surgical wounds involving a major break in sterile technique or a large amount of spillage from the Gastrointestinal tract

Body heat

And elevated body temperature increases metabolism rate thus increasing the cells need for oxygen

What drugs interfere with healing

Anti-inflammatory drugs (e.g. steroids and aspirin) and anti-neoplastic agents interfere with healing

Aquathermia pad

Also referred to as the K pad is constructed with tubes containing water. The pad is attached by tubing that has an opening for water in a temperature gauge. It was only be filled two thirds full of water and you must set the desired temperature

Spiral turns

Bandages parts of body that are fairly uniform in circumference, for example, the upper arm or upper leg

Inflammatory phase

Begins immediately after injury and lasts 3 to 6 days; two major processes occur during this phase: hemostasis, phagocytosis

Maturation phase aka Remodeling phase

Begins on about day 21 and can extend 1 to 2 years after injury; fibroblast continue to synthesize collagen and the wound is remodeled and contracted: scar tissue becomes stronger

Types of wounds

Clean, clean contaminated ,contaminated and dirty or infected

Chemical debridement

Collagenase enzyme agents are used

Keloid

Dark, thick scars that are caused by an abnormal amount of collagen during the maturation phase of healing.

Ischemia

Deficiency in the blood supply to the tissue

Nortons pressure area risk assessment scoring system (pg 834)

Includes the categories of general physical condition, mental state, activity, mobility, incontinence. A category of medications is added by some users, resulting in a possible score of 24. Scores of 15 or 16 should be viewed as indicators. not predictors, of risk. Should be assessed on admission and again when the client's condition changes.

Excoriation

Loss of the superficial layers of the skin also known as a denuded area

Partial thickness versus full thickness

Partial thickness is confined to the skin (dermis and epidermis) and it can heal by regeneration; Full thickness (dermis, epidermis and subcutaneous tissue) requires connective tissue repair

Mechanical debridement

Scrubbing force or damp to damp dressings

Impaired mental status

People who are confused need monitoring during applications of heat and cold to ensure safe therapy

Two aspects of controlling wound infection

Preventing micro organisms from entering the wound and a preventing the transmission of blood-borne pathogen's

What to major objection agents affect the skin in children

Staphylococcus and fungus

Frequently used irrigation solutions

Sterile normal saline, lactated Ringer's solution and antibiotic solutions

Clean contaminated wounds

Surgical wounds in which the respiratory, alimentary*, genital, or urinary tract has been entered and there has been little to no spillage. These wounds show no signs of infection. *Alimentary tract includes the organs that food and liquids travel through when they are swallowed, digested, absorbed, and leave the body as feces. These organs include the mouth, pharynx (throat), esophagus, stomach, small intestine, large intestine, rectum, and anus.

Pressure ulcer scale for healing ( PUSH)

One method of documenting the progress of healing in pressure ulcers; This tool assigns scores to the ulcer length, width, amount of exudate and tissue type. The change in the score over time can be used as an indication of healing.

How does diabetes and cardiovascular disease play a role as a risk factor of skin breakdown

They compromise oxygen delivery to tissues by poor perfusion

How much pressure should irrigation have

4 to 15 pounds per square inch (psi)

Black wound

Covered with thick necrotic tissue , require debridement

Yellow wound

Characterized primarily by liquid to semi liquid slough; irrigating the wound and then cleansing the wound .

First step to do when obtaining a wound drainage

Check the medical order to determine if the specimen is to be collected for aerobic or anaerobic culture

Primary intention healing

Occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss; it is characterized by the formation of minimal granulation tissue and scarring. It is also known as primary union or first intention healing; An example of wound healing by primary intention is a closed surgical incision or the use of tissue adhesive; The edges of these wounds are approximated and held together with sutures, bandages, or tissue adhesive. Scarring is minimal with these wounds.

Types of healing

Primary intention healing, secondary intention healing, tertiary intention