Pressure Ulcers, Wounds, and Wound Management

Purosanguineous

a mixed drainage of pus and blood (e.g. newly infected wound)

Pressure ulcer

(decubitus ulcer) is a specific type of tissue injury from unrelieved pressure or friction over bony prominences that results in ischemia and damage to the underlying tissue.

Stage IV (treatment)

-Clean/debride the following perscribed dressing surgical intervention Protelytic enzyme -Perform nonadherant dressing changes every 12 hrs -Treatment (skin grafts, specialized therapy such as hyperbaric oxygen) -provide nutritional supplements -Adminster anaglesics -administer antimicrobials

Secondary intention

-Loss of tissue -wound edges widely separated, unapproximated (pressure ulcers, open burn areas) -longer healing time -increase for risk of infection -scarring -Heals by granulation Example: Pressure ulcer left open to heal

Stage II treatment

-Moist healing environment (saline/occlusive dressing) -Apply hydrocolloid dressing -Promote natural healing while preventing the formation of scar tissue -Provide nutritional supplements -Administer Analgesics

Nursing interventions

-Provide adequate hydration and meet protein and calorie needs -Perform wound cleansing

Hemorrhage

-dislodgement -internal bleeding -hematoma -wound hemorrhage is an emergency

Nursing interventions

-intake of 2,000-3,000 mL of fluid/day -good protein -serum albumin levels (below 3.5 g/dL= low) -lack of protein increases risk in delay in wound healing/ infection -provide nutritional support (vitamin/mineral supplements, nutritional supplements, and enteral/parenteral nutrition) -1,500 kcals/day for nutritional support

Primary Intention

-little or no tissue loss -edges approximated, as with surgical incision -heals rapidly -low risk of infection -No or minimal scarring Ex. closed surgical incision with staples or sutures or liquid glue to seal laceration

Tertiary intention

-widely separated -deep -Spontaneous opening of a previously closed wound -closure of wound occurs when free of infection -risk of infection -Extensive drainage and tissue debris -Closed later -long healing time Ex: Abdominal wound initially left open until infection is resolved and then closed.

The nurse in a long-term care facility is teaching a group of new unlicensed assistive personnel. Which information regarding skin care should the nurse emphasize? 1. Keep the skin moist by leaving the skin damp after the bath. 2. Do not rub any lotion into the skin. 3. Turn clients who are immobile at least every two hours 4. Only the licensed nursing staff may care for the client's skin

3. Clients should be turned at least every one (1) to two (2) hours to prevent pressure areas on the skin.

The nurse is caring for clients in a long-term care facility. Which is a modifiable risk factor for the development of pressure ulcers? 1. Constant perineal moisture 2. Ability of the clients to reposition themselves. 3. Decreased elasticity of the skin 4. Impaired cardiovascular perfusion of the periphery

1. All the skin should be kept free of moisture. It is within the realm of nursing to provide this service. Clients with constant moisture on the skin are at high risk for impaired skin integrity.

The paraplegic client is being admitted to a medical unit from home with a stage IV pressure ulcer over the right ischium. Which assessment tool should be completed on admission to the hospital? 1.Complete Braden scale 2. Monitor the client on a Glasgow coma 3. Assess fro Babinski's sign 4. Initiatie a Brudzinski flow sheet.

1. The Braden and Norton scales are tools that identify clients risk for skin problems. This client should be ranked on this scale, and appropriate measures should be initiated for controlling further damage to the skin.

The nurse is caring for a client who has developed stage IV pressure ulcers on the left trochanter and coccyx. Which collaberative problem has the highest priority? 1. Impaired cognition 2. Altered nutrition 3. Self-care deficit 4. Altered coping

2. Altered nutrition is a collaborative problem involving the nurse, dietician, and HCP. The client will need a diet high in protein and vitamins if there is a chance for the client to heal.

Evisceration

A dehiscence that involves the protrusion of visceral organs through a wound opening.

What is the scientific rationale for placing lift pads under an immobile client? 1. The pads will absorb any urinary incontinence and contain stool. 2. The pads will prevent the client from being diaphoretic. 3. The pads will keep the staff from workplace injuries such as a pulled back muscle. 4. The pads will help prevent friction shearing when repositioning the client.

4. Lifting the client with a "lift" pad rather than pulling the client against the sheets helps to prevent skin damage from friction shearing.

The wound care nurse documented a client's pressure ulcers on admission as 3.3 cm x 4 cm stage II coccyx. which information would alert the nurse that the client's pressure ulcer is getting worse? 1. The skin is not broken and is and is 2.5 cm x 3.5 cm with erythema that does not blanch. 2. There is a 3.2 cm x 4.1 cm blister that is red and drains occasionally. 3. The skin covering the coccyx is intact but the client complains of pain in the area. 4. The coccyx wound extends to the subcutaneous layer and there is drainage.

4. This is a stage III ulcer and is a worsening of the clients condition.

Prevention

Avoid skin trauma Provide supportive devices Maintain skin hygiene Encourage proper nutrition

Infection

Risk factors Manifestations Nursing interventions (3-11 days after injury)

Complicaitons and Nursing implications

-Deterioration to higher-stage ulceration or infection -Systemic infection

Stage III treatment

-clean/debride the following: prescribed dressing surgical intervention protelytic enzymes -provide nutritional supplements -administer analgesics -Administer antimicrobials (topical/systemic)

Pressure ulcers

-suspected deep tissue injury, depth unknown -Stage I, nonblanchable erythema -Stage II, partial thickness -Stage III, full-thickness skin loss -Stage IV, full-thickness tissue loss -Unstageable/ unclassified, full-thickness skin or tissue loss, depth unknown

Wound Dressings

-woven gauze -nonadherant material -Damp to damp 4-inch by 4-inch dressings -Self adhesive, transparent film -Hydrocolloid -Hydrogel

Dehiscence:

a partial or total rupture (separation) of a sutured wound, usually with separation of underlying skin layers.

Self-adhesive, transparent film

a temporary "second skin" ideal for small, superficial wounds

Color of wounds

Red: healthy regeneration Yellow: Presence of purulent drainage and slough Black: Presence of eschar that hinders healing and requires removal.

Hydrogel

Composition is mostly water. Gels after contact with exudate, promoting autolytic debridement and cooling. Rehydrates and fills dead space. -For infected, deep wounds, or necrotic tissue -Not for moderately to heavy draining wounds -Provides a moist wound bed -Can stay in place for 3 days

Complications and Nursing Implications

Dehiscence and evisceration

Factors affecting wound healing

1. Age 2. Overall wellness 3. Decreased leukocyte count 4. Some medications 5. Malnourished clients 6. Tissue perfusion 7. Low Hgb levels 8. Obesity 9. Chronic diseases 10. Smoking 11. Wound stress

Inflammatory stage

begins with the injury and lasts 3-6 days -controlling bleeding with vasoconstriction and retraction of blood vessels, and with clot formation -Delivering oxygen, white blood cells, and nutrients to the area via the blood supply. Hemostasis occurs along with fibrin formation. Macrophages engulf microorganisms and cellular debris.

Woven gauze (sponges)

absorbs exudate from the wound

Hyrdocolloid

an occlusive dressing that swells in the presence of exudate; composed of gelatin and pectin, it forms a seal at the wounds surface to prevent evaporation of moisture from the skin. -maintains a granulating wound bed -Can stay in place up to 7 days

Healing process

1. Primary intention 2. Secondary intention 3. Tertiary intention

Serosanguineous drainage

contains both serum and blood. It is watery and appears blood-streaked or blood-tinged

Sanguineous drainage

contains serum and red blood cells. It is thick and appears reddish. Brighter drainage indicates fresh bleeding; darker drainage indicates older bleeding/drainage

Drainage (exudate)

is a result of the healing process and occurs during the inflammatory/proliferative phases of healing

Unstageable (treatment)

debride until staging is possible -do not use alcohol, Dakin's solution, acetic acid, povidone-iodine, hydrogen peroxide, or any other cytotoxic cleansers on a pressure ulcer wound

nonadherent material

does not stick to the wound bed

Treatment (stage I)

relieve pressure frequent turning/ repositioning pressure reduction (air matteresses/foam) keep client dry, clean, well-nourished, and hydrated

Assessment/Data collection

relieve pressure and provide optimal nutrition and hydration -braden, norton scales for skin breakdown risk

Serous drainage

the portion of the blood (serum) that is watery and clear or slightly yellow in appearance (eg. fluid in blisters)

Purulent drainage

the result of infection. It is thick and contains white blood cells, tissue debris, and bacteria. It may have a foul odor, and its color such as yellow, tan, brown reflects the type of organism present (green for Pseudomonas aeruginosa infection)

Damp to damp 4-inch by 4-inch dressings

used to mechanically debride a wound until granulation tissue starts to form in the wound bed. Must keep moist at all times to prevent pain and disruption of wound healing.

Assessment/Data Collection

Appearance Drainage (exudate) Wound closure Status Pain

Proliferative stage

Lasts the next 3-24 days -Replacing lost tissue with connective or granulated tissue or collagen. -Contracting the wounds edges -Resurfacing of new epithelial cells

Stages of wound healing

1. Inflammatory stage 2. Proliferative stage 3. Maturation or remodeling stage

Maturation stage

Occurs after day 21 and involves the strengthening of the collagen scar and the restoration of a more normal appearance. It can take more than 1 year to complete, depending on the extent of the original wound.

Vacuum-assisted closure system

foam strips laid into the wound bed with an occlusive sealed drape applied and suction tubing is placed for negative pressure (suction) to occur once the tubing is connected to the systems therapy unit.