Wounds Ch. 31

Third-intention (Tertiary)

Is used for a deep wound that may have not been sutured properly, deeper wider scar, treatment was delayed to allow edema or infection to resolve

Medical treatment/Nursing management of Pressure Ulcers

Obtain nursing history Skin assessment Wound assessment

Second-intention (Secondary)

Occurs in an infected wound, or in a wound in which edges have not been approximated, may have drainage tube or gauze packing inserted into the abscess pocket to allow drainage to escape easily.

PRESSURE ULCER

a wound with a localized area of injury to the skin and/or underlying tissue. A pressure ulcer may be an acute wound or a chronic wound. The underlying cause is pressure.

Stage IV

involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of wound bed and often include undermining and tunneling

Wound assessment

involves inspection (sight and smell) and palpation for appearance, drainage, warmth, odor, and pain. Determines the status of the wound, identifies barriers to healing process, and identifies signs of complications. Drainage (ex.serous), sutures and staples.

Dermis

layer of the skin below the epidermis

Factors affecting wound healing

local factors systemic factors age related changes

Age

loose binding between the layers causes the layers to separate easily during an inflammatory process, placing infants and small children at risks for impaired skin integrity.

Granulation tissue

new tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill up open wounds when they start to heal

Appearance of the wound

note the location (described in relation to nearest anatomic landmark), document the size of wound (cm or mm), assess for approximation of wound edges and signs of dehiscence or evisceration. Assess color, presence of drains, tubes, staples, and sutures. Assess pt's mobility and nutritional status, moisture and incontinence.

Nutrition and hydration

protein-calorie malnutrition predisposes a person to pressure ulcer formation because poorly nourished cells are damaged easily. Protein deficiency leading to a negative nitrogen balance, electrolyte imbalances, and insufficient caloric intake also predisposes skin to injury.

Evisceration

protrusion of viscera through an incision

Anxiety and Fear

pts are apprehensive about the possibility of the wound opening, how much privacy will be lost as the wound is being cared for, and how others will react to the appearance and smell of the wound. When caring for pts demonstrate acceptance empathy, encouraging the expression of feelings, answering questions accurately and honestly, and avoid excessive exposure of body parts when giving care.

Medications and Health Status

pts who take corticosteroid (decrease inflammatory process) drugs or require postoperative radiation therapy (depresses bone marrow function) are at high risk for delayed healing and wound complications. Chronic health problems, chemotherapeutic agents, and prolonged antibiotic therapy all aid in the process of healing.

Trauma

repeated ________to a wound area results in delayed healing or the inability to heal

Serous

resembling blood serum; clear and watery in appearance

Excessive bleeding

results in large clots. Large clots increase the amount of space must be filled during healing and interferes with oxygen diffusion to the tissue. In addition, accumulated blood is an excellent place for growth of bacteria and infection.

proper wound measurement

size of wound depth of wound wound tunneling

Maceration

softening through liquid; overhydration

Epithelialization

stage of a wound in which the epithelial cells form across the surface of a wound; tissue color ranges from the color of "ground glass" to pink

External pressure

ulcers may occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue to cushion damage to the skin. Of the susceptible areas, most pressure ulcers occur over the sacrum and coccyx, followed by the trochanter and the calcaneus (heel).

Subcutaneous tissue

underlying layer of the skin that anchors the skin layers to the underlying tissues of the body

Nutritional Status

wound healing requires adequate proteins, carbohydrates, fats, vitamins, and minerals. Calories and proteins are necessary to rebuild cells and tissues. Vitamins A and C are essential for epithelialization and collagen synthesis. Zinc plays a role in proliferation of cells. Fluids are necessary for optional function of cells.

techniques for surgical asepsis

1. All objects used in a sterile field must be sterile. 2. A sterile object becomes non-sterile when touched by a non-sterile object. 3. Sterile items that are below the waist level, or items held below waist level, are considered to be non-sterile. 4. Sterile fields must always be kept in sight to be considered sterile. 5. When opening sterile equipment and adding supplies to a sterile field, take care to avoid contamination. 6. Any puncture, moisture, or tear that passes through a sterile barrier must be considered contaminated. 7. Once a sterile field is set up, the border of one inch at the edge of the sterile drape is considered non-sterile. 8. If there is any doubt about the sterility of an object, it is considered non-sterile. 9. Sterile persons or sterile objects may only contact sterile areas; non-sterile persons or items contact only non-sterile areas. 10. Movement around and in the sterile field must not compromise or contaminate the sterile field.

pressure ulcer classification

6 stages (4 numbered and two unnumbered): suspected deep-tissue injury, stage I, stage II, stage III, stage IV, and unstageable.

debridement techniques

Autolytic (dressing) Biosurgical (use of maggots) Enzymatic (putting an ointment on the wound) Mechanical (laser and surgery)

Removing the Dressing and applying new dressing

Clean gloves Can use adhesive remover Note any drainage Clean the Wound NS (0.9% sodium chloride) NS stands for Normal Saline May need irrigation Ordered cleanser antibiotic??? Apply a New Dressing Apply skin barrier Do not apply tape under tension to prevent blisters and skin shearing May require packing

Eschar

a thick, leathery scab or dry crust that is necrotic and must be removed for adequate healing to occur

Biofilm

a thin coating of bacteria or fungi embedded in a moist, adhesive matrix that may cover mucous membranes and devices placed inside the body, including catheters and stents

what needs to be included in the documentation of wounds and wound care

Documentation related to wound care is an important nursing responsibility. Clear and accurate documentation is essential for communication of wound status and tracking of progression of healing. Precise documentation contributes to continuity of care, accurate evaluation of care, and appropriate changes in wound care, if necessary. Use a skin assessment tool to accurately record assessment findings and treatment interventions. Photographs of a wound would contribute to accurate assessment documentation and measurement of changes over time.

Size of the Wound

Draw the shape and describe it. Measure the length, width, and diameter (if circular)

Types of Dressings

Dry gauze - 2x2, 4x4, 4x8 Surgical/ Abdominal pads Nonadherent gauzes: Sterile petrolatum gauze; Telfa gauze- Seen a lot on surgical wounds. These gauze pads do not stick to the drainage from the wound. (Is the same consistency as the center rectangle of a Band-Aids). Special gauze dressings - Precut halfway to fit around drains or tubes Transparent films (IV sites) - Semi-permeable membrane dressing , Adhesive and waterproof

phases and mechanisms of wound healing

Hemostasis Inflammatory Phase Proliferation Phase Maturation Phase

Appearance of existing pressure ulcer

Location of lesion or ulcer Identification of the stage Size of the ulcer; presence of undermining Color and type of wound tissue Presence of any abnormal pathways in the wound Visible necrotic tissue Presence of an exudate or drainage Presence of odor Presence or absence of granulation tissue Visible evidence of epithelialization Periwound skin condition

Develop planning for pressure ulcers

Maintain skin integrity Demonstrate self-care measures to prevent pressure ulcer development Demonstrate self-care measures to promote wound healing Demonstrate evidence of wound healing Demonstrate increase in body weight and muscle size, if appropriate Remain free of infection at the site of the wound or pressure ulcer Remain free of signs and symptoms of infection Experience no new areas of skin breakdown Verbalize that the pain management regiment relieves pain to an acceptable level. Be discharged to home within established parameters Demonstrate appropriate wound care measures before discharge Verbalize understanding of signs and symptoms to report and necessary follow-up care.

First-intention (Primary)

Minimal scarring, Dry dressing, Aseptically created wounds. granulation tissue is not visible and scar formation is minimal.

Depth of the wound

Perform hand hygiene. Put on gloves Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90 degree angle with the tip down. Mark the point on the swab that is even with the surrounding skin surface, or grasp the applicator with the thumb and forefinger at the point corresponding to the wound's margin. Remove the swab and measure the depth with a ruler.

Changing the dressing

Prepare the pt Does the pt need an analgesic? When do you give this? When giving orally about 30-45 minutes When giving through IV around 5 minutes Avoid meal time Provide privacy Use aseptic technique Hand hygiene

unstageable

Pressure ulcers are classified as _____________ when the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, black) in the wound bed.

age related skin changes

Skin looses turgor and is more fragile Decreased secretion of enzymes and absorption of nutrients and minerals may increase risk for delayed wound healing. Slower inflammatory response Reduced antibody production and endocrine system function Increased incidence of chronic illnesses, such as diabetes mellitus and cardiovascular disease that compromise circulation and tissue oxygenation.

Wound Tunneling

Use standard precautions; use appropriate transmission based precautions when indicated. Perform hand hygiene; put on gloves. Determine direction: moisten a sterile, flexible applicator with saline and gently insert a sterile applicator into the site where tunneling occurs. View the direction of the applicator as if it were the hand of a clock. The direction of the pt's head represents 12 o'clock. Moving in a clockwise direction, document the deepest sites where the wound tunnels. Determine the depth: while the applicator into the site where tunneling occurs, mark the point on the swab that is even with the wound's edge, or grasp the applicator with the thumb and forefinger at the point corresponding to the wound's margin. Remove the swab and measure the depth with a ruler. Document both the direction and depth of tunneling.

Sinus tract

a cavity or channel underneath the wound that has potential for infection

Pressure ulcer

a lesion caused by unrelieved pressure that results in damage to underlying tissue

Bandage

a piece of soft, usually absorbent gauze applied to a limb or other part of the body as a dressing

Dehiscence

a separation of the layers of a surgical wound partial, superficial, or a complete disruption of the surgical wound

Negative pressure wound therapy (NPWT)

activity that promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid

Obtain nursing history

address question on skin and pt activities that may contribute to development of pressure ulcer

Circulation and Oxygenation:

adequate blood flow to deliver nutrients and oxygen and to remove local toxins, bacteria, and other debris is essential for wound healing. Circulation may be impaired in older adults and in people with peripheral vascular disorders, cardiovascular disorders, and hypertension. Oxygenation of tissues is decreased in people with anemia or chronic respiratory disorders and in those who smoke.

systemic factors

age circulation and oxygenation nutritional status medications and health status immunosuppression

Proliferation Phase

also known as the fibroblastic regenerative or connective tissue phase. Proliferation stage LASTS FOR SEVERAL WEEKS. New tissue is built to fill the wound space, primarily through the action of fibroblasts. Fibroblasts are connective tissue cells that synthesize and secrete collagen and produce specialized growth factors responsible for inducing blood vessel formation as well as increasing the number and movement of endothelial cells. CAPILLARIES GROWN across the wound, bringing oxygen and nutrients required for continued healing. New tissue is formed, granulation tissue, forms the foundation for SCAR tissue development. After 2 weeks WBCs have almost completely left the wound site. Nutritional factors that are important for healing: Zinc, Vitamins A & C, proteins, hydration, etc

Fistula

an abnormal passage from an internal organ to the skin or from one internal organ to another

Retention sutures

are there for pts that are fairly obese or for a pt that has a lot of swelling. These are used to help the wound stay together even with sutures or staples on a wound.

Dehydration

as well as edema can interfere with circulation and subsequent cell nourishment.

Edema

at a wound site interferes with the blood supply to the area, resulting in an inadequate supply of oxygen and nutrients to the tissue.

Exudate

fluid that accumulates in a wound; may contain serum, cellular debris, bacteria, and white blood cells

Infection

bacteria in a wound increases stress on the body, requiring increased energy to deal with the invaders. Infection requires large amounts of energy being spent by the immune system to fight off the microorganisms, leaving little to no reserves to attend the job of repair and healing. What areas of the body are at high risk? Below the waste, *********** area When do symptoms start? 2-7 days after surgery or acquirement of wound What are the symptoms of? High WBC, heat, redness, pussy or yellow drainage, swelling, pain

Skin assessment

be sure to inspect skin systematically in head-to-toe fashion, including bony prominences, on admission and then at regular intervals for all at risk pts. Early detection and treatment of skin problems are important nursing functions.

sutures

black silk, synthetic, fine wire

Serous drainage

composed of clear, serous portion of the blood and from serous membranes

Purulent drainage

compromised of white blood cells, liquefied dead tissue debris, and both dead and live bacteria

Scar

connective tissue that fills a wound area

Sanguineous:

containing or mixed with blood

Sanguineous drainage

containing or mixed with blood. RED

Purulent

containing pus

Stage I

defined area of intact skin with nonblanchable redness of localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. Area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue.

Desiccation

dehydration; the process of being rendered free from moisture

Slough

dead matter or necrosed tissue separated from living tissue or an ulceration

Necrosis

death of cells and tissue

Ischemia

deficiency of blood in a specific area

pressure

disrupts the blood supply to the wound area. Persistent or excessive pressure interferes with blood flow to the tissue and delays healing

major predisposing factor for a pressure ulcer

external pressure applied over an area, which results in occluded blood capillaries and poor circulation to tissues.

Inflammatory Phase

follows hemostasis and lasts about 4 to 6 days. WBCs, predominately leukocytes and macrophages, move to the wound. Leukocytes arrive first to ingest bacteria and cellular debris. About 24 hrs after the injury, macrophages enter the wound area and remain for an extended period. Macrophages are essential to healing process, they ingest debris and release growth factors that are necessary for the growth of new epithelial cells and new blood vessels. Increase in temperature, Increase WBC

Shear

force created when layers of tissue move on one another

factors contributing to ulcer development

immobility, nutrition and hydration, skin moisture, mental status, and age

hypoxia

inadequate amount of oxygen available to cells

complications in wound healing

infection hemorrhage dehiscence evisceration fistula

Wound

injury that results in a disruption in the normal continuity of a body tissue

hemorrhage

may occur from slipped suture, a dislodged clot at the wound site, infection, or the erosion of a blood vessel by a foreign body, such as a drain. What can cause this? Staples or stitches coming out How do you monitor? Monitor VS, and the dressing on the wound. Hematoma is internal bleeding and is a way that a person can bleed to death (purplish color)

Serosanguinous

mixture of serum and red blood cells

Serosanguinous drainage

mixture of serum and red blood cells. PINK

Hemostasis

occurs immediately after the initial injury. Involve blood vessels constrict and blood clotting (clotting factors) begins through platelet activation and clustering. After a brief period on constriction, these same blood vessels dilate and capillary permeability increases, allowing plasma and blood components to leak out into the area that is injured, forming a liquid called exudate. Exudate causes swelling (edema) and pain. Increased perfusion results in heat and redness. If the wound is small, the clot loses fluid and a hard scab is formed to protect the injury. inflammation phase begins about 24hrs after.

Friction

occurs when two surfaces rub against each other; the resulting injury resembles an abrasion and can also damage superficial blood vessels directly under the skin

Age

older adults are at greater risk for pressure ulcer formation because the aging skin is more susceptible to injury. Chronic and debilitating diseases, more common in this age group, may adversely affect circulation and oxygenation of dermal structures.

psychological factors associated with wounds

pain anxiety and fear ADLs changes in body image

Pain

pain from wounds is often increased by activities such as ambulating, coughing, moving in bed, and dressing changes. The actual pain may be worsened by the pts apprehension about such activities. Nursing interventions to reduce pain can greatly reduce emotional stress

Dressing

protective covering placed over a wound

Factors in Pressure Ulcer Development

pathologic changes at a pressure ulcer site result from blood vessel collapse caused by pressure, usually from body weight. Necrosis eventually occurs, leading to the characteristic ulcer. Two mechanisms contribute to development: external pressure that compresses blood vessels, and friction and shearing forces that tear and injure blood vessels and abrade the top layer of skin.

Activities of Daily Living

physical, financial, and medical restrictions can result in limitations on a pts ability to preform things normally done in daily living including any daily activity related to self care, work, homemaking, and leisure, restricting the pts life.

Suspected deep-tissue injury

presents as a 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. It may initially present as a painful, firm, mushy, boggy, warmer, or cooler area as compared to adjacent skin.

Stage III

presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Ulcers at this stage may include undermining and tunneling.

local factors

pressure Desiccation Maceration Trauma Edema Infection Excessive bleeding Necrosis (slough and eschar) Biofilm

Stage II

pressure ulcer involves partial thickness loss of dermis and presents as a shallow, open ulcer.

Moisture

primary sources of skin moisture include perspiration, urine, feces, and drainage from wounds. Prolonged moisture on the skin reduces the skin's resistance to trauma, particularly damage from friction and shear, when skin is damp, less friction is required to blister and abrade skin.

Epidermis

superficial layer of the skin

Immunosuppression

suppression of the immune system as a result of disease, medication, or age can delay wound healing.

Maturation Phase

the final stage of healing, maturation begins around 3 WEEKS after injury and can continue for MONTHS OR YEARS. Collagen that was haphazardly deposited into the wound is remodeled, making the healed wound stronger and more like adjacent tissue. New collagen continues to be deposited, which compresses blood vessels in the healing wound, so the scar eventually becomes flat, an avascular collagen tissue that does not sweat, grow hair, or tan in sunlight.

Mental status

the more alert a person is, the more likely the individual is to protect skin integrity by relieving pressure periodically and maintaining adequate skin hygiene.

Debridement

the removal of a foreign material and dead or damaged tissue, especially in a wound

Changes in Body Image

when skin and tissues are traumatized a person's image is changed, requiring the person to adapt and reformulate the concept of self.