Ch 31 skin integrity and wound care
WHat are the effects of ulcers?
Very costly Patient discomfort Disfigurement Decreased quality of life Health care expenditures
Necrosis
death of tissue
Sinus tract
is a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation.
What is dehiscence?
partial or total separation of the wound layers Excessive stress on wound that is not healed
How does age affect skin?
< 2 years: skin is thinner and weaker Infants skin and mucous membranes easily injured easily and subject to infection. Handle with care Child's skin becomes increasingly resistant to injury and infection Aging: maturation of epidermal cells is prolonged = thin, easily damaged skin Circulation and collagen formation are impaired = decreased elasticity and increased risk for tissue damage from pressure
Epithelialization
The formation of granulation tissue into an open wound allows the _______ phase to take place, as _______ cells migrate across the new tissue to form a barrier between the wound and the environment.
What are risks associated with wounds?
Risk: Obese Malnourished Smokers Anticoagulants Infection Excessive coughing, vomiting or straining
What are some age related changes in older people?
Skin looses turgor and is more fragile Decreased secretion of enzymes and absorption of nutrients and minerals = risk for delayed wound healing Risk of infection Slower inflammatory response Reduced antibody production and endocrine system function Increased incidence of chronic illness, ie. Diabetes and cardiovascular disease
What is a hemorrage?
Slipped suture Dislodged clot at the wound site Infection Erosion of a blood vessel by a foreign body (drain) ** check the dressing and the wound under the dressing
What are some factors in developing ulcers? external pressure compresses blood vessels? ischemia? hypoxia? other?
. External pressure compresses blood vessels Bony prominences Sacrum Coccyx Trochanter Calcaneus Ischemia: deficiency of blood in an area Hypoxia: inadequate amount of oxygen available to cells Edema Inflammation Necrosis Ulcer formation Casts, orthopedic devices, support stockings: check, assess, check, assess
Dressing
a sterile pad or compress applied to a wound to promote healing and protect the wound from further harm
Bandage
a strip of material used to bind a wound or to protect an injured part of the body. ex: dressing
What are other at risk populations for ulcer population?
Other at risk populations Spinal cord injuries Traumatic brain injuries Neurovascular disorders
Shearing one layer of tissue slider over another layer, shear separates the skin from underlying tissue
Patients being pulled rather than lifted in bed Sitting halfway up in bed Sitting in a chair and sliding down
What are functions of the skin?
Protection Temperature regulation psychosocial Sensation Vitamin D production Immunologic Absorption Elimination
what is wound care/ wound management?
Provide physical, psychological, and aesthetic comfort Prevent, eliminate, or control infection Absorb drainage Maintain a moist wound environment Protect the wound from further injury Remove necrotic tissue, if appropriate Protect the skin surrounding the wound
Symptoms of Infections?
Purulent drainage Increased drainage Pain Redness Swelling in and around the wound Increased body temperature Increased white blood cell count Delayed healing and discoloration of granulation tissue Chronic wound: pain and delayed healing may be the only symptoms **wound infections can lead to chronic wounds, osteomyelitis (bone infection) and sepsis (presence of pathogenic organisms in the blood or tissues)
How to document wound care?
Clear and accurate Progression of healing Continuity of care Accurate evaluation of care Appropriate changes in wound care
What is the purpose of cold therapy?
Constricts peripheral blood vessels Reduces muscle spasms Promotes comfort Reduces blood flow to tissues and decreases the local release of pain-producing substances (histamine, serotonin, and bradykinin) Reduces formation of edema and inflammation Decreases metabolic needs and capillary permeability Increased coagulation of blood at the wound site Facilitates the control of bleeding Reduces edema formation
Proliferation Phase
Fibroblastic, regenerative or connective tissue phase Lasts several weeks New tissue is build to fill the wound space (fibroblasts) Granulation tissue: forms the foundation for scar tissue development Highly vascular, red, and bleeds easily Healing by first intention: epidermal cells seal the wound within 24 to 48 hours Healing by secondary intention: longer to heal and forms more scar tissue
Inflammatory Phase
Follows hemostasis, lasts 4-6 days Leukocytes and macrophages move into the wound to ingest bacteria and cellular debris Pain, heat, redness, and swelling in the site of injury
What are unstageable pressure ulcers?
Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be softened or removed.1
What is guaze?
Gauze, iodoform gauze, NuGauze: allow healing from base of wound Infected wounds, after removal of hemorrhoids
What are systematic factors effecting wound healing? health status, radiation, chronic illness, immunosuppression, medications, chemotherapy, prolonged antibiotic
Health status: radiation therapy = high risk for wound healing Radiation depresses bone marrow function = decreased leukocytes and increased risk of infection Chronic illness: impairs wound healing Immunosuppression: Impairs wound healing AIDS, lupus or medication (chemotherapy) Medication use: corticosteroids decrease the inflammatory process = delay healing Chemotherapy: impair or stop proliferation of all growing cells Prolonged antibiotic therapy = possibility of secondary infection and superinfection
What is rebound phenonemen?
Heat maximum vasodilation in 20 to 30 minutes Longer = tissue congestion and vasoconstriction occurs Cold maximum vasoconstriction occurs when the skin reaches 60 degrees F, then vasodilation begins Initially, heat and cold skin receptors are stimulated strongly by sudden changes in temperature A hot application, even if the temperature remains constant, does not feel as warm after adaptation has taken place Do not increase temperature or lengthening the time of application Can cause serious injury
Pressure Ulcer
Injury to skin and underlying tissue resulting from prolonged pressure on the skin.
What is deep tissue injury?
Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin.
What is internal hemorrage?
Internal hemorrhage = hematoma =possible pressure on surrounding blood vessels = tissue ischemia
What is the structure of skin?
Largest organ in the body Skin Subcutaneous layer directly under the skin Appendages of the skin Glands Hair Nails Integumentary system also includes: Blood vessels, nerves Sensory organs of the skin
Risk pressure ulcer mental status?
Mental status: when alert, move around to relieve pressure Apathy, confusion, comatose = diminish self-care activities
Risk pressure ulcer aging?
aging skin more susceptible to injury, chronic illness, malnutrition and immobility
Subcutaneous tissue
also called the hypodermis, hypoderm (from Greek, meaning 'beneath the skin'), subcutis, or superficial fascia, is the lowermost layer of the integumentary system in vertebrates.
Fistula
an abnormal or surgically made passage between a hollow or tubular organ and the body surface, or between two hollow or tubular organs.
Serosanguineous drainage
common of all drainage types is serosanguineous. This leakage is thin and watery, and it's pink in color (it can also be a darker red). The pink tinge is the effect of red blood cells in the fluid, which is a sign that there is damage to the capillaries.
Serous drainage
is clear, thin, watery plasma. It's normal during the inflammatory stage of wound healing and smaller amounts is considered normal wound
Maceration
overhydration, edema, trauma, infection and excessive bleeding
Purulent drainage
described by patients as being "milky" in appearance, the drainage is almost always a sure sign of infection. This type of exudate can be green, yellow, brown or white in color and is a thick liquid
What is a penrose drain?
provides sinus tract After incision and drainage of abscess, in abdominal surgery
Dermis
the thick layer of living tissue below the epidermis that forms the true skin, containing blood capillaries, nerve endings, sweat glands, hair follicles, and other structures.
What is the process of biofilm?
thick grouping of microorganisms, embedded in a thick, self-made, protective slimy barrier of sugars and proteins Decreased effectiveness of antibiotics (antibiotic resistance) Decreases the effectiveness of the normal immune response Contribute to chronic wound inflammation
Sanguineous drainage
wound exudate is also known as the fresh blood that comes from a recent wound, and is characterized by a bright red color. Most commonly, it is seen in partial thickness and full thickness wounds
What to do if bleeding occurs in hemorrage?
Additional pressure dressings Packing Fluid replacement Surgical intervention
What are systematic factors effecting wound healing? Age, circulation, oxygenation of tissues, wound condition, vitamin a and c , zinc
Age: infants and small children Epidermal stripping: tape removal Circulation: Peripheral vascular disease, cardiovascular disorders, hypertension, diabetes, anemia, Oxygenation of tissues: chronic respiratory disorders, smokers Nutritional status: Wound condition: healing requires protein, carbs, fats, vitamins, and minerals Vitamins A and C: epithelialization and collagen synthesis Zinc: proliferation of cells
Why are older adults high risk for ulcers?
Aging skin Chronic illnesses Immobility Malnutrition Urinary incontinence Altered LOC
What is the subcutaneous layer?
Anchors the skin layers to the underlying tissues of the body Adipose tissue: fat cells and connective tissue: stores fat for energy, and heat insulator for the body, and cushioning effect for protection
What is the blanch test? blanchable vs. non blanchable?
Apply light pressure. Skin should blanch or lighten. Release. Skin should return to normal color due to normal reactive hyperemia. Blanchable: Skin blanches with pressure. Color returns immediately with release. Non-blanchable: No blanch, persistent redness in lightly pigmented skin.
Which type of wound is caused by a blunt instrument that causes injury to underlying soft tissue with the overlying skin remaining intact? A. Contusion B. Abrasion C. Laceration D. Avulsion
Answer: A. Contusion Rationale: A contusion is caused by a blunt instrument and may result in bruising or hematoma. An abrasion is the rubbing or scraping of epidermal layers of skin. A laceration is the tearing of skin and tissue with a blunt or irregular instrument. Avulsion is the tearing of a structure from normal anatomic position.
Which wound complication is caused by overhydration related to urinary and fecal incontinence? A. Necrosis B. Edema C. Desiccation D. Maceration
Answer: D. Maceration Rationale: Maceration is caused by overhydration related to incontinence that causes impaired skin integrity. Necrosis is dead tissue present in the wound that delays healing. Edema is swelling at a wound site that interferes with blood supply to the area. Desiccation is the process in which the cells dehydrate and die.
Tell whether the following statement is true or false. Blood vessels in the skin dilate to dissipate heat. A. True B. False
Answer: A. True Rationale: Blood vessels in the skin dilate to dissipate heat.
In phase of wound healing is new tissue built to fill the wound space, primarily through the action of fibroblasts? A. Hemostasis B. Inflammatory phase C. Proliferation phase D. Maturation phase
Answer: C. Proliferation phase Rationale: In the proliferation phase, granulation tissue is formed to fill the wound. In hemostasis, involved blood vessels constrict and blood clotting begins. In the inflammatory phase, white blood cells move to the wound. In the maturation phase, collagen is remodeled, forming a scar.
What is skin? what does it protect?
Body's first line of defense Protects underlying structures from invasion by organisms Knowledgeable and skilled wound care is vital
What is the dermis?
Dermis: framework of elastic connective tissue Nerves, hair follicles, glands and blood vessels located in the dermis Hair: shaft and hair follicle
Hemostasis Phase
Immediately after the injury Blood vessels constrict and clotting begins Exudate: plasma and blood components leak out into the area Exudate causes swelling and pain
Effects of prolonged heat exposure?
Increased cardiac output Sweating Increased pulse rate Decreased blood pressure
What reduced sensation puts skin at risk?
Reduced Sensation: paralysis, local nerve damage, circulatory insufficiency
What is stage two pressure ulcer?
Partial thickness loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel.
what changes in health risk put skin at risk?
Changes in Health Status: dehydration or malnutrition
Acute wounds
How long they had them Usually heal in days to weeks Wound edges well approximated Risk of infection is low
What is the epidermis?
top layer Layers of stratified epithelial cells Protective waterproof layer No blood vessels, depend on underlying tissues for nourishment and waste removal Regenerates easily and quickly when well nourished
Tell whether the following statement is true or false. A stage III pressure ulcer requires débridement through wet-to-dry dressings, surgical intervention, or proteolytic enzymes. A. True B. False
Answer: A. True Rationale: A sétage III pressure ulcer requires débridement through wet-to-dry dressings, surgical intervention, or proteolytic enzymes.
What is nursing process for skin? Assess? Identify? implement? provide?
Assess the patient and the wound Identify and prevent complications Implement and evaluate skills essential to wound care Provide physical and emotional support to facilitate healing, adaptation, and self-care Wound care given in any health care setting Complex wound care at home is rising
After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this ulcer would be classified as: a. Stage I b. Stage II c. Stage III d. Stage IV
B Stage II A stage II pressure ulcer involves partial thickness loss of dermis and presents as a shallow open ulcer with a red pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister.
The nurse uses the RYB wound classification system to assess the wound of a client who cut his arm on a factory machine. The nurse documents the wound as "red." What would be the priority nursing intervention for this type of wound? a. Irrigate the wound. b. Provide gentle cleansing of the wound. c. Débride the wound. d. Change the dressing frequently.
B. Provide gentle cleansing of the wound. Red wounds are in the proliferative stage of healing and reflect the color of normal granulation tissue. Wounds in this stage need protection with nursing interventions that include gentle cleansing, use of moist dressings, and changing of the dressing only when necessary, and/or based on product manufacturer's recommendations. To cleanse yellow wounds, nursing interventions include the use of wound cleansers and irrigating the wound. The eschar found in black wounds requires débridement (removal) before the wound can heal.
What is purpose of heat therapy?
Bring about a local or systemic change in body temperature for various therapeutic purposes Dilates peripheral blood vessels Increases tissue metabolism Reduces blood viscosity Increases capillary permeability Reduces muscle tension Helps relieve pain
What is RYB yellow color?
Cleanse in the wound may indicate presence of exudate (drainage) or slough, and requires wound cleansing. wounds are characterized by oozing from the tissue covering the wound often accompanied by purulent drainage. drainage can be whitish yellow, creamy yellow, yellowish green or beige. use the wound cleansers and irrigate the wound.
Shear
is what you get when you have friction plus the force of gravity. Let's think of that same patient in bed, with his head in a raised position.
Closed Wound Classification
results from a blow, force, or strain caused by trauma such as a fall, assault, or a motor vehicle crash Skin surface is not broken Soft tissue is damaged Internal injury and hemorrhage may occur: ecchymosis and hematomas
What is stage three pressure ulcer?
Full thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunnelingmay occur. Fascia, muscle, tendon, ligament, cartilage or bone is not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.
What is stage four pressure ulcer?
Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.1
What to do when dehiscence and evisceration occurs?
Dehiscence and evisceration Excessive drainage on day 4 or 5 postop "something has just given way" "Who do I call" Not the ghostbusters Dehiscence: cover the wound area with sterile towels moistened with sterile 0.9% NaCl and notify the surgeon ASAP This is a medical emergency Place the patient in a low Fowler's position and do as above Do not leave the patient alone Call the surgeon immediately Back to the operating room
Chronic wounds
Healing process is slow Often not approximated Risk of infection increased Normal healing time is delayed Examples: wounds related to venous or arterial insufficiency and pressure ulcers
Factors that place an individual at skin risk? illness, diagnostic measures, therapeutic measures, casts, aquathermia, medications, radiation therapy?
Illness: Diabetes mellitus cuts and sores that do not heal Lesions on the lower extremities that ulcerate and become necrotic Recurrent bacterial and fungal infections Diagnostic measures: Colon prep = diarrhea= irritated skin Therapeutic measures: Bedrest predisposes to skin breakdown Casts: irritating to the skin Aquathermia unit: maceration if left on too long Medications: allergic skin reactions/rashes Radiation therapy: exposes normal skin cells along with cancer cells
What are some wound complications?
Infection: patient's immune system fails to control the growth of microorganisms Bacteria can invade a wound Time of trauma During surgery Any time after the initial wound occurs Contaminated wound is more likely to become infected than a non contaminated wound Surgery involving intestines Hospital acquired infections (HAIs)
What is stage one pressure ulcer?
Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.
Lifestyle factors that put skin at risk?
Lifestyle variables: homosexuality, history of multiple sexual partners (HIV/AIDS/Kaposi's sarcoma), IV drug users Occupation that involves prolonged exposure to the sun (skin cancer) Body piercing: potential interference with airway management. Risk for bacterial and viral infections, scarring, nerve damage, tissue trauma, and deformity
What do mucous membranes line? located?
Line body cavities that open to the outside of the body, joining with the skin Digestive tract Respiratory passages Urinary and reproductive tracts Epithelium covers mucous membrane surfaces/secrets mucous
mucous membranes insensitive and sensitive to? absorb?
Mucous membranes are insensitive to temperature, except the mouth and rectum Mucous membranes are sensitive to pressure Mucous membranes absorb substances from their surface Digested food absorbed through the mucous membrane in the small intestine
What do mucous membranes have? what irritating substance cause mucous membrane to do?
Mucous membranes have receptors that offer protection Irritating substance in the upper respiratory tract causes a person to sneeze and food caught in the larynx or trachea causes a person to cough
WHat is process of necrosis?
Necrosis: death of tissue, dead tissue present in the wound delayed healing. Slough: moist, yellow, stringy tissue Eschar: dry, black, leathery tissue Healing will not take place until slough and eschar are removed
Risk pressure ulcer nutrition?
Nutrition: protein/calorie malnutrition (poorly nourished cells are damaged easily Protein deficiency - negative nitrogen balance - electrolyte imbalances - insufficient caloric intake Vitamin C deficiency = fragile capillaries = poor circulation to the area Poor dentition = poor nutrition Dehydration/edema = interferes with circulation
What are Four local factors affecting wound healing?
Pressure: disrupts blood supply to the wound, delays healing Desiccation: dehydration (drying up) Causes crust to form over the wound and delays healing Maceration: overhydration, softening and breakdown of skin Urinary and fecal incontinence Damage related to moisture, changes in the pH, overgrowth of bacteria and infection of the skin Trauma: delayed healing or inability to heal
What is RYB red color?
Protect in the proliferative stages of healing and reflect the color of normal granulation tissue. wounds need gentle cleansing, use of moist dressings and change the dressing only when necessary.
Maturation Phase
Remodeling of collagen Scar is an avascular collagen tissue that does not sweat, grow hair or tan in sunlight Secondary intention takes loner to remodel
. Friction forces tear and injure blood vessels and abrade the top layer of skin
Resembles an abrasion Wrinkled sheets =_____ Elbows and heels when patient trying to help move themselves up in bed Back when patients are pulled over sheets while being moved up in bed or transferred to a stretcher
What is the Braden Scale?
Sensory Perception: Completely limited, very limited, slightly limited, no impairment Moisture: constantly moist, very moist, occasionally moist or rarely moist Activity: bedfast, chair-fast, walks occasionally, walks frequently Mobility: completely immobile, very limited, slightly limited, no limitation Nutrition: usual food intake: Very poor, probably inadequate, adequate, excellent Friction and shear: problem, potential problem, no apparent problem
what are the four types of drainage? serous, sanguineous, serosanguineous, purulent
Serous drainage: clear, serous portion of the blood: clear and watery Sanguineous drainage: red blood cells, looks like blood. Bright red sanguineous drainage = fresh bleeding, darker drainage = older bleeding Serosanguineous drainage: mixture of serum and red blood cells; light pink to blood tinges Purulent drainage: white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Thick, often has a musty or foul odor, varies in color (dark yellow or green)
What are the guidelines for measuring wounds and pressure ulcers?
Size of the wound: draw and describe, measure Depth of the wound: use a sterile flexible applicator with saline, insert gently into wound then measure Wound tunneling: use sterile applicator with saline. Draw a clock and moving in a clockwise direction, document the deepest sites where the wound tunnels Document both the direction and depth of tunneling
Risk pressure ulcer skin moisture?
Skin moisture: perspiration, urine, feces, wound drainage Prolonged moisture reduces the skin's resistance to trauma (friction and shear) When skin is damp less friction is required to blister and abrade (scrape or wear away) skin Urine and feces: chemical irritation (ammonia/urine) Ammonia raises the alkalinity of the skin pH (skin is normally acidic) Promotes premature shedding of skin cells Decreases skin's defense against bacteria Enhanced growth of pathogens (yeast and staphylococci)
Why aggressive intervention and treatment?
Spare the patient unnecessary pain and discomfort Prevent further tissue deterioration Hasten wound healing Save millions of health care dollars
What are age related factors in skin?
Subcutaneous and dermal tissue become thin Skin more easily injured Less capacity to insulate Wrinkles more easily Sensation of pressure and pain is reduced Activity of the sebaceous and sweat glands decreases Skin becomes dryer Pruritus Cell renewal is shorter Healing time is delayed Melanocytes decline in number Hair becomes gray/white Skin may become unevenly pigmented Collagen fiber is less organized Skin loses elasticity
Friction
The act of rubbing the surface of an object against that of another. 2. The force required for relative motion of two bodies that are in contact.
Evisceration
The process whereby tissue or organs that usually reside within a body cavity are displaced outside that cavity, usually through a traumatic disruption of the wall of the cavity; ____of bowel.
Epidermis
The upper or outer layer of the two main layers of cells that make up the skin. is mostly made up of flat, scale-like cells called squamous cells. Under the squamous cells are round cells called basal cells.
What are some factors affecting skin integrity?
Unbroken and healthy skin serve as the first line of defense against harmful agents Factors influencing resistance include age, the amount of underlying tissue and illness Nourished and hydrated body cells are resistant to injury Adequate circulation is necessary to maintain cell life
Unintentional Wound classification
Unexpected trauma: (accidents, stabbing, gunshot, burns) Unsterile environment, contamination is likely Wound edges are ragged, multiple traumas common Bleeding uncontrolled High risk for infection and longer healing time
Characteristics of Ulcers
Wound with a localized area of injury to the skin and/or underlying tissue May be acute or chronic Cause is pressure Soft tissue is compressed between a bony prominence and external surface
Risk pressure ulcer immobility?
_____: patients who spend long periods of time in bed or seated without shifting body weight, Unconscious Paralyzed Cognitive impairment
Intentional Wound classification
_______ l: surgery, IV therapy, lumbar puncture Wound edges are clean Bleeding is controlled Risk for infection decreased (sterile conditions)
A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply. a. Serous drainage is composed of the clear portion of the blood and serous membranes. b. Sanguineous drainage is composed of a large number of red blood cells and looks like blood. c. Bright red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding. d. Purulent drainage is composed of white blood cells, dead tissue, and bacteria. e. Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor. f. Serosanguineous drainage can be dark yellow or green depending on the causative organism.
a, b, c, d Serous drainage is composed of the clear portion of the blood and serous membranes. Sanguineous drainage is composed of a large number of red blood cells and looks like blood. Bright red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding. Purulent drainage is composed of white blood cells, dead tissue, and bacteria. Serous drainage is composed primarily of the clear, serous portion of the blood and serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink or darker red
The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure? Select all that apply. a. Use standard precautions or transmission-based precautions when indicated. b. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. c. Clean the wound in full or half circles beginning on the outside and working toward the center. d. Work outward from the incision in lines that are parallel to it from the dirty area to the clean area. e. Clean to at least one inch beyond the end of the new dressing if one is being applied. f. Clean to at least three inches beyond the wound if a new dressing is not being applied.
a, b, e Use standard precautions or transmission-based precautions when indicated. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. Clean to at least one inch beyond the end of the new dressing if one is being applied. The correct procedure for cleaning a wound with unapproximated edges is: (1) use standard precautions and appropriate transmission-based precautions when indicated, (2) moisten sterile gauze pad or swab with prescribed cleansing agent and squeeze out excess solution, (3) use a new swab or gauze for each circle, (4) clean the wound in full or half circles beginning in the center and working toward the outside, (5) clean to at least one inch beyond the end of the new dressing, and (6) clean to at least two inches beyond the wound margins if a dressing is not being applied.
A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply. a. Hemostasis occurs immediately after the initial injury. b. A liquid called exudate is formed during the proliferation phase. c. White blood cells move to the wound in the inflammatory phase. d. Granulation tissue forms in the inflammatory phase. e. During the inflammatory phase, the patient has generalized body response. f. A scar forms during the proliferation phase.
a, c, e Hemostasis occurs immediately after the initial injury. White blood cells move to the wound in the inflammatory phase. During the inflammatory phase, the patient has generalized body response. Hemostasis occurs immediately after the initial injury and exudate occurs in this phase due to the leaking out of plasma and blood components into the injured area. White blood cells, predominantly leukocytes and macrophages, move to the wound in the inflammatory phase to ingest bacteria and cellular debris. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. New tissue, called granulation tissue, forms the foundation for scar tissue development in the proliferation phase. New collagen continues to be deposited in the maturation phase, which forms a scar.
What is the process of excessive bleeding?
results in large clots which increase the amount of space that must be filled during healing Interferes with oxygen diffusion to the tissue Accumulated blood is a place for bacteria to grow Promotes infection
Debridement
the removal of damaged tissue or foreign objects from a wound.
A nurse is measuring the depth of a patient's puncture wound. Which technique is recommended? a. Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down. b. Draw the shape of the wound and describe how deep it appears in centimeters. c. Gently insert a sterile applicator into the wound and move it in a clockwise direction. d. Insert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface with a marker.
a. Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down. To measure the depth of a wound, the nurse should perform hand hygiene and 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; and remove the swab and measure the depth with a ruler.
Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan? a. Document the findings and continue to monitor the patient. b. Administer antipyretics, as ordered. c. Increase the frequency of assessment to every hour and notify the patient's primary care provider. d. Increase the frequency of wound care and contact the primary care provider for an antibiotic order.
a. Document the findings and continue to monitor the patient. The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.
What is a fistula? why created?
abnormal passage from an internal organ or vessel to the outside of the body Or from one internal organ or vessel to another Created purposely: arteriovenous fistula for kidney dialysis Usually result of an infection that as turned into an abscess (collection of infected fluid that has not drained) applies pressure to surrounding tissues = unnatural passage
Wound
an injury, usually involving division of tissue or rupture of the integument or mucous membrane, due to external violence
Biofilm
any group of microorganisms in which cells stick to each other and often also to a surface. These adherent cells become embedded within a slimy extracellular matrix that is composed of extracellular polymeric substances (EPS)
A nurse is developing a plan of care for an 86-year-old woman who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure ulcer development for this patient? Select all that apply. a. The patient takes time to think about her responses to questions. b. The patient's age of 86 years. c. Patient reports inability to control urine. d. A scheduled hip arthroplasty e. Lab findings include BUN 12 (elderly normal 8-23 mg/dL) and creatinine 0.9 (adult female normal 0.61-1 mg/dL). f. Patient reports increased pain in right hip when repositioning in bed or chair.
b, c, d, f The patient's age of 86 years. Patient reports inability to control urine. A scheduled hip arthroplasty Patient reports increased pain in right hip when repositioning in bed or chair. Pressure, friction, and shear, as well as other factors, usually combine to contribute to pressure ulcer development. The skin of older adults is more susceptible to injury; incontinence contributes to prolonged moisture on the skin, as well as negative effects related to urine in contact with skin; hip surgery involves decreased mobility during the postoperative period, as well as pain with movement, contributing to immobility; and increased pain in the hip may contribute to increased immobility. All these factors are related to an increased risk for pressure ulcer development. Apathy, confusion, and/or altered mental status are risk factors for pressure ulcer development. Dehydration (indicated by an elevated BUN and creatinine) is a risk for pressure ulcer development.
What is the process of infection?
bacteria in the wound increases stress on the body requiring large amounts of energy to fight the microorganisms Toxins produced by bacteria and released when bacteria die interfere with healing and cause cell death.
A patient who has a large abdominal wound suddenly calls out for help because she feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? Arrange from first to last. a. Notify the physician immediately of the situation. b. Cover the exposed tissue with sterile towels moistened with sterile NSS. c. Place the patient in the low Fowler's position.
c, b, a Place the patient in the low Fowler's position. Cover the exposed tissue with sterile towels moistened with sterile NSS. Notify the physician immediately of the situation. Dehiscence and evisceration is a postoperative emergency that requires prompt surgical repair. The correct order of implementation by the nurse is to place the patient in the low Fowler's position, cover the exposed tissue with sterile towels moistened with sterile NSS, and notify the physician immediately of the situation.
The nurse assesses the wound of a patient who cut himself on the upper thigh with a chain saw. The nurse then documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply. a. Enhanced healing due to the presence of sugars and proteins b. Delayed healing due to dead tissue present in the wound c. Decreased effectiveness of antibiotics against the bacteria d. Impaired skin integrity due to overhydration of the cells of the wound e. Delayed healing due to cells dehydrating and dying f. Decreased effectiveness of the patient's normal immune process
c, f Decreased effectiveness of antibiotics against the bacteria Decreased effectiveness of the patient's normal immune process Wound biofilms are the result of wound bacteria growing in clumps, imbedded in a thick, self-made, protective, slimy barrier of sugars and proteins. This barrier contributes to decreased effectiveness of antibiotics against the bacteria (antibiotic resistance) and decreases the effectiveness of the normal immune response by the patient (Beitz, 2012). Necrosis (dead tissue) in the wound delays healing. Maceration or overhydration of cells related to urinary and fecal incontinence can lead to impaired skin integrity. Desiccation is the process of drying up, in which cells dehydrate and die in a dry environment.
A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation? a. "I can expect to have more discomfort in the area where the cold is applied." b. "I should expect more drainage from the incision after the ice has been in place." c. "I should see less swelling and redness with the cold treatment." d. "My incision may bleed more when the ice is first applied."
c. "I should see less swelling and redness with the cold treatment." The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues, decreases the local release of pain-producing substances, decreases metabolic needs, and capillary permeability. The resulting effects include decreased edema, coagulation of blood at the wound site, promotion of comfort, decreased drainage from wound, and decreased bleeding.
A nurse is providing patient teaching regarding the use of negative-pressure wound therapy. Which explanation provides the most accurate information to the patient? a. The therapy is used to collect excess blood loss and prevent the formation of a scab. b. The therapy will prevent infection, ensuring that the wound heals with less scar tissue. c. The therapy provides a moist environment and stimulates blood flow to the wound. d. The therapy irrigates the wound to keep it free from debris and excess wound fluid.
c. The therapy provides a moist environment and stimulates blood flow to the wound. Negative-pressure wound therapy (or topical negative pressure [TNP]) 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, while providing a moist wound healing environment. The negative pressure results in mechanical tension on the wound tissues, stimulating cell proliferation, blood flow to wounds, and the growth of new blood vessels. It is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or healing slowly.
A patient, age 16, was in an automobile accident and received a wound across her nose and cheek. After surgery to repair the wound, the patient says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate? a. Pain b. Impaired Skin Integrity c. Disturbed Body Image d. Disturbed Thought Processes
c. Disturbed Body Image Wounds cause emotional as well as physical stress.
A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection? a. Using sterile dressing supplies b. Suggesting dietary supplements c. Applying antibiotic ointment d. Performing careful hand hygiene
d Performing careful hand hygiene Although all of the answers may help in preventing wound infections, careful hand washing (medical asepsis) is the most important.
A nurse is developing a plan of care related to prevention of pressure ulcers for residents in a long-term care facility. Which action would be a priority in preventing a patient from developing a pressure ulcer? a. Keeping the head of the bed elevated as often as possible b. Massaging over bony prominences c. Repositioning bed-bound patients every 4 hours d. Using a mild cleansing agent when cleansing the skin
d. Using a mild cleansing agent when cleansing the skin To prevent pressure ulcers, the nurse should cleanse the skin routinely and whenever any soiling occurs by using a mild cleansing agent with minimal friction, and avoiding hot water. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible. Bony prominences should not be massaged, and bed-bound patients should be repositioned every 2 hours.
What is a Jackson - Pratt drain?
decreases dead space by collecting drainage After breast removal, abdominal surgery
What is a hemovac drain?
decreases dead space by collecting drainage After abdominal, orthopedic surgery
What is a T-tube drain?
for bile drainage After gallbladder surgery
What is the RYB black color?
indicate the presence of eschar (necrotic tissue) which is usually black but may be brown, gray or tan. The eschar requires debridement (removal) before the wound can heal. the wound after debridement is treated as a yellow wound then a red wound.
Open wound classification
intentional or unintentional trauma Skin surface is broken = portal of entry for microorganisms Bleeding, tissue damage and increased risk for infection Delayed healing Incisions and abrasions
What is the process of edema?
interferes with the blood supply to the area (poor oxygen and nutrients to the tissue)
Eschar
is a slough or piece of dead tissue that is cast off from the surface of the skin, particularly after a burn injury, but also seen in gangrene, ulcer, fungal infections, necrotizing spider bite wounds, spotted fevers and exposure to cutaneous anthrax.
Dehiscence
is a surgical complication in which a wound ruptures along a surgical incision. Risk factors include age, collagen disorder such as Ehlers-Danlos syndrome, diabetes, obesity, poor knotting or grabbing of stitches, and trauma to the wound after surgery.
Negative-pressure wound therapy (NPWT)
is a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds and enhance healing of second and third degree burns.
Exudate
is any fluid that filters from the circulatory system into lesions or areas of inflammation. It can be a pus-like or clear fluid. When an injury occurs, leaving skin exposed, it leaks out of the blood vessels and into nearby tissues. The fluid is composed of serum, fibrin, and white blood cells.
Granulation tissue
is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process. tissue typically grows from the base of a wound and is able to fill wounds of almost any size
Ischemia
is the medical term for what happens when your heart muscle doesn't get enough oxygen. usually happens because of a shortage of blood and oxygen to the heart muscle. It is usually caused by a narrowing or blockage of one or more of the coronary arteries (which supply blood to the heart muscle).
Desiccation
is the state of extreme dryness, or the process of extreme drying. A desiccant is a hygroscopic (attracts and holds water) substance that induces or sustains such a state in its local vicinity in a moderately sealed container
What is evisceration?
wound completely separates with protrusion of viscera through the incisional area (guts are falling out)