ch 48

widths of tape

1,3,2.5, 5 and 7.5 cm

what are the types of emergency setting wounds

1. abrasion 2. laceration 3. puncture

identify the risk factors that predispose a patient to pressure ulcer formation

1. impaired sensory perception 2. impaired mobility 3. alteration in level of consciousness 4. shear 5. friction 6. moisture

list the factors that place a patient at risk for a pressure ulcer

1. mobility 2. nutritional status 3. body fluids 4. pain

list the factors that influence pressure ulcer formation

1. nutrition 2. tissue perfusion 3. infection 4. infection 5. age 6. psychological impact of wounds

name the 22 pressure ulcer sites

1. occipital bone 2. scapula 3. spinous process 4. elbow 5. iliac crest 6. sacrum 7. ischium 8. Achilles tendon 9. heel 10. sole 11. ear 12. shoulder 13. anterior iliac spine 14. trochanter 15. thigh 16. medial knee 17. lateral knee 18. lower leg 19. medial malleolus 20. lateral malleolus 21. lateral edge of foot 22. posterior knee

identify the pressure factors that contribute to pressure ulcer development

1. pressure intensity 2. pressure duration 3. tissue tolerance

The Braden Scale was developed for assessing pressure ulcer risks. Identify the subscales of this tool

1. sensory perception 2. moisture 3. activity 4. mobility 5. nutrition 6. friction or shear

pain

Adequate pain control and patient comfort will increase mobility, which in turn reduces risk.

body fluids

Continuous exposure of the skin to body fluids, especially gastric and pancreatic drainage, increases the risk for breakdown.

staging system for pressure ulcers are based on the depth of tissue destroyed. Briefly describe each stage.

I - intact skin with nonblanchable redness of a localized area over a bony prominence. II- partial-thickness with tissue loss III- full-thickness with tissue loss IV- full-thickness tissue loss with exposed bone, tendon, or muscle.

dehiscence

a partial or total separation of wound layers; risks are poor nutritional status, infection, or obesity

identify three components involved in the healing process of a partial-thickness wound

a. inflammatory response b. epithelial proliferation (reproduction) c. migration with reestablishment of the epidermal layers.

character of wound drainage

assess amount, color, odor, and consistency of drainage, which depends on the location and the extent of the wound.

wound appearance

assess whether the wound edges are closed, the condition of tissue at the wound base; look for complications and skin coloration

eschar

black or brown necrotic tissue

hemorrhage

bleeding from a wound site; occurs after hemostasis indicates a slipped surgical suture, a dislodged clot, infection, or erosion of a blood vessel by a foreign object (internal or external)

puncture

bleeds in relation to the depth and size, with a high risk of internal bleeding and infection.

sanguineous

bright red, indicates active bleeding

serous

clear, watery plasma

inflammatory phase

damaged tissues and mast cells secrete histamine (vasodilates) with exudation of serum and WBC into damaged tissues.

exudate

describes the amount, color, consistency, and odor of wound drainage.

cold applications

diminishes swelling and pain, prolonged results in reflex vasodilation.

darkly pigmented skin

does not blanch

what are the complications of wound healing?

hemorrhage, hematoma, health care-associated infection, dehiscence, evisceration

what are the four phases involved in the healing process of a full-thickness wound?

hemostasis, inflammatory phase, proliferative phase, remodeling

heat applications

improves blood flow to an injured part; if applied for more than 1 hour, the body reduces blood flow by reflex vasoconstriction to control heat loss from the area.

hemostasis

injured blood vessels constrict, and platelets gather to stop bleeding; clots form a fibrin matrix for cellular repair.

dermis

inner layer of the skin that provides tensile strength and mechanical support

abrasion

is superficial with little bleeding and is considered a partial-thickness wound

hematoma

localized collection of blood underneath the tissue

pressure ulcer

localized injury to the skin and underlying tissue over a body prominence

nutritional status

malnutrition is a major risk factor; a loss of 5% of usual weight, weight less than 990% of IDW, or a decrease of 10 lb in a brief period.

remodeling

maturation, the final stage, may take up to 1 year; the collagen scar continues to reorganize and gain strength for several months.

types of tape

nonallergenic paper, plastic tapes, common adhesive tapes, elastic adhesive tape.

blanching

normal red tones of light-skinned patients are absent

drains

observe the security of the drain and its location with respect to the wound and the character of the drainage; measure the amount

serosanguineous

pale, pink, watery, mixture of clear and red fluid

mobility

potential effects of impaired mobility; muscle tone and strength

granulation tissue

red, moist tissue composed of new blood vessels, which indicates wound healing

health care-associated infection

second most common nosocomial infection; purulent material drains from the wound (yellow, green, or brown, depending on the organism)

laceration

sometimes bleeds more profusely depending on depth and location

slough

stringy substance attached to wound bed that is soft, yellow, or white tissue.

wound closures

surgical wounds are closed with staples, sutures, or wound closures. Look for irritation around staple or suture sites and note whether the closures are intact.

purulent

thick, yellow, green, tan, or brown

epidermis

top layer of the skin

evisceration

total separation of wound layers with protrusion of visceral organs through a wound opening requiring surgical repair.

collagen

tough, fibrous, protein

proliferative phase

with the appearance of new blood vessels as reconstruction progresses, the proliferative phase begins and lasts from 3 to 24 days. The main activities during this phase are the filling of the wound with granulation tissue, contraction of the wound, and resurfacing of the wound by epithelialization.

secondary intention- physiological process

wound is left open until it becomes filled by scar tissue; chance of infection is greater.

primary intention- physiological process

wound that is closed by epithelialization with minimal scar formation.