Tissue Integrity

Measuring wound length and width to facilitate meaningful comparisons of wound measurements across time

Use a uniform, consistent method for measuring

Hemostasis

a process where injured blood vessels constrict and platelets gather to stop the bleeding

Collagen

a tough, fibrous protein

What does it mean if the erythematous area does not blanch (non blanching erythema) when pressure is applied

deep tissue damage is probable

damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and exudation of serum and WBC's into damaged tissues

inflammatory phase (redness, warmth, swelling, throbbing)---est. a clean wound bed

hematoma

localized collection of blood beneath the tissues- appears as swellings, change in color, sensation, or warmth or mass that often takes a bluish discoloration

Pressure ulcer

localized injury to the skin and other underlying tissue, usually over a body prominance, as a result of pressure or pressure in combination with shear and/or friction

factors that put a pt at risk for impaired skin integ

pressure friction shearing

Purposes of dressings

protects a wound from microorganism contamination aids in hemostasis promotes healing by absorbing drainage and debriding a wound supports or splints the wound site protects pt from seeing the wound promotes thermal insulation of the wound surface provides a moist environment

hyperemia

redness of the skin due to vasodilation

Assess the skin surrounding the wound for (periwound)

redness, macerations, edema, warmth, any deterioration

when does hemostasis occur?

within several minutes unlless large blood vessels are involved/or poor clotting function

disruption of the integrity and function of tissues in the body

wound

Skin-associated issues prominent in older adults

-skin becomes more fragile -delayed wound healing decrease in vitamin D -susceptible to dry skin -decrease in sensory perception -greater risk of hypothermia or hyperthermia -elasticity decreases -decreased perspiration

To help decrease the threat of melanoma in a blonde-haired, fair-skinned patient at risk, the nurse would advise the patient to (Select all that apply):

. Wear sunglasses. D. Apply sunscreen 30 minutes prior to exposure. Wearing sunglasses and using sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamin K can cause the blood to clot and has not been indicated.

how long does the prolif. phase last?

3-24 days

What's the nurses most important responsibilities when it comes to the skin?

1. assessing/monitoring skin integrity 2. identifying problems 3. planning 4. implementing 5. evaluating interventions to maintain the skin integrity

ways to look for hemorrhage

1. distention or swelling of affected body area 2. change in the type or amount of drainage from surgical drain 3. signs of hypovolemic shock

3 processes involved in the healing process of a partial thickness wound

1. inflammatory response 2. epithelial proliferation (reproduction) and migration 3. reestablishment of the epidermal layers

In the presence of evisceration, what would you do?

1. place sterile towels soaked in sterile saline over the extruding tissues to reduce chances of bacteria infection or drying out and damage of tissues 2. this is a surgical emergency, so you would make sure pt is NPO and contact surgery team IMMEDIATELY 3. look for signs and symptoms of shock 4. prep pt for emergency surg.

Since pressure is the major element in the cause of pressure ulcers, what are three pressure-related factors that contribute to pressure ulcer development

1. pressure intensity (how much) 2. pressure duration (how long) 3. tissue intolerance (decreased response to stimulus after prolonged exposure)

the cutoff score for onset of pressure ulcer risk in the general adult population is

18

The nurse in the skilled nursing facility is very busy and unable to answer the call bell lights. Which tasks related to skin care can the nurse delegate to the nursing assistant? (Select all that apply):

A. Applying over-the-counter lotions to skin that is not broken. B. Assisting the client with frequent turning to prevent pressure ulcers. C. Covering the client who complains of being cold with more blankets. D. Placing a sterile gauze pad over broken skin to contain drainage. All the above options can be delegated to an unlicensed assistive personnel employee except for assessing a patient complaining of an itching rash. Assessment of a rash should be done by the nurse so the appropriate referrals can be made if necessary. The nurse needs to investigate a new rash for the possibility of an allergic reaction.

The nurse practitioner orders a wet-to-dry normal saline solution (NSS) dressing for a patient who has a stage III pressure ulcer on the sacral area. The patient's daughter will be dressing the wound at home. Which of the following steps should the nurse include in the teaching plan? (Select all that apply):

A. Cleansing the wound. B. Managing pain. Administering pain medications will ensure that the patient is comfortable prior to a dressing change. The nurse should cleanse the wound and then apply the sterile dressing. The order calls for a wet-to-dry normal saline dressing. A cold water bath would be contraindicated for pressure ulcer treatment.

11. What is the removal of devitalized tissue from a wound called?

A. Debridement Debridement is the removal of nonliving tissue, cleaning the wound to move toward healing.

The nurse would explain to a patient that effective treatments for atopic pruritus include (Select all that apply):

A. Oral steroids. B. Topical steroids. Oral and topical steroids may be given for acute cases of atopic pruritus. Oral and topical antihistamines are not usually given, because they are ineffective and may cause further irritation. Petroleum is also ineffective.

Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain?

A. Stage I A stage I pressure ulcer does not have a break in the skin but has a redness that does not blanch. Depending on the skin color, there may be a discoloration; the area may feel warm because of the vasodilation or cool if blood is constricted in the area; and the tissue may feel firm if there is edema in the area or soft if the blood flow is compromised. The patient may report pain in the area.

When is an application of a warm compress indicated? (Select all that apply.)

A. To relieve edema C. To improve blood flow to an injured part Warm compresses can improve circulation by dilating blood vessels, and they reduce edema. The moisture of the compress conducts heat.

6. For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part?

B. Ice bag An ice bag helps to constrict excess fluid in tissues, which prevents edema. The blood vessels become constricted, help to control bleeding, and can decrease pain where the ice bag is placed.

Innermost epidermal layer

Basal layer (stratum basale)

widely used risk-assessment tool for assessing oncoming pressure ulcers

Braden's scale; 6-23; lower the number, higher the risk

Which description best fits that of serous drainage from a wound?

C. Clear, watery plasma Serous fluid generally is serum and presents as light red, almost clear fluid.

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first?

C. Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration If a patient has an opening in the surgical incision and a portion of the small bowel is noted, the small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist.

A nurse is instructing a nursing assistant in how to prevent pressure ulcers in a frail elderly client. The nursing assistant indicates that she understands the instruction when she agrees to (Select all that apply):

C. Offer nutritional supplements and frequent snacks. D. Turn the patient at least every 2 hours. The patient should be turned at least every 2 hours because permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while the patient is on a 2-hour turning schedule, the patient must be turned more frequently. Protein-calorie malnutrition is another major risk factor for developing pressure ulcers. Additional supplements boost nutritional status, which is essential to healthy skin. Use of donut pads, elevation of the head of the bed, and overstimulation of the skin may all stimulate, if not actually encourage, dermal decline.

9. Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound?

C. Reduction of stress on the abdominal incision A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreasing stress from coughing and movement.

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient's pressure ulcer?

C. Unstageable To determine the stage of a pressure ulcer you examine the depth of the tissue involvement. Since the pressure ulcer assessed was covered with necrotic tissue, the depth could not be determined. Thus this pressure ulcer cannot be staged.

7. Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence?

C. Using an incontinence cleaner, followed by application of a moisture-barrier ointment Skin that is in contact with stool and urine can become moist and soft, allowing it to become damaged. The stool contains bacteria and in some cases enzymes that can harm the skin if in contact for a prolonged period of time. The use of an incontinence cleaner provides a gentle removal of stool and urine, and the use of the moisture-barrier ointment provides a protective layer between the skin and the next incontinence episode.

What's the largest organ in the body and constitutes 15% of the total adult body weight

The skin

What do you call it when you cannot stage an ulcer covered with necrotic tissue, because the necrotic tissue is covering the depth of the ulcer (slough or eschar); necrotic tissue must be debrided in order to make an assessment

Unstageable

Recommendations when assessing pressure ulcers on dark skin tones

Use proper lighting (natural or halogen)

are all chronic dermal wounds considered contaminated with bacteria? even if culture finding says otherwise

YES

Would an administration of steroids slow down an immune response?

YES; such as corticosteroids, they suppress the immune system; cancer would also it down or HIV

How to assess impaired skin integrity in darker skin

-color -temperature - appearance

Who's at risk for pressure ulcer development

a patient experiencing decreased mobility decreased sensory perception fecal or urinary incontinence poor nutrition the elder

Ischemia

a vascular disease involving an interruption in the arterial blood supply to a tissue, organ, or extremity that, if untreated, can lead to tissue death. It can be caused by embolism, thrombosis of an atherosclerosis artery, or trauma.

thin, outermost layer of the epidermis and consists of flatted, dead, keritinized cells

Stratum corneum

How can you assess blancing hyperemia

Pressing the fingernail and assessing capillary refill (<2 secs). If this happens after blanching (turning lighter in color), the hyperemia is transient and is an attempt to overcome the ischemic episode

Which of the following describes a hydrocolloid dressing?

D. A dressing that forms a gel that interacts with the wound surface A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing.

When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when a reddened area blanches on fingertip touch?

D. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode. When repositioning an immobile patient, it is important to assess all bony prominences for the presence of redness, which can be the first sign of impaired skin integrity. Pressing over the area compresses the blood vessels in the area; and, if the integrity of the vessels is good, the area turns lighter in color and then returns to the red color. However, if the area does not blanch when pressure is applied, tissue damage is likely.

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?

D. Wound after it has first been cleaned with normal saline Drainage that has been present on the wound surface can contain bacteria from the skin, and the culture may not contain the true causative organisms of a wound infection. By cleaning the area before obtaining the culture, the skin flora is removed.

When a wound fails to heal properly and the layers of the skin or tissue separate?

Disherence; most commonly occurs before collagen formation (3-11 days after injury)

are all wounds created equal?

FALSE

CANDIDA

Fungal infection commonly called yeast infection -can occur orally or in the vagina -occurs on the skin due to prolonged wetness -occurs orally/vaginally usually due to use of antibiotics -assess pt's skin and oral mucous membranes may appear red and scaly on skin oral form known as thrush; the tongue will have a white coating that cannot be removed -treated with medicated powders or creams for the skin form; medicated mouthwash such as Nystatin for the oral form

Triggers a complex healing response

Injury to the skin

why do obese people have a higher risk of poor healing

bbc of constant strain placed on their wounds and the poor healing qualities of fat tissue

after inflammatory response, epithelial cells do what

begin to regenerate, providing new cells to replace the lost cells

hemorrhage

bleeding from a wound sites (normal during and immediately after initial trauma)

How to assess the tissue type in the wound base

amount (%) and appearance (color) of viable and nonviable tissue

what differentiates the contaminated wounds from infected wounds?

amount of bacteria present

how early does collagen appear

as early as the second day

Nurses job

assess pressure ulcers at a regular time interval using systematic parameters, plan appropriate interventions, and evaluate progress

Psoriasis

autoimmune disorder with over production of skin cells; exacerbations and remissions do occur scaling disorder with underlying dermal inflammation psoriasis vulgaris most often seen exfoliative psoriasis- an explosively eruptive and inflammatory form of the disease TREATMENT: corticosteroids (suppresses immune system) other topical therapies UV light therapy Systemic therapy (suppressant) emotional support due to poor body image

Functions of the skin

1. protective barrier again disease-causing organisms and the outside world 2. sensory organ for pain, temperature, and touch 3. synthesizes vitamin D

Functions of stratum corneum

1. protects underlying cells and tissues from dehydration 2. prevents entrance of certain chemical agents 3. allows evaporation of water from the skin 4. permits absorption of certain topical meds

Purpose of the dermis; the innermost layer of the skin

1. provides tensile strength 2. mechanical support 3. protection to the underlying muscles, bones, and organs

main activities during prolif. phase

filling of the wound with granulation tissue contraction of the wound (reduces size of area that requires healing) resurfacing of the wound by epithialization fibroblasts present during this phase VASCULAR BED IS REESTABLISHED AND THE AREA IS FILLED WITH REPLACEMENT TISSUE (COLLAGEN, CONTRACTION, AND GRANULATION TISSUE) SURFACE IS REPAIRED BY EPITHELIALIZATION

Fibroblasts

found in the dermis, responsible for collagen formation; see this in the proliferative phase

Difference between friction and shearing

friction damages the epidermis and shearing damages the dermis

stage 3

full thickness skin loss or blister- wound digs down to the fat past the epidermis and dermis,however muscle and bone are not showing. some slough. some tunnels.

stage 4

full thickness skin loss- muscle and bone ARE visible Slough or eschar may be present. often includes undermining and tunneling

Tinea Pedis

fungal infections commonly called athletes foot -spread through direct contact with inanimate objects -lesions may be scaly patches with raised borders -pruritis is common symptom TREATED WITH ANTIFUNGAL SPRAYS AND CREAMS teach patient about medications, hygiene practices, how to prevent it

Tissue integrity antecedents

good nutrition lack of external trauma adequate perfusion limited pressure on site

4 phases involved in a full thickness healing process

hemostasis, inflammatory, proliferative, and remodeling

macrophages "garbage cell"

clean the wound of debride and release growth factors that attract fibroblasts, which synthesize collagen

Form a fibrin matrix that later provides a framework for cellular repair

clot

how does the nurse recognize wen an imbalance is developing or has developed?

comprehensive history skin and overall health assessment, risk assessment (braden's scale)

what's the purpose of hemostasis

control blood loss, est. bacterial control, seal the defect

according to centers for disease control, when is a wound infected

if purulent material drains from it, even if a culture is not taken or has negative results

what does the change in the size of the wound tell you

if the wound is healing or not

what does it mean when hemorrhage happens after hemostasis

indicates a slipped suture dislodged clot infection or erosion of a blood vessel by a foreign object

Excessive exudate

indicates presence of infection

Pediculosis

infestation of human lice head lice- Pediculosis capitis body lice- pediculosis corporis pubic or crab lice- pediculosis pubis pruritis most common symptom drugs laundering of clothing and bed linen teach patient how to prevent infestation teach hygiene practices

tissue integ assessment

intact tissue integ itching burning pain excessively dry skin; peeling draining wound stage I to IV pressure ulver tear in skin, laceration, abrasion depression, low self-esteem changes in skin color, skin temperature fluid and electrolyte imbalance

impetigo

is a common skin infection usually caused by streptococcus or staphylococcus bacteria most common in children occurs when a break in the skin allows bacteria to enter causing inflammation and infection exam: physical and wound culture treatment: topical antibiotics, if left untreated may lead to glomerulonephritis HOW TO PREVENT: KEEPING SKIN CLEAN AND DRY CLEANING MINOR CUTS AND SCRAPES WITH SOAP AND WATER IF INFECTION AVOID SHARING CARE ITEMS WITH FAMILY MEMBERS AFTER TOUCHING INFECTED AREA, WASH HANDS WITH SOAP AND WATER

secondary intention

longer wound healing by granulation tissue- edges not approximated (pressure ulcers, surgical wounds that have tissue loss, burns, lacerations) pain mgmt repositioning using barrier creams checking incontinent pt's frequently (skin dry, clean, intact) hygiene provide appropriate nutrients to promote healthy skin for wound healing admin meds prevent spread of infect's or infestations use lotions and oatmeal baths for pruritis

Two concerns related to the duration of pressure

low pressure for a prolonged period high pressure for a short period both cause tissue damage

Dermal epidermal- junction

membrane that separates the two layers of the skin (epidermis and the dermis)

Capillary closing pressure

minimal amount of pressure required to collapse a capillary (exceeds 15-32 mm Hg)

How does moisture affect risk for ulcer formation

moisture reduces the resistance of the skin to other physical factors such as pressure and/or shear. Prolonged moisture softens the skin making it more susceptible to damage (nurse needs to remember importance of keeping skin clean, dry, and intact) occurs from wound drainage, excessive perspiration, and fecal or urinary incontinence

How many organisms per gram until a wound is considered infected

more than 100,000

primary acting WBC

neutrophil, first on the seen, begin to ingest bacteria and small debris. once they ingest, they die and form into pus

how to know if someone has impetigo

one or more blisters that itch filled with yellow or honey colored fluid blisters ooze and crust over spread by direct contact with fluid in blisters can spread on the patient by patient scratching and then touching another area of body

negative consequences of impaired tissue integ

pain infection decubiti altered self-image loss of fluid and electrolyes

what non pharmacologic intervention might you use when disherence is about to occur?

place a thin folded blanket or pillow (sterile) over an abdominal wound when the pt is couging to provide a splint to the area, supporting the healing tissue when coughing increases the intraabdominal pressure

pt at risk for poor wound healing

poor nutritional status, obesity, infection

How do you assess a pressure ulcer

depth of tissue involvement (staging) type approximate percentage of tissue in wound bed wound dimensions exudate description condition of surrounding skin odor

Wound exudate

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

What's the purpose of the staging system

describing the depth of tissue destroyed

black or brown necrotic tissue

eschar

How to assess duration

evaluating the amount of pressure determining the amount of time that a patient tolerates pressure

Terms used to describe impaired skin integrity related to unrelieved, prolonged pressure

pressure ulcer (most current), pressure sore, decubitus ulcer (outdated), and bedsore

components of tissue integ

primary prevention self-care behaviors 3 stages of wound healing (primary, secondary, tertiary)

positive outcomes of tissue integrity

protection from infection adaptation to the environment maintenance of fluid and electrolyte balance regulation of acid-base balance vitamin D production

Suspected deep tissue injury

purple or maroon localized area of discolored intact skin of blood-filled blister caused by damage of underlying soft tissue from pressure and or shear; difficult to assess in dark skin tones

Function of our tissue

receive oxygen and nutrients and eliminates metabolic wastes via the blood. Any factor that interferes with blood flow in turn interferes with cellular metabolism and the function or life of the cells

Granulation tissue

red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing: remember G is for Growth

Concepts incorporated on a braden's scale

sensory perception moisture activity mobility nutrition friction and shearing

partial-thickness wounds

shallow wounds involving loss of the epidermis and sometimes partial loss of the dermis (heal by regeneration, bc epidermis regenerates) surgical wound or abrasion

Factors affecting the skins ability to tolerate pressure

shear, friction, moisture ability of the underlying skin structures (blood vessels, collagen) to assist in redistributing pressure poor nutrition increased age hydration status (turgor) low BP

Stage I

skin intact, discolored, nonblanchable, can be hard or firm, warmer or cooler than adjacent tissues, but may sill be painful harder to assess in dark skinned peoples

Cyanosis

slightly bluish-grayish slatelike or dark purple discoloration of the skin caused by the presence of at least 5 grams of reduced hemoglobin in arterial blood.

Soft yellow or white tissue , stringy substance attached to the wound bed

slough

What do wound classification systems describe

status of skin integrity, cause of the wound, severity or extent of tissue injury or damage, cleanliness of the wound, descriptive qualities of the tissue (color)

5 layers of the epidermis

stratum corneum stratum lucidum stratum granulosum stratum spinosum stratum basale

Attributes of tissue integrity

structurally intact and functioning integument

definition of tissue integrity

the ability of the body to regenerate and or repair to maintain normal physiological processes

Friction

the force of two surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as a bed linen resulting in red and painful skin or sheet burn (restless pt's, spastic pt's and those who are dragged and not lifted)

a surgical wound infection usually doesn't develop until when

the fourth or fifth post op day. pt shows signs of fever, tenderness and pain at the wound site, elevated WBC count, edges of wound inflamed, odorous and purulent drainage, color is yellow, green, or brown, depending on the causitive organism

The ability of tissue to endure pressure depends on what

the integrity of the tissue and the supporting structures

What is shearing

the sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary (head of bed elevated and skeleton starts to slide, but skin is fixed bc of friction with the bed. skin and subcut. layers adhere to the surface of the bed, layers of muscle and bone slide in the direction of body movement causing underlying tissue capillaries to stretch and become angulated causing tissue necrosis deep in the tissues

what determines the mechanism for repair for any wound

the tissue layers involved and their capacity for regeneration

Why do people who have decreased sensory perception have more of a risk for developing a pressure ulcer?

they are unable to feel or sense when a portion of their body undergoes increased, prolonged pressure or pain

why do full thickness wounds heal by scar formation

they extend into the dermis and deeper structures do not regenerate

two types of wounds

those with loss of tissue and those without loss of tissue

what causes the inflammatory response

tissue trauma; causes redness and swelling with small amount of exudate (first 24 hours after wounding)

How to measure depth of a wound

using a cotton-tipped applicator in the wound bed

when to be on alert for potential disherence?

when there is an increase in serosanguineous drainage from the wound

when do leukocytes reach the wound

within a few hours

tertiary intention

would left open for several days, then would edges are approximated (wounds that are contaminated and require observation for signs of inflammation)--- teach pt about home care and concerning pressure relief, would care, hygiene, and incontinence care, pruritis relief wit oatmeal bath, lotion, nutrition, safety behaviors

wound edges are approximated

wound edges are closed

involves integrated physiological processes

wound healing process

chronic wound class

wound that fails to proceed through an orderly and timely reparative process to produce anatomical and functional integrity (vascular compromise, chronic inflammation or repetitive insults to tissue) such as continued exposure to insult impedes wound healing

primary intention

wound that is closed (surgical incision, wound that is sutured or stapled) rapid healing- patient education includes: identify risk factors for impaired skin integ and impaired tissue integ, the importance of nutrition, mobility, and keeping skin clean, dry, and intact to prevent skin/tissue probs. Safety behaviors to prevent trauma

Acute wound class

wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity (trauma, surgical incision)---easily cleaned and repaired. wound edges are clean and intact

exemplars of tissue integrity

wounds dermal ulcers impetigo tinea pedis candida pediculosis psoriasis

does a moist environment promote wound healing

yes

should eschar be debrided from the heels?

NO; serves as a natural biologic cover for the body

A wound left open to air can resurface within ____ to ____ days. One kept moist can resurface in ___ days

6 to 7 days; 4 days this is due to the fact that epidermal cells only migrate across a moist surface

patients who are confused or disoriented and those who have expressive aphasia or other inability to verbalize or changing levels of consciousness are unable to protect themselves prom pressure ulcer development bc they can't ask for help or don't know how

Alteration in level of consciousness

What does the Braden Scale evaluate?

B. Risk factors that place the patient at risk for skin breakdown The Braden Scale measures factors in six subscales that can predict the risk of pressure ulcer development. It does not assess skin or wounds.

Layer of skin that contains collagen, blood vessels, and nerves

Dermal

Top, outermost layer of the skin

Epidermis

Evisceration

Extrusion of viscera or intestine through a surgical wound

Stage 2

Partial thickness skin loss- depth: down into the epidermis and dermis. shallow pink wounded bed without slough. Could also be an intact or open/ruptured serum-filled blister or serosanguineous filled blister. shiny or dry and shallow without slough or bruising (skin tears, tape burns, incontinence-associated dermatitis, maceration, or excoriation)

Biggest difference between primary and secondary intention?

Risk for infection is greater in secondary, tissue loss, and healing time

Impaired mobility and tissue integ

Pt's unable to independently change positions are at risk for pressure ulcers

Dehiscence

Separation or splitting open layers of a surgical wound

is it true that wound infection is greater when the wound contains dead or necrotic tissue?

TRUE; there are foreign bodies in or near the wound and the blood supply and local tissue defenses are reduced

Blanching

Occurs when the normal red tones of the light skinned patient are absent