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.