Fundamentals - Exam 1 (CH 48) Study Guide

CH 48 - Describe the PRESSURE ULCER STAGING SYSTEM

(p. 1179-1180) STAGE I: Nonblanchable Redness of Intact Skin --intact skin with nonblanchable erythema of a localized area (usually over a bony prominence) --skin discoloration, warmth, edema, hardness, or pain a(dark pigmented skin "at-risk" may not have visible blanching, difficult to detect) --area may be painful, firm, soft, warmer, or cooler than adjacent tissue. STAGE II: Partial-thickness Skin Loss or Blister --partial-thickness loss of dermis --shiny or dry shallow open ulcer with red-pink wound bed without slough or bruising. --may present as an intact or open/ruptured serum-filled or serosangineous filled blister -- this stage shouldn't be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration, or excoriation STAGE III: Full-thickness Skin Loss (Fat Visible) --subcutaneous fat may be visible; but bone, tendon, or muscle is not exposed. --some slough may be present. --may include undermining and tunneling --depth of a stage III pressure ulcer varies by anatomical location. (bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue; and stage III ulcers can be shallow) --areas of significant adiposity can develop extremely deep stage III pressure ulcers. --Bone/tendon is not visible or directly palpable STAGE IV: Full-thickness Tissue Loss (Muscle/Bone Visible) --exposed bone, tendon, or muscle. --slough/eschar may be present; often includes undermining and tunneling. --depth of a stage IV pressure ulcer varies by anatomical location. (bridge of nose, ear, occiput, and malleolus don't have (adipose) subcutaneous tissue; and these ulcers can be shallow) --can extend into muscle and/or supporting structures (fascia, tendon, or joint capsule), making osteomyelitis or osteitis likely to occur. --exposed bone/muscle is visible or directly palpable UNSTAGEABLE/UNCLASSIFIED: Full-thickness Skin or Tissue Loss—Depth Unknown --base of the wound cannot be visualized --loss in which actual depth of ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in wound bed --until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but is either a stage III or IV. --Stable eschar (dry, adherent, intact without erythema or fluctuance) on heels serves as "the natural (biological) cover of the body" and should not be removed. SUSPECTED DEEP-TISSUE INJURY —Depth Unknown --purple/maroon localized area of discolored intact skin or blood-filled blister caused by damage of underlying soft tissue from pressure and/or shear --area may be preceded by tissue that's painful, firm, mushy, boggy, warmer, or cooler than adjacent tissue. --difficult to detect in individuals with dark skin tones. --evolution may include a thin blister over a dark wound bed. --may further evolve and become covered by thin eschar. --evolution may be rapid, exposing additional layers of tissue even with treatment.

CH 48 - Describe the differences of wound healing by PRIMARY and SECONDARY INTENTION

(p. 1181, 1182) PRIMARY INTENTION --wounds without loss of tissue --clean surgical incision, wound sutured or stapled (skin edges are approximated, or closed, and the risk of infection is low) --healing occurs quickly, by epithelialization, with minimal scar formation, as long as infection and secondary breakdown are prevented SECONDARY INTENTION --wounds involving loss of tissue --burn, pressure ulcer, or severe laceration --heals by granulation tissue formation, wound contraction, and epithelialization --wound is left open until it becomes filled by scar tissue --takes longer to heal, thus chance of infection is greater. --if scarring from secondary intention is severe, loss of tissue function is often permanent

CH 48 - Describe the differences between nursing care of ACUTE and CHRONIC WOUNDS

(p. 1181, 1194, 1199) ACUTE WOUNDS --wound heals promptly and without complications; easily cleaned and repaired; wound edges are clean and intact. --needs immediate intervention; require close monitoring (every 8 hours) --skill of applying dry and moist dressings to the new acute wound can't be delegated to nursing assistive personnel (NAP) --Wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity --trauma, a surgical incision CHRONIC WOUNDS --course of treatment is lengthy and costly --patient's hygiene is more important --assessment occurs less frequently (usually not more than 1 time per day) --stable, but difficult to heal --uses clean technique --wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity --vascular compromise, chronic inflammation, or repetitive insults to tissue --continued exposure to insult impedes wound healing

CH 48 - Discuss the NORMAL PROCESS of WOUND HEALING, including types of drainage assessed

(p. 1182 -83) ***PARTIAL-THICKNESS WOUNDS: --shallow wounds involving loss of the epidermis and possibly partial loss of dermis. --heal by epidermis regeneration (surgical wound or an abrasion) 1) INFLAMMATORY RESPONSE: --causes redness and swelling with moderate amount of serous exudate. --generally limited to the first 24 hours after wounding 2) EPITHELIAL PROLIFERATION (reproduction) and MIGRATION: --epithelial cells regenerate, providing new cells to replace lost cells. --start at both the wound edges and epidermal cells lining epidermal appendages, allowing for quick resurfacing. --epithelial cells migrate across wound bed soon after --a wound left open to air can resurface within 6 to 7 days, whereas one that is kept moist can resurface in 4 days. --the difference in healing rate is related to the fact that epidermal cells only migrate across a moist surface. (in a dry wound the cells migrate down into a moist level before migration can occur) 3) REESTABLISHMENT of EPIDERMAL LAYERS: --new epithelium is only a few cells thick and must undergo reestablishment of epidermal layers. --cells slowly reestablish normal thickness and appear as dry, pink tissue. ***FULL THICKNESS WOUNDS --extend into dermis (involving both layers of tissue) --heal by scar formation, because deeper structures don't regenerate (pressure ulcers) 1) HEMOSTASIS: --injured blood vessels constrict, and platelets gather to stop bleeding. --clots form a fibrin matrix that provides a framework for cellular repair 2) INFLAMMATORY RESPONSE: --damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and exudation of serum and WBCs into damaged tissues. --localized redness, edema, warmth, and throbbing --leukocytes (WBCs) reach wound within a few hours. --neutrophil (primary-acting WBC): ingest bacteria and small debris. --monocyte (transforms to macrophages): the "garbage cells" that clean a wound of bacteria, dead cells, and debris by phagocytosis. --macrophages continue clearing wound debris and release growth factors that attract fibroblasts (cells that synthesize collagen) --collagen (appears as early as second day): connective tissue main component of scar tissue. 3) PROLIFERATIVE PHASE --lasts from 3-24 days --filling the wound with granulation tissue, contraction of the wound, and resurfacing of wound by epithelialization. --fibroblasts synthesize collagen, providing matrix for granulation --collagen: mixes with granulation tissue (supports reepithelialization), provides strength and structural integrity to a wound. --wound contracts to reduce area that requires healing. --finally epithelial cells migrate from wound edges to resurface. --in a clean wound: vascular bed is reestablished (granulation tissue), area is filled with replacement tissue (collagen, contraction, and granulation tissue), and surface is repaired (epithelialization) 4) REMODELING --maturation takes place for more than a year, depending on the depth and extent of the wound. --collagen scar continues to reorganize and gain strength for several months. (however, a healed wound usually doesn't have tensile strength of the tissue it replaces) --collagen fibers undergo remodeling/reorganization before assuming their normal appearance. --scar tissue contains fewer pigmented cells (melanocytes) and has a lighter color than normal skin. --in dark-skinned individuals scar tissue may be more highly pigmented than surrounding skin.

CH 48 - Describe COMPLICATIONS of wound healing

(p. 1183) 1) HEMORRHAGE --bleeding from a wound site (normal during and immediately after initial trauma) --occurs after hemostasis: a slipped surgical suture, dislodged clot, infection, or erosion of a blood vessel by a foreign object (a drain). --occurs externally or internally --hematoma (internal): localized collection of blood underneath tissues. It appears as a swelling, change in color, sensation, or warmth or mass that often takes on a bluish discoloration. (hematoma near a major artery/vein is dangerous because pressure from the expanding hematoma obstructs blood flow) 2) INFECTION --infected if purulent material drains from it, even if a culture is not taken or has negative results --wounds with more than 100,000 (105) organisms per gram of tissue are infected --chances of wound infection are greater when: wound contains necrotic tissue, there are foreign bodies in or near the wound, and the blood supply and local tissue defenses are reduced. --bacterial wound infection inhibits wound healing 3) DEHISCENCE --wound fails to heal properly, the layers of skin and tissue separate (commonly occurs before collagen formation 3-11 days after injury). --partial or total separation of wound layers. --patients who's at risk for poor wound healing (poor nutritional status, infection, or obesity) is at risk --obese patients have a higher risk: constant strain placed on their wounds and poor healing qualities of fat tissue --involves abdominal surgical wounds and occurs after a sudden strain (coughing, vomiting, or sitting up in bed) --increase serosanguineous drainage: potential dehiscence 4) EVISCERATION --total separation of wound layers (protrusion of visceral organs through a wound opening) occurs. --emergency condition that requires surgical repair. --place sterile towels soaked in sterile saline over extruding tissues to reduce chances of bacterial invasion and drying of tissues. --if organs protrude through wound, blood supply to tissues is compromised. --immediately contact surgical team, don't allow patient anything by mouth (NPO), observe for signs and symptoms of shock, and prepare for emergency surgery.

CH 48 - Explain the factors that IMPEDE or PROMOTE wound healing

IMPEDE HEALING --when there's too little inflammation occurs during inflammatory phase (cancer or after administration of steroids) --when there's too much inflammation, because arriving cells compete for available nutrients. (wound infection in which increased metabolic energy requirements compete for available calorie intake) --systemic factors: age, anemia, hypoproteinemia, and zinc deficiency. --poor nutritional status, infection, or obesity --dry wound left open to air can resurface within 6 to 7 days; cells will migrate down into a moist level before migration can occur PROMOTE HEALING --wound that's kept moist can resurface in 4 days, because epidermal cells only migrate across a moist surface. --Calories: fuel for cell energy "protein protection" --Protein: fibroplasia, angiogenesis, collagen formation and wound remodeling, immune function --Vitamin C: collagen synthesis, capillary wall integrity, fibroblast function, immunological function, antioxidant --Vitamin A: reduces the negative effects of steroids on wound healing, epithelialization, wound closure, inflammatory response, angiogenesis, collagen formation --Zinc (trace element): epithelialization, collagen synthesis, protein synthesis, cell membrane and host defenses --Copper: collagen fiber linking --Fluid: essential fluid environment for all cell function --Oxygen

CH 48 - List appropriate NURSING INTERVENTIONS for a patient with IMPAIRED SKIN integrity

INTERVENTIONS (p. 1193) **Pressure Management: --reposition every 90 minutes. --offer pain medication as needed. --when patient transfers from bed to chair, remind them not to slide over sheets but to pick up pelvis and relocate from one position to another. --be careful not to slide patient on sheets. --elevate head of bed no more than 30 degrees. **Pressure Ulcer Care: --keep skin dry and clean; avoid rubbing area. --use moisture barrier ointment over ulcer at least 3 times a day to decrease friction and provide moisture to open tissue. **Surgical Wound Care: --irrigate wound with saline solution twice per day per wound care provider's order. --apply dressing (gauze moistened with antibiotic solution twice a day after irrigation) according to wound care provider's order. --at frequent intervals, evaluate patient's pain level and offer pain medication as indicated by assessment. PRESSURE ULCER PREVENTION (p. 1196) **Decreased sensory perception: --assess pressure points for signs of nonblanching reactive hyperemia. --provide pressure-redistribution surface. **Moisture: --assess need for incontinence management. --following each incontinent episode, clean area with no-rinse perineal cleaner and protect skin with moisture-barrier ointment. **Friction and shear: --reposition patient using drawsheet and lifting off surface. --provide trapeze to facilitate movement. --position patient at a 30-degree lateral turn and limit head elevation to 30 degrees. **Decreased activity/mobility: --establish and post individualized turning schedule. **Poor nutrition: --provide adequate nutritional and fluid intake; assist with intake as necessary. --consult dietitian for nutritional evaluation.

CH 48 - Discuss RISK FACTORS that contribute to PRESSURE ULCER formation

RISK FACTORS of pressure ulcer (p. 1177-1179) (1) PRESSURE INTENSITY: --if pressure applied over a capillary exceeds normal capillary pressure and vessel is occluded for a prolonged period of time, tissue ischemia can occur --if patient has reduced sensation and cannot respond to discomfort of ischemia, tissue ischemia and tissue death result. (2) PRESSURE DURATION: --low pressure over a prolonged period and high-intensity pressure over a short period cause tissue damage. --extended pressure occludes blood flow and nutrients and contributes to cell death (3) TISSUE TOLERANCE: --ability of tissue to endure pressure depends on integrity of tissue and supporting structures. --extrinsic factors: shear, friction, and moisture affect ability of skin to tolerate pressure (the greater the degree to which the factors of shear, friction, and moisture are present, the more susceptible the skin will be to damage from pressure) --depends on ability of skin structures (blood vessels, collagen) to assist in redistributing pressure. --systemic factors (poor nutrition, increased aging, hydration status, and low blood pressure) affect tolerance of tissue to externally applied pressure. (4.) IMPAIRED SENSORY PERCEPTION: --unable to feel when a portion of their body undergoes increased, prolonged pressure or pain. Thus the patient who can't feel or sense that there is pain or pressure is at risk for the development of pressure ulcers. (5.) IMPAIRED MOBILITY: --unable to reposition off bony prominences. (6.) ALTERATION IN LEVEL OF CONSCIOUSNESS: --patients who are confused/disoriented, have expressive aphasia, other inability to verbalize, or has changing levels of consciousness are unable to protect themselves from pressure ulcer. --patients who are confused/disoriented are sometimes able to feel pressure but aren't able to understand how to relieve it or communicate their discomfort. --patients in a coma can't perceive pressure and are unable to move voluntarily to relieve pressure. (7.) SHEAR: --sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary --skin and subcutaneous layers adhere to surface of bed, and layers of muscle and bones slide in direction of body movement --underlying tissue capillaries are stretched and angulated by shear force. As a result, necrosis occurs deep within tissue layers. (tissue damage occurs deep in tissues, causing undermining of dermis) (8.) FRICTION: --the force of two surfaces moving across one another such as mechanical force exerted when skin is dragged across a coarse surface (bed linens) --affects epidermis/top layer of the skin. --denuded skin appears red and painful and is sometimes referred to as a "sheet burn." --occurs in: patients who are restless, who have uncontrollable movements (spastic conditions), and in those whose skin is dragged rather than lifted from the bed surface during position changes (9.) MOISTURE --reduces resistance of skin to other physical factors (pressure and/or shear force). --prolonged moisture softens skin, making it more susceptible to damage. --immobilized patients who are unable to perform their own hygiene needs depend on the nurse to keep the skin dry and intact. --skin moisture originates from wound drainage, excessive perspiration, and fecal/urinary incontinence.