Unit 9 Surgical Client Needs/Skin Integrity and Wound Care

secondary intention healing

wound in which the tissue surfaces are not approximated and there is extensive tissue loss; formation of excessive granulation tissue and scarring

Pressure injury

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

Pressure points

areas of the body that bear much of its weight

assessing wound measurement depth

measure with measuring stick

Pressure injury prevention (NO ULCERS)

- prevent friction and shear - position to relieve pressure points

slough

Tissue that is yellow is color and devitalized, wet stringy

eschar

a thick layer of dead tissue

serous wound drainage

clear and watery fluid

Risk factors for wound healing

- Obesity - Diabetic - Poor nutrition - Low oxygenation - Radiation - Corticosteroids - Infection - Dry wounds - Necrotic tissue

Tertiary intention healing

(delayed primary intention) - type of wound healing where wounds that are left open 3-5 days to allow edema or infection to resolve or exudates to drain and are then closed with sutures, staples or adhesive skin

wound tunneling

- wounds with channels that extend through and deeper into the subcutaneous tissue and muscle - measure with face of clock

Neuropathic Foot Ulcers

-Tend to occur where weight bearing pressure on areas where fat pads have shifted away - Can be secondarily infected - Quickly lead to cellulitis abscess formation, and osteomyelitis - sepsis may complicate, resulting in gangrene

induration

Act of hardening; a specific area of hardened tissue

Sanguineous wound drainage

Bright red; indicates active bleeding

Serosanguineous wound drainage

Pale, pink, watery; mixture of clear and red fluid

Arterial wound

Cause: insufficient blood supply to area, causing ischemia (dead tissue)

Venous wound

Cause: pooling causing increased pressure in veins

Remodeling healing phase

Collagen scar continues to gain strength, usually fewer melanocytes. Takes months to years. 80% tensile strength the scar tissue

stage 4 pressure injury

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.

Laceration wound

Jagged, irregular break or tear of tissue, usually caused by blunt trauma.

inflammatory phase of healing

Platelets for clots, white blood cellsclean up, fibrin matrix for repair Localized redness, edema, warmth.Up to 3 days

Kennedy terminal ulcer

Skin breakdown or failure related to dying process Sacral/coccygeal ulcer Often shaped like a butterfly Similar to abrasion or blister at first, deteriorates quickly

Unstagable pressure injuries

Unstagable pressurefull-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 injuries

Puncture wound

a deep hole made by a sharp object

fistula

abnormal passageway between two organs or between an internal organ and the body surface

Contusion wound

bruise

Proliferative phase of wound healing

collagen peaks and capillary networks (new bloodvessels) granulation, epithelialization, contraction and resurfacing.

necrosis

dead tissue

stage 3 pressure injury

full thickness loss, looks like deep crater extend to fascia, subcutaneous tissue damaged/neocritical visible undermining/tunneling may be present damage to surrounding tissue

assessing wound measurements

length/width/depth in cm

assessing wound circumference

measured in cm

granulation tissue

new blood vessels or vascular bed and connective tissues in a wound bed

stage 1 pressure injury

non-blanchable erythema of intact skin

stage 2 pressure injury

partial thickness skin loss with exposed dermis

deep tissue injury

persistent non-blanchable deep red, maroon, or purple discoloration

Fibrin clot

protein involved in the clotting of blood, a "mesh"

erythema

redness of the skin

braden score

sensory perception, moisture, activity, mobility, nutrition, friction and shear

maceration

softening of tissue by soaking

??

surface repair; regeneration of the epidermis across the wound surface

purulent wound drainage

thick, yellow, green drainage

wound undermining

tissue destruction that occurs under wound intact skin around the perimeter

Primary intention healing

tissue surfaces are approximated (closed) and there is minimal or no tissue loss, formation of minimal granulation tissue and scarring

denuded

to make naked or bare