Final: Week 12 Skin and Wounds

Calcium alginate, hydrofiber, foam (3-4)

Use when there is moderate-heavy exudate.

Secondary intention

Wound edges are not approximated Wound healing involving loss of tissue, such as a burn, pressure ulcer, or severe laceration. Filled by scar tissue from the bottom up Causes: pressure ulcers, surgical wounds that have tissue loss Implications for healing: Wound heals by granulation tissue formation, wound contraction, and epitheliazation

Serous

clear

Condition of skin surrounding the wound

is evaluated for redness, warmth, maceration, or edema (swelling); can indicate wound deterioration.

Exudate

is the amount, color, consistency, and odor of wound drainage; can indicate presence of infection.

Maceration

moisture

wet-to-dry dressings

only for debridement.

Stage II: Partial-thickness Skin Loss or Blister

A partial-thickness loss of dermis presents as a shallow open ulcer with a red-pink wound bed without slough. It may also present as an intact or open/ruptured serum-filled or serosangineous filled blister. Further description: Stage II presents as a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration, or excoriation

Pressure Ulcers

(a.k.a pressure sore, decubitus ulcer, bed sore) is localized injury to the skin and other underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction (NPUAP, '07). Moisture and bacteria Bacteria like alkaline Want pH to be 5.5 = acidic

Avoiding Pressure Points: 30° Lateral Position (pic)

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Cleansing a Wound Site (pic)

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Hydrocolloid, Hydrogel,Calcium Alginate (pic)

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Packing Wound (pic)

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Pressure Points (pic)

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Pressure Ulcer: Stage 2 (pic)

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Pressure Ulcers (pic)

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Shearing Force (pic)

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Stage 1 Pressure Ulcer: (pic)

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Stage 3 Pressure Ulcer: (pic)

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Stage 4 Pressure Ulcer: (pic)

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Unstageable Pressure Ulcer (pic)

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Wound Vac (pic)

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Wound healing (pic)

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Define the risks factors that contribute to pressure ulcer formation.

*Impaired Sensory Perception-unable to feel pain and pressure, therefore at risk for impaired skin integrity *Impaired Mobility-pts unable to independently change positions are at risk *Alteration in Level of Consciousness-inability to verbalize or changing LOC unable to know pressure ulcer formation *Shear-sliding movement of skin and subq tissue while underlying muscle and bone are stationary *Friction-force of two surfaces moving across one another such as bed linen *Moisture-reduces the resistance of skin to pressure and/or shear force.

13What does the Braden Scale evaluate? 1Skin integrity at bony prominences, including any wounds 2Risk factors that place the patient at risk for skin breakdown 3The amount of repositioning that the patient can tolerate 4The factors that place the patient at risk for poor healing

2Risk 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.

4After 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? 1Allow the area to be exposed to air until all drainage has stopped 2Place several cold packs over the area, protecting the skin around the wound 3Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration 4Cover the area with sterile gauze, place a tight binder over it, and ask the patient to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly

3Cover 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.

14On 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? 1Stage II 2Stage IV 3Unstageable 4Suspected deep tissue damage

3Unstageable 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.

7Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence? 1Keeping the buttocks exposed to air at all times 2Using a large absorbent diaper, changing when saturated 3Using an incontinence cleaner, followed by application of a moisture-barrier ointment 4Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel

3Using 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.

2Which 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? 1Stage I 2Stage II 3Stage III 4Stage IV

1Stage 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.

10When is an application of a warm compress indicated? (Select all that apply.) 1To relieve edema 2For a patient who is shivering 3To improve blood flow to an injured part 4To protect bony prominences from pressure ulcers

1To relieve edema 3To 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.

Stage III: Full-thickness Skin Loss (Fat Visible)

A stage III ulcer is a full-thickness tissue loss. Subcutaneous fat may be visible; but bone, tendon, or muscle is not exposed. Some slough may be present. It may include undermining and tunneling. Further description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue; and stage III ulcers can be shallow. In contrast, 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)

A stage IV ulcer is a full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. It often includes undermining and tunneling. Further description: The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue; and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule), making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable

8Which of the following describes a hydrocolloid dressing? 1A seaweed derivative that is highly absorptive 2Premoistened gauze placed over a granulating wound 3A debriding enzyme that is used to remove necrotic tissue 4A dressing that forms a gel that interacts with the wound surface

4A 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

1When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when a reddened area blanches on fingertip touch? 1A local skin infection requiring antibiotics 2Sensitive skin that requires special bed linen 3A stage III pressure ulcer needing the appropriate dressing 4Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.

4Blanching 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.

3When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? 1Necrotic tissue 2Wound drainage 3Drainage on the dressing 4Wound after it has first been cleaned with normal saline

4Wound 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.

Describe various nursing diagnoses for a client with impaired skin integrity.

Risk for Infection Imbalanced Nutrition (< body requirements) Pain (acute/chronic) Impaired Physical Mobility Impaired Skin (Stage 1&2 )/Tissue Integrity (Stage 3&4), unstageable Risk for Impaired Skin Integrity Ineffective Tissue Perfusion - decreased oxygen to area Self-esteem

Nursing Diagnoses

Risk for Infection Imbalanced Nutrition (< body requirements) Pain (acute/chronic) Impaired Physical Mobility Impaired Skin (Stage 1&2 )/Tissue Integrity (Stage 3&4), unstageable Risk for Impaired Skin Integrity Ineffective Tissue Perfusion - decreased oxygen to area Self-esteem

Skin

The skin is the body's largest organ, comprising 15% of the total body weight. The skin provides: A protective barrier against disease-causing organisms; A sensory organ for pain, temperature, and touch; Vitamin D synthesis Injury to the skin poses risks to safety and triggers a complex healing response. Knowing the normal healing pattern will help students recognize alterations that require intervention.

Wound V.A.C.

Uses negative pressure to support healing. is a device that assists in wound closure by applying localized negative pressure to remove fluid from the surrounding wound, reducing edema and improving circulation to the area and to draw the edges of the wound together. Accelerates wound healing by promoting the formation of granulation tissue, collagen, fibroblasts, and inflammatory cells in order to completely close or improve the health of a wound in preparation for a skin graft.

Braden Scale

Sensory perception, moisture, activity, mobility, nutrition, and friction and shear; most commonly used scale. Determines if pt. is at high risk for developing pressure ulcer The lower the # = higher risk The higher the # = lower risk

Assessment

Skin: Subjective (sensation, movement, continence status) and objective data (color, temperature, turgor, integrity) Risk for Pressure Ulcers: Braden & Norton Scales Mobility Nutritional (atleast 35-45 kcal) & Fluid Status (increase fluids), Vit A, C, Zinc Pain Body Fluids/Existing Wounds Laboratory Results

12Name the three important dimensions to consistently measure to determine wound healing.

Width, length, and depth

Measuring Wound Depth

Wound dimensions should include: measurements of depth, length, and width; indicator for wound healing. Length is the largest area from a head-to-toe perspective; width, the largest area from a side-to-side perspective. Measure depth by using a cotton-tipped applicator in the wound bed (dip in .9% NS to reduce injuring newly formed granulation tissue). If the depth is uneven, measure several areas; document the range and which part of the wound is the deepest. When a wound has an irregular shape, a tracing is useful to document size. If a wound is photographed a written consent must be obtained; adhere to the facility's policies and procedures. Use wound film with size markings included or place a ruler in the photograph for perspective. The assessment of tissue type in a pressure ulcer indicates the amount (%) and appearance/color of viable and nonviable tissue. Red, moist tissue is indicative of granulation tissue which is progressing toward healing. Soft yellow or white tissue can be characteristic of slough (stringy substance attached to wound bed) which is tissue that must be removed before the wound can heal. Black/brown tissue is generally eschar (necrotic tissue) which must be removed before healing can proceed. Exudate is the amount, color, consistency, and odor of wound drainage; can indicate presence of infection. Condition of skin surrounding the wound is evaluated for redness, warmth, maceration, or edema (swelling); can indicate wound deterioration.

Tertiary intention

Wound left open for several days, then wound edges are approximated Causes: wounds that are contaminated and require observation for signs of inflammation Implications for healing: Closure of wound is delayed until risk of infection is resolved

Chronic

Wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity. Causes: vascular compromise, chronic inflammation or repetitive insults to the tissue. Implications for healing: continued exposure to insult impedes wound healing

Primary intention

Wound that is closed Wound healing with little tissue loss. Causes: Surgical incision, wound that is sutured or stapled Implications for healing: Healing occurs by epitheliazation; heals quickly with minimal scar formation

Acute

Wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity Causes: trauma, a surgical incision Implications for healing: wounds are usually easily cleaned and repaired. Wound edges are clean and intact

Wound assessment requires

a description of the appearance of the wound base, size, presence of exudate, and the periwound skin condition.

Describe the pressure ulcer staging system.

Staging systems for pressure ulcers are based on describing the depth of tissue destroyed. Accurate staging requires knowledge of the skin layers. A major drawback of a staging system is that you cannot stage an ulcer covered with necrotic tissue because the necrotic tissue is covering the depth of the ulcer. The necrotic tissue must be debrided or removed to expose the wound base to allow for assessment. Pressure ulcer staging describes the pressure ulcer depth at the point of assessment. Thus, once you have staged the pressure ulcer, this stage endures even as it heals. Pressure ulcers do not progress from a stage III to a stage I; rather, a stage III ulcer demonstrating signs of healing is described as a healing stage III pressure ulcer.

Stage 2 Pressure Ulcer:

Partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.

Norton Scale

Physical and mental condition, activity, mobility, and continence.

Contributing factors to the development of pressure ulcers.

Pressure, shearing force, and friction

Suspected Deep Tissue Injury

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Unstageable/Unclassified: Full-thickness Skin or Tissue Loss—Depth Unknown

The EPUAP and the NPUAP (2009) developed a definition for an ulcer in which the base of the wound cannot be visualized and a definition of tissue injury in which the depth of injury is unknown. An unstageable ulcer is a full-thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed Further description: Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it is either a stage III or IV. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the natural (biological) cover of the body" and should not be removed.

Wound Management

Cleanse Wound NS or non-cytotoxic cleaners; clean from area of least to most contaminated, away from wound edges. Irrigation - gets rid of debris but not the bacteria Sterile technique with 19g needle/angiocath and 35-ml syringe that delivers 8 psi. Debridement Mechanical, autolytical, chemical, or surgical/sharp

Wound Management

Client Education Consider: educational methods & tools, caregiver support, pain management, resources, and referrals. Nutrition Consider: diet, nutritional consult, lab values, supplements, and physical assessment data.

Goals & Outcomes

Client will exhibit wound improvement by 2 weeks. Client will have higher percentage of granulation tissue in the wound base. Client will have no further skin breakdown in any body location. Client will increase caloric intake by 10%.

Changing Dressings

Determine sterile vs. clean technique, know type of dressing, placement of drains, and equipment needed.

Skin

Epidermis - top layer, Thinner than dermis Older adults have less adipose tissue Dermis Collagen Fibroblasts

Unstageable Pressure Ulcer

Full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar, therefore true depth and stage cannot be determined. The base of the wound bed cannot be visualized until enough slough and/or eschar is removed.

Stage 4 Pressure Ulcer:

Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound. Often includes undermining and tunneling.

Stage 3 Pressure Ulcer:

Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Tunneling = use saline soaked Qtip and measure how deep it is Undermining = how deep layer is gone "impregnate" = hydrogel - moisten area With a moist wound = use "felt"

Full-Thickness Wound Repair

Full-thickness wounds extending into the dermis (involving both layers of tissue) heal by scar formation because deeper structures do not regenerate.

Hydrogel (2-4)

Gauze or sheet dressings with water or glycerin gel or in tube; secondary dressing. Maintains a moist surface to support healing.

Describe appropriate nursing interventions for a client with impaired skin integrity.

Health Promotion Topical Skin Care Protect bony prominences, skin barriers for incontinence. Positioning Turn every 1 to 2 hours as indicated; 30° lateral position (sacral) ; use of transfer board. Support Surfaces Decrease the amount of pressure exerted over bony prominences. Education

Complications of Wound Healing

Hemorrhage Hematoma Infection - day 3 Dehiscence - opening of wound Sutures or staples removed Evisceration - bowel Fistula - opening between organ to organ or organ to outside -Coming out from wrong spot Ex. Poop from vagina

Stage I: Nonblanchable Redness of Intact Skin

Intact skin presents with nonblanchable erythema of a localized area usually over a bony prominence. Discoloration of the skin, warmth, edema, hardness, or pain may also be present. Darkly pigmented skin may not have visible blanching. Further description: The area may be painful, firm, soft, warmer, or cooler than adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. It may indicate "at-risk" persons

Stage 1 Pressure Ulcer:

Intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from surrounding area. Nonblanching erythema - Area of skin will not blanch; Darker skin -> area will be darker purple

moist environment

Many wounds may require a dressing that will continuously provide a moist environment. A moist wound environment has the potential to damage the wound edges (periwound skin). This damage is maceration; the tissues of the periwound skin soften, and the connective fibers are damaged. This condition is also classified as moisture-associated skin damage (MASD).

When the external pressure against the skin is greater than the pressure needed to keep the capillary open

blood flow decreases to the adjacent tissues.

Granulation

blood suppy, pink

11What is the removal of devitalized tissue from a wound called? 1Debridement 2Pressure reduction 3Negative pressure wound therapy 4Sanitization

1Debridement Debridement is the removal of nonliving tissue, cleaning the wound to move toward healing.

6For 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? 1Binder 2Ice bag 3Elastic bandage 4Absorptive diaper

2Ice 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.

Induration

hardness/firmness

Wound assessment scales

help measure improvement of a healing pressure ulcer; do not use the staging system for this purpose.

Sanguineous

hemorrhage

Undermining

how deep layer is gone

Soft yellow or white tissue

can be characteristic of slough (stringy substance attached to wound bed) which is tissue that must be removed before the wound can heal.

Pressure ulcers

contribute to patient discomfort and decreased functional status, increased length of stay in acute and extended care settings, and increased cost of care.

The principles of wound first aid include

control of bleeding, cleaning, and protection.

Preventive skin care is aimed at

controlling external pressure on bony prominences and keeping the skin clean, well lubricated and hydrated, and free of excess moisture.

Sero-sanguineous

in healing wounds, post-op incision

Dermis

inner layer which provides tensile strength (resistance to longitudinal stress), mechanical support, and protection to muscles, bones, and organs. Collagen, blood vessels, & nerves are in the dermal layer. (Contains mostly connective tissue & few skin cells.) Responds to restore structural integrity (collagen) & physical properties of the skin.

Wound

is a disruption of the integrity and function of tissues in the body. Not all wounds are created equal. Wound classification systems describe status of skin integrity, cause, severity or extent of injury or damage, cleanliness, or descriptive qualities.

Red, moist tissue

is indicative of granulation tissue which is progressing toward healing.

Purulent

odor, green, yellow

Eschar

dead -don't remove if on heels = protective barrier = if removed, cause more problems

The wet-to-dry dressing mechanically removes

dead tissue and wound exudate to debride the wound.

Meticulous ongoing assessment of the skin and identification of risk factors are important in

decreasing the opportunity for pressure ulcer development.

The layers of a dry dressing absorb

drainage and prevent entrance of bacteria.

Slough

dying tissue

Erythema

red and warm

Proper positioning

reduces the effects of pressure and guards against the shearing force

Fibroblasts

responsible for collagen formation and are the only distinctive cells within the dermis.

When tissue loss is extensive, a wound heals by

secondary intention.

A moist environment

supports wound healing.

When cleaning wounds or drain sites, clean from

the least to most contaminated area, away from wound edges.

The chances of wound infection are greater when

the wound contains dead or necrotic tissue, when foreign bodies lie on or near the wound, and when the blood supply and tissue defenses are reduced.

Direct nutritional interventions at improving wound healing

through increasing protein and calorie levels.

Epidermis

top layer with several layers. Stratum corneum, thin outermost layer, consists of flattened dead keratinized cells, which originated from basal layer. Protects underlying cells and tissue from dehydration and prevents entrance of certain chemical agents. Allows evaporation of water & permits absorption of certain topical meds. Functions to resurface injured skin & restore the barrier against invading organisms.

Collagen

tough, fibrous protein found in dermal layer; makes up the structural integrity of skin.

Tunneling

use saline soaked Qtip and measure how deep it is

Black/brown tissue is generally eschar (necrotic tissue)

which must be removed before healing can proceed.

Partial-Thickness Wound Repair

wounds are shallow wounds involving loss of the epidermis (top layer) and possibly partial loss of the dermis. 3 days

Discuss evaluation criteria for a client with impaired skin integrity.

Nursing interventions for reducing and treating pressure ulcers or impaired skin/tissue integrity need to be evaluated to determine if the client has met the identified outcomes or goals. Evaluate need for additional referrals.

Factors Influencing Wounds

Nutrition (Table 48-5, pg 1290) Tissue Perfusion: diabetes, smoking, radiation, drugs Infection: obesity, diabetes, drugs Age Psychosocial Impact: body image, social resources

5Which description best fits that of serous drainage from a wound? 1Fresh bleeding 2Thick and yellow 3Clear, watery plasma 4Beige to brown and foul smelling

3Clear, watery plasma Serous fluid generally is serum and presents as light red, almost clear fluid.

9Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? 1Collection of wound drainage 2Reduction of abdominal swelling 3Reduction of stress on the abdominal incision 4Stimulation of peristalsis (return of bowel function) from direct pressure

3Reduction 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.

A dressing serves several purposes

• 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 the client from seeing the wound (if perceived as unpleasant); • Promotes thermal insulation of the wound surface; • Provides a moist environment.

Hydrocolloid (1-3)

Adhesive and occlusive dressings; promotes moist environment and autolytic debridement.

Rresponds best to cold applications.

An acute sprain, closed fracture, or bruise

Packing a Wound

Assess size, depth, & shape, know type of technique, dressing & equipment, keep periwound skin dry, and pack deep, but not too tight.

Characteristics of Dark Skin at Risk for Skin Breakdown

Assessment Issues (Blanching does not occur) Natural or halogen light source best for assessing skin. Fluorescent light source, to be avoided, because it casts a bluish hue, making accurate assessment difficult. Color Appears darker than surrounding skin. May have purplish/bluish hue. Temperature Initial warmth when compared with surrounding skin. Later coolness as tissue is devitalized. Touch: Indurated; edema; soft/boggy Appearance:Taut; shiny; scaly

Increase the risk for pressure ulcer development.

Alterations in mobility, sensory perception, level of consciousness, and nutrition and the presence of moisture

Assessment of Wounds (Stable Setting)

Appearance Character of Drainage Drains: Penrose, Hemovac, Jackson-Pratt Closure: staples, sutures, dermabond Palpation of Wound Wound Cultures: aerobic, anaerobic

Implementation

Health Promotion Topical Skin Care Protect bony prominences, skin barriers for incontinence. Positioning Turn every 1 to 2 hours as indicated; 30° lateral position (sacral) ; use of transfer board. Support Surfaces Decrease the amount of pressure exerted over bony prominences. Education

Describe complications of wound healing.

Hemorrhage-bleend from a wound site Infection-second most common health care-associated infection -wound is infected if there is drainage -signs of infection show within 2-3 days -surgical wound infection develops on 4th or 5th postop day -fever, tenderness, pain, increased WBC, edges are inflamed, odorous Dehiscence-when wound fails to heal properly and the layers of skin and tissue separate -commonly occurs before collagen formation (3-11 days after injury) Evisceration-protrusion of vesceral organs through a wound opening

Pressure Ulcer Pathogenesis

PRESSURE is the major cause in ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓ pressure ulcer formation. Pressure Intensity (tissue ischemia) Blanching Pressure Duration Tissue Tolerance

Dry or Moist

Pressure, gauze, and wet-to-dry.

Skin Assessment

Pt. front and back -sacral prominence

Risk Factors for Developing Ulcers

Impaired Sensory Perception Impaired Mobility Altered LOC Shear - example when putting HOB up -> put feet up first instead -> When bones move but skin stays in place Friction - skin to skin -> Must lift instead Moisture

Describe the differences between wound healing by primary, secondary, and tertiary intention.

Primary intention-Primary union of the edges of a wound, progressing to complete scar formation without granulation. Secondary intention-Wound closure in which the edges are separated; granulation tissue develops to fill the gap; and, finally, epithelium grows in over the granulation, producing a larger scar than results with primary intention. Tertiary intention-Wound left open for several days, then wound edges are approximated. Closure of wound is delayed until risk of infection is resolved.

Acute Care Wound Management

Principles to maintain a healthy wound environment: prevent and manage infection, cleanse the wound, remove nonviable tissue, manage exudate, maintain the wound in a moist environment, and protect the wound. Physicians write treatment orders, however utilize the expertise of multidisciplinary health care professionals.