Inflammation & Wound Healing Part II - NOTES

Hyperbaric O2 therapy (HBOT) is the *delivery of O2* at *increased atmospheric pressures*. It can be given

1. TOPICALLY: by creating a chamber around the injured limb. (20 minutes twice daily or 4 to 6 hours daily. ) 2. SYSTEMICALLY: with the patient placed in an enclosed chamber, where 100% O2 is administered at 1.5 to 3 times the normal atmospheric pressure. (90 to 120 minutes, and the number of treatments may vary from 10 to 60 depending on the condition being treated)

4. A nurse is caring for a patient who has a pressure ulcer that is treated with debridement, irrigations, and moist gauze dressings. How should the nurse anticipate healing to occur? a. Tertiary intention b. Secondary intention c. Regeneration of cells d. Remodeling of tissues,

Secondary intention

If the patient is unable to eat during wound healing, *enteral feedings* and supplements should be the first choice if the GI tract is functional. *Parenteral nutrition*

is indicated when enteral feedings are contraindicated or not tolerated.

A pressure ulcer is

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.

The most common complication of a pressure ulcer is

recurrence. Therefore it is important to note the location of previously healed pressure ulcers on a patient's initial admission assessment.

Swab specimens can be obtained from wounds using *Levine's technique*, which involves

rotating a culture swab over a cleansed 1-cm2 area near the center of the wound. Use sufficient pressure to extract wound fluid from deep tissue layers. (A culture must be taken of the clean tissue because exudate and necrotic tissue will not provide an accurate sample.) When collecting samples, do not use cotton-tipped applicators. The sample must be sent to the laboratory within 1 hour.

The most common site for pressure ulcers is the

sacrum, with heels being second.

Pressure ulcers generally fall under the category of healing by

secondary intention.

Risk Factors for Pressure Ulcers

• Advanced age • Anemia • Contractures • Diabetes mellitus • Elevated body temperature • Friction (rubbing of surfaces together) • Immobility • Impaired circulation • Incontinence • Low diastolic blood pressure (<60 mm Hg) • Mental deterioration • Neurologic disorders • Obesity • Pain • Prolonged surgery • Vascular disease

Nursing diagnoses for the patient with a pressure ulcer may include, but are not limited to, the following:

• Impaired skin integrity related to mechanical factors and physical immobilization • Impaired tissue integrity related to impaired circulation and imbalanced nutritional state

Stage/Category IV: Full-Thickness Tissue Loss

*Full-thickness tissue* loss with *exposed bone, tendon, or muscle*. *Slough or eschar* may be present. Often includes undermining and tunneling. Depth of pressure ulcer varies by anatomic location. 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.

The overall goals are that the patient with a pressure ulcer will

(1) have no deterioration of the ulcer, (2) reduce or eliminate the factors that lead to pressure ulcers, (3) not develop an infection in the pressure ulcer, (4) have healing of pressure ulcers, and (5) have no recurrence.

Platelet-derived *growth factor* is released from the platelets and stimulates cell proliferation and migration. *Becaplermin (Regranex)*, a recombinant human platelet-derived growth factor gel, actively stimulates wound healing.

*Becaplermin (Regranex)* 1. drug used to stimulate cell proliferation and migration to stimulate wound healing 2. used to treat foot ulcers in patients with diabetes 3. should be used only when the wound is free of dead tissue and infection. 4. should not be used if cancer is suspected in the wound

Nursing Assessment: Pressure Ulcers SUBJECTIVE DATA Objective Data General Fever Integumentary Diaphoresis, edema, and discoloration, especially over bony areas such as sacrum, hips, elbows, heels, knees, ankles, shoulders, and ear rims, progressing to increased tissue damage characteristic of ulcer stages* Possible Diagnostic Findings Leukocytosis, positive cultures for microorganisms from pressure ulcer

*Important Health Information* *Past health history*: Stroke, spinal cord injury; prolonged bed rest or immobility; circulatory impairment; poor nutrition; altered level of consciousness; prior history of pressure ulcer; immunologic abnormalities; advanced age; diabetes; anemia; trauma *Medications*: Use of opioids, hypnotics, systemic corticosteroids *Surgery or other treatments*: Recent surgery *Functional Health Patterns* *Nutritional-metabolic*: Obesity, emaciation; decreased fluid, calorie, or protein intake; vitamin or mineral deficiencies; clinically significant malnutrition as indicated by low serum albumin, decreased total lymphocyte count, and decreased body weight (15% less than ideal body weight) *Elimination*: Incontinence of urine, feces, or both *Activity-exercise*: Weakness, debilitation, inability to turn and position body; contractures *Cognitive-perceptual*: Pain or altered cutaneous sensation in pressure ulcer area; decreased awareness of pressure on body areas; capacity to follow treatment plan

Stage/Category II: Partial Thickness

*Partial-thickness loss* of *dermis* presenting as a *shallow open ulcer* with a r*ed-pink wound bed*, WITHOUT SLOUGH May also present as an *intact or open/ruptured serum-filled or serosanguineous-filled blister*. Presents as a *shiny or dry shallow ulcer without slough or bruising*. (Bruising indicates deep tissue injury.)

Stage/Category I: Nonblanchable Erythema

1. *Intact skin* with 2. *nonblanchable redness* of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching. Its color may differ from the surrounding area. 3. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue.

If an infection develops in a wound,

1. *a culture and sensitivity test* should be done to determine the organism and the *most effective antibiotic* for that specific organism. 2. the culture should be taken before the first dose of antibiotic is given. 3. Cultures can be obtained by needle aspiration, tissue culture, or swab technique. Physicians obtain needle and tissue punch biopsy samples. As a nurse, you can obtain cultures using the swab technique.

Special nutritional measures facilitate wound healing.

1. *high fluid intake* a. needed to replace fluid loss from perspiration and exudate formation. b. increased metabolic rate intensifies water loss. 2. *diet high in protein* a. Protein is needed to correct the negative nitrogen balance resulting from the increased metabolic rate. b. necessary for synthesis of immune factors, leukocytes, fibroblasts, and collagen, which are the building blocks for healing. 3. *carbohydrate* a. needed for the increased metabolic energy required in inflammation and healing. b. If there is a carbohydrate deficit, the body will break down protein for the needed energy. 4. *vitamins* a. Vitamin A - aids in the process of epithelialization. Increases collagen synthesis and tensile strength of the healing wound. b. Vitamin B COMPLEX - necessary as coenzymes for many metabolic reactions. If a vitamin B deficiency develops, a disruption of protein, fat, and carbohydrate metabolism will occur. c. Vitamin C - needed for *capillary synthesis* & *collagen production by fibroblasts* 5. *moderate fat intake* a. help in the synthesis of fatty acids and triglycerides (part of the cellular membrane)

Individuals at risk for wound healing problems are those with malabsorption problems

1. Crohn's disease 2. gastrointestinal [GI] surgery 3. liver disease 4. deficient intake 5. high energy demands - malignancy, major trauma or surgery, sepsis, fever) 6. diabetes.

PAtient teaching for wound healing

1. Emphasize the importance of adequate rest and good nutrition throughout this time. 2. Physical and emotional stress should be minimal. 3. Observing the wound for complications such as contractures, adhesions, and secondary infection is important. 4. Teach the patient and caregiver the signs and symptoms of infection. 5. Have them note changes in the wound color and amount of drainage. 6. Teach the patient to notify the HCP of any signs of abnormal wound healing.

HBOT allows O2 to diffuse into the serum, rather than RBCs, and be transported to the tissues. By increasing the O2 content in the serum,

1. HBOT moves the O2 past narrowed arteries and capillaries where RBCs cannot go. 2. elevated O2 levels a. stimulate *angiogenesis* (production of new blood vessels) b. kill anaerobic bacteria c. increase the killing power of WBCs and certain antibiotics (e.g., fluoroquinolones, aminoglycosides). 3. HBOT accelerates granulation tissue formation and wound healing.

Patient & Caregiver Teaching Pressure Ulcer When teaching the patient and caregiver to prevent and care for pressure ulcers, do the following.

1. Identify and explain risk factors and etiology of pressure ulcers to patient and caregiver. 2. Assess all at-risk patients at time of first hospital and/or home visit or whenever the patient's condition changes. Thereafter assess at regular intervals based on care setting (every 24 hours for acute care or every visit in home care). 3. Teach the caregiver techniques for incontinence. If incontinence occurs, cleanse skin at time of soiling and use absorbent pads or briefs. 4. Demonstrate correct positioning to decrease risk of skin breakdown. Instruct caregiver to reposition a bed-bound patient at least every 2 hours, a chair-bound patient every hour. NEVER position the patient directly on the pressure ulcer. 5. Assess resources (i.e., caregiver's availability and skill, finances, equipment) of patients requiring pressure ulcer care at home. When selecting ulcer care dressing, consider cost and amount of caregiver time required. 6. Teach patient and/or caregiver to place clean dressings over sterile dressings using "no touch" technique when changing dressings. Instruct caregiver on disposal of contaminated dressings. 7. Teach patient and caregiver to inspect skin daily. Tell them to report any significant changes to the HCP. 8. Teach patient and caregiver the importance of good nutrition to enhance ulcer healing. 9. Evaluate program effectiveness.

Factors that influence the development of pressure ulcers include the

1. amount of pressure (intensity), 2. length of time the pressure is exerted on the skin (duration), and 3. ability of the patient's tissue to tolerate the externally applied pressure. Other factors that contribute to pressure ulcer formation include 4. shearing force (pressure exerted on the skin when it adheres to the bed and the skin layers slide in the direction of body movement [e.g., when pulling patient up in bed]) and 5. excessive moisture (increases risk for skin breakdown).

What lab work should be implemented through wound healing using a neg-pressure wound vac?

1. serum protein levels 2. Fluid and eletrolytes (Na, K, Cl, Ca) 3. Coagulation Studies (PT, PTT)

NEGATIVE_PRESSURE wound therapy 1. pulls excess fluid from the wound 2. reduces bacterial load 3. encourages blood flow into the wound base. you should Monitor the patient's,

1. serum protein levels 2. fluid and electrolyte balance *because of losses from the wound*. Additionally, monitor the patient's 3. coagulation studies (platelet count, prothrombin time [PT], partial thromboplastin time [PTT]).

Negative-pressure wound therapy (NPWT) is used to treat acute and chronic wounds.

A vacuum source creates continuous or intermittent negative pressure inside the wound to remove fluid, exudates, and infectious materials to prepare the wound for healing and closure.

A patient in the unit has a 103.7° F temperature. Which intervention would be most effective in restoring normal body temperature? a. Use a cooling blanket while the patient is febrile. b. Administer antipyretics on an around-the-clock schedule. c. Provide increased fluids and have the UAP give sponge baths. d. Give prescribed antibiotics and provide warm blankets for comfort.

Administer antipyretics on an around-the-clock schedule.

Untreated ulcers may lead to

CELLULITIS (spreading of inflammation to subcutaneous or connective tissue), chronic infection, sepsis, and possibly death.

Which one of the orders should a nurse question in the plan of care for an elderly immobile stroke patient with a stage III pressure ulcer? a. Pack the ulcer with foam dressing. b. Turn and position the patient every hour. c. Clean the ulcer every shift with Dakin's solution. d. Assess for pain and medicate before dressing change.

Clean the ulcer every shift with Dakin's solution.

Unstageable/Unclassified: Full-Thickness Skin or Tissue Loss (Depth Unknown

Full-thickness tissue 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 wound, the true depth cannot be determined; but it *will be either a stage III or stage IV*. Stable (dry, adherent, intact without erythema, or fluctuance) *eschar on the heels serves as "the body's natural (biologic) cover" and should not be removed.*

Stage/Category III: Full-Thickness Skin Loss

Full-thickness tissue loss. *Subcutaneous fat may be visible* but bone, tendon, or muscle are not exposed. *Slough may be presen*t but does not obscure depth of tissue loss. May include *undermining and tunneling*. The depth of a category/stage III pressure ulcer *varies by anatomic location*.

A 65-year-old stroke patient with limited mobility has a purple area of suspected deep tissue injury on the left greater trochanter. Which nursing diagnoses are most appropriate (select all that apply)? a. Acute pain related to tissue damage and inflammation b. Impaired skin integrity related to immobility and decreased sensation c. Impaired tissue integrity related to inadequate circulation secondary to pressure d. Risk for infection related to loss of tissue integrity and undernutrition secondary to stroke e. Ineffective peripheral tissue perfusion related to arteriosclerosis and loss of blood supply to affected area

Impaired skin integrity related to immobility and decreased sensation

A nurse is caring for a patient with diabetes who is scheduled for amputation of his necrotic left great toe. The patient's WBC count is 15.0 × 106/µL, and he has coolness of the lower extremities, weighs 75 lb more than his ideal body weight, and smokes two packs of cigarettes per day. Which priority nursing diagnosis addresses the primary factor affecting the patient's ability to heal? a. Imbalanced nutrition: obesity related to high-fat foods b. Impaired tissue integrity related to decreased blood flow secondary to diabetes and smoking c. Ineffective peripheral tissue perfusion related to narrowed blood vessels secondary to diabetes and smoking d. Ineffective individual coping related to indifference and denial of the long-term effects of diabetes and smoking

Impaired tissue integrity related to decreased blood flow secondary to diabetes and smoking

An 85-year-old patient is assessed to have a score of 16 on the Braden Scale. Based on this information, how should the nurse plan for this patient's care? a. Implement a 1-hr turning schedule with skin assessment. b. Place DuoDerm on the patient's sacrum to prevent breakdown. c. Elevate the head of bed to 90 degrees when the patient is supine. d. Continue with weekly skin assessments with no special precautions.

Implement a 1-hr turning schedule with skin assessment.

NPWT systems consist of a 1. vacuum pump 2. drainage tubing 3. foam or gauze wound dressing 4. adhesive film dressing that covers and seals the wound.

In this therapy, the wound is cleaned and a gauze or foam dressing is cut to the dimensions of the wound. A large occlusive dressing is applied and a small hole is made over the gauze or foam dressing where the tubing is attached. The tubing is connected to a pump, which creates a negative pressure in the wound bed.

Suspected Deep Tissue Injury (Depth Unknown)

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. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.

An 82-year-old man is being cared for at home by his family. A pressure ulcer on his right buttock measures 1 × 2 × 0.8 cm in depth, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form? a. Stage I b. Stage II c. Stage III d. Stage IV

Stage III

A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5° F temperature, slight erythema at the incision margins, and 30 mL serosanguineous drainage in the Jackson-Pratt drain. Based on this assessment, what conclusion would the nurse make? a. The abdominal incision shows signs of an infection. b. The patient is having a normal inflammatory response. c. The abdominal incision shows signs of impending dehiscence. d. The patient's physician must be notified about her condition.

The patient is having a normal inflammatory response.

The nurse assessing a patient with a chronic leg wound finds local signs of erythema and the patient complains of pain at the wound site. What would the nurse anticipate being ordered to assess the patient's systemic response? a. Serum protein analysis b. WBC count and differential c. Punch biopsy of center of wound d. Culture and sensitivity of the wound

WBC count and differential

• Stage III or IV (full skin-thickness injury) pressure ulcer acquired after admission to a health care setting is considered

a serious reportable event (SRE) NEVER EVENT

Assessing for Pressure Ulcers

acute care = every 24 hours. long-term care = weekly for the first 4 weeks after admission and then at least monthly or quarterly. In home care = every visit

Dakin's solution

an aqueous solution of sodium hypochlorite (bleach) used as an antiseptic for wound irrigation

Individuals at risk for pressure ulcers include those who are

older incontinent unable to reposition or unaware of the need to reposition (e.g., spinal cord injury), and bed- or wheelchair-bound.

Digital Images To monitor wound progress, use digital photography. For the best images:

• Include a ruler with date, length, width, and depth of the wound in each photo. • Position the patient the same way for each photo. • Take the photo from the same angle each time. Pointing perpendicularly at the wound is best. • Use natural light, without flash, whenever possible. • Show the wound on a solid background, avoiding shiny underpads. • Avoid patient identifiers such as jewelry, tattoos, or visible family members.

Assessing Patients With Dark Skin

• Look for changes in skin color, such as skin that is darker (purplish, brownish, bluish) than surrounding skin. • Use natural or halogen light source to accurately assess the skin color. Fluorescent light casts blue color, which can make skin assessment difficult. • Assess the area for the skin temperature using your hand. The area may feel initially warm, then cooler. • Touch the skin to feel its consistency. Boggy or edematous feel may indicate a stage I pressure ulcer. • Ask the patient if he or she has any pain or itchy sensation.

Preventing Pressure Ulcers

• Use devices to reduce pressure and shearing force (e.g., low-air-loss mattresses, foam mattresses, wheelchair cushions, padded commode seats, boots [foam, air], lift sheets) as appropriate. These devices do not replace the need for frequent repositioning. • Reposition patients frequently to prevent pressure ulcers.