Skin Integrity and Wound Care
Proliferative healing phase
-begins approximately 2 to 3 days after injury -fibroblasts produce collagen that, after maturation, will become scar tissue and strengthen the wound -Granulation tissue starts to appear after formation of new capillaries, fibroblasts, and fibrous tissue -Granulation tissue appears under the scab as red, fleshy material
epidermis, dermis, subcutaneous
3 layers of the skin
wound vac
A medical device that applies negative pressure to a wound to promote healing and prevent infections.
remodeling phase
Also known as the Maturation Phase Can last up to 1 year post injury Strengthening of scar tissue occurs during this phase
heat therapy
Improves blood flow, promotes muscle relaxation. (Vasodilation)
should you disturb dry stable eschar ?
LEAVE IT ALONE
cold therapy
Promotes vasoconstriction, increases blood viscosity, decreases metabolism of tissues, has local anesthetic effect
Pyridium (phenazopyridine)
Urinary Tract Analgesic changes urine to dark red or orange
Hemostatic or inflammatory Proliferative Remodeling
What are the 3 phases of wound healing ?
Remodeling phase of wound healing
Which phase of wound healing has strong collagen replaced with soft collagen ?
hemoglobin
a protein in your red blood cells that carries oxygen throughout the body
negative pressure wound therapy
activity that promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid
hematoma
collection of blood under the tissue
purple or maroon localized area of discolored intact skin or blood-filled blister
describe a deep tissue injury
intact skin with nonblanchable redness
describe a stage 1 pressure ulcer
partial-thickness skin loss involving epidermis, dermis, or both
describe a stage 2 pressure ulcer
full-thickness tissue loss with visible fat
describe a stage 3 pressure ulcer
full-thickness tissue loss with exposed bone, muscle, or tendon
describe a stage 4 pressure ulcer
hemorrhage
excessive bleeding
Dehiscence
partial or total separation of skin and tissues above the fascia
hematocrit
percentage of red blood cells in whole blood
tissue ischemia blanching
pressure intensity can lead to what 2 things
evisceration
separation of wound layers below the fascia with protrusion of visceral contents
hemostasis
stoppage of bleeding
transparent film (tegaderm)
type of dressing able to visualize wound traps moisture protects wound from contaminants
alginate (hydrofiber)
type of dressing highly absorptive for wounds with large amount of exudate can be silver impregnated
hydrogel
type of dressing provides moisture to dry wound
hydrocolloid
type of dressing traps moisture but not absorbent protects from contamination softens eschar provides debridement
immunocompromised pts concern for infection
what are 2 reasons you would monitor someones white blood cell count
pressure intensity pressure duration tissue tolerance
what are 3 main factors contributing to the pathogenesis (development of) pressure ulcers
hemorrhage infection dehiscence evisceration
what are 4 complications of wound healing
sensory perception moisture activity mobility nutrition friction and shear
what are 6 factors to score a patient on when assessing the braden risk scale
impaired sensory perception impaired mobility alteration in level of consciousness shear friction moisture
what are 6 risk factors for pressure ulcer development
nutrition tissue perfusion infection age psychosocial impact of wounds overall wellness decreased leukocyte count medications malnourished clients tissue perfusion low Hgb levels obesity chronic diseases smoking wound stress
what are factors affecting wound healing
pressure sore decubitus ulcer bed sore
what are other names for pressure ulcer
exposure time exposed skin temperature age perception of sensory stimuli
what are some factors influencing heat and cold tolerance
hemostasis (stop bleeding) clean protect
what are the 3 steps when applying first aid for wounds
stage 1 stage 2 stage 3 stage 4
what are the 4 classifications of pressure ulcers
calories protein vitamin c vitamin a zinc fluid
what are the main nutritional values a person needs
emergency setting stable setting wound appearance character of wound drainage drains
what are things to assess on wounds
infection
what does it mean if someone has a high white blood cell count
pt has a decreased ability to fight infection
what does it mean if someone has a low white blood cell count
clean surgical wound with approximated edges
what is a primary intention
chronic pressure ulcer with no approximated edges
what is a secondary intention
the opening of a previously closed wound
what is a tertiary intention
37-47%
what is the average hematocrit percentage in females
42-52%
what is the average hematocrit percentage in males
12-16 g/dL
what is the average hemoglobin level in females
14-18 g/dL
what is the average hemoglobin level in males
5000-10000
what is the normal white blood cell count
serous
what kind of drainage is a clear, watery plasma
serosanguineous
what kind of drainage is a pale red, watery mixture
sanguineous
what kind of drainage is fresh bleeding, bright right
purulent
what kind of drainage is pus-like and can vary in color: brown, green, yellow
10-12
what score means high risk on the braden scale
15-18
what score means mild risk on the braden scale
13-14
what score means moderate risk on the braden scale
18
what score means no risk on the braden scale
less than 9
what score means very high risk on the braden scale
check hemoglobin and hematocrit
what should you do if you suspect someone is bleedings or note a large amount of drainage
analgesic
what should you give the pt 30-60 minutes prior to a dressing change to relieve pain
wound bed has slough or eschar
what would make a pressure ulcer unstageable
blanching
when the normal red tones of a light skinned patient are absent
Hemostatic
which stage of wound healing would present healing with swelling from plasma leaking into tissue