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