Potter & Perry: Chapter 48 Skin and Wound Care
Inflammatory response(stage 1 of partial-thickness wound healing): Causes redness and swelling to the area with a moderate amount of _______ _______. This response is generally limited to the first __ hours after wounding.
serous exudate, 24
For patients weakened or debilitated by illness, nutritional therapy is especially important. A patient who has undergone surgery and is well nourished still requires at least 1_00 kcal/day for nutritional maintenance.
1500 kcal/day
The outer edges of a wound normally appear inflamed for the first
2 to 3 days, but this slowly disappears.
A goal frequently identified when working with a patient with a wound is to see wound improvement within a
2-week period
A tetanus antitoxin injection is necessary if the patient has not had one within _ years.
5
partial-thickness wound healing: A wound left open to air can resurface within _ to _ days, whereas one that is kept moist can resurface in _ days.
6-7 days, 4 days
hydrogel dressings are useful in _______ wounds because they are very soothing to the patient and do not adhere to the wound bed and cause little trauma during removal.
painful
An abrasion is superficial with little bleeding and is considered a __________________ wound.
partial-thickness
Hydrogel dressings are for
partial-thickness and full-thickness wounds, deep wounds with some exudate, necrotic wounds, burns, and radiation-damaged skin.
If scarring from secondary intention is severe, loss of tissue function is often
permanent
secondary, systemic factors that effect tolerance of the tissues: (4)
poor nutrition, increased aging, hydration status, and low blood pressure
the greater the degree to which the factors of shear, friction, and moisture are present, the more susceptible the skin will be to damage from
pressure
No single device eliminates the effects of
pressure on the skin. Repositioning is your friend.
Elevating the head of the bed to 30 degrees or less decreases the chance of
pressure ulcer development from shearing forces
main factor that contributes to the formation of pressure ulcers
pressure............. duh
A clean surgical incision with little tissue damage heals by
primary intention
the risk of infection in low in
primary intention
Too much inflammation also _________ healing because arriving cells compete for available nutrients.
prolongs
A large, open wound may expose bone or tissue that needs to be
protected.
Inspect the wound dressing and external drains only unless
provider orders a dressing change
Indications that a wound infection is present include the presence of
purulent drainage; change in odor, volume, or character of wound drainage; redness in the surrounding tissue; fever; and pain.
Types of wound drainage include
serous, sanguineous, serosanguineous, and purulent
stage III ulcers can be ________ or ________ depending on _________
shallow, deep, location
The extrinsic factors of _____, _______, & _______ affect the ability of the skin to tolerate pressure
sheer, friction, moisture
A wound is infected if
purulent material drains from it, even if a culture is not taken or has negative results****** TEST QUESTION
hyperemia
redness- excessive blood in a part of the body
The necrotic tissue must be _________ to expose the wound base to allow for assessment
removed
eschar and slough must be
removed before a wound is able to heal
what causes a pressure ulcer?
result of prolonged ischemia (decreased blood supply) in tissues
Gauze can be saturated with solutions and used to clean and pack a wound. When used to pack a wound, the gauze is
saturated with the solution (usually normal saline), wrung out, unfolded, and lightly packed into the wound.
Full-thickness wounds heal by _____ formation because deeper structures do not regenerate
scar
Factors that affect the patient's perception of the wound include the presence of
scars, drains (drains are often necessary for weeks or months after certain procedures), odor from drainage, and temporary or permanent prosthetic devices.
It takes longer for a wound to heal by ________ intention, and the chance of infection is greater.
secondary
wound involving loss of tissue, such as a burn, pressure ulcer, or severe laceration, heals by
secondary intention.
skin assessment for wounds: Focusing on specific elements such as a patient's level of
sensation, movement, and continence status helps guide the skin assessment
Soft yellow or white tissue is characteristic of slough (stringy substance attached to wound bed), and it must be removed by a
skilled clinician before the wound is able to heal.
The nurse checks pressure dressings to ensure that they do not interfere with circulation to a body part. In order to accomplish this, the nurse assesses
skin color, pulses in distal extremities, the patient's comfort, and changes in sensation
Stage II ulcer should not be used to describe (5)
skin tears, tape burns, incontinence-associated dermatitis, maceration, or excoriation.
slough
slough is a yellow fibrinous tissue that consists of fibrin, and pus. Slough can be found on the surface of a previously clean wound bed and it is thought to be associated with bacterial activity.
excessive exudate _______ the would healing process
slows
A transparent film dressing is ideal for
small superficial wounds such as partial-thickness wounds or to protect high-risk skin. Can also be used for autolytic debridement of small wounds.
When cleaning the skin, the nurse should avoid
soap and hot water. Cleaners with nonionic surfactants that are gentle to the skin should be used.
a moist environment
speeds epithelial cell growth
moisture cream is indicated for what stage ulcer?
stage I ulcer
Hemostasis occurs within several minutes of the wound healing process unless
unless large blood vessels are involved or the patient has poor clotting function.
why is tissue perfusion critical to wound healing?
Oxygen fuels the cellular functions essential to the healing process
Purposes of dressings
Protect the wound, promote healing, support wound site, and provide a moist environment
Evisceration
Protrusion of visceral organs through a wound opening
Protein needs especially are increased during would healing and are essential for
tissue repair and growth
desiccate
to remove moisture from
Stage I: pressure ulcer
Stage I: Nonblanchable erythema (redness) of intact skin.
After a period of tissue ischemia, if the pressure is relieved and the blood flow returns, the skin
turns red
Stage II: pressure ulcer
Stage II: partial thickness wound- skin loss or blister, shallow open ulcer, pink wound bed, without slough or bruising
1st step of taking a wound culture
The nurse cleans a wound first with normal saline to remove skin flora
how do you asses hyperemia?
blanching
Tissues receive oxygen and nutrients and eliminate metabolic wastes via
blood
Dakin's solution
breaks down and loosens dead tissue in a wound
If infection develops, the area directly surrounding the wound becomes
brightly inflamed and swollen
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) or eschar (tan, brown, or black) in the wound bed.
The nurse checks pressure dressings to ensure that they do not interfere with ____________ to a body part.
circulation
Mechanical debridement is never used in a
clean, granulating wound
The inflammatory response is beneficial, and there is no value in attempting to cool the area or reduce the swelling unless the swelling occurs within a
closed compartment (e.g., ankle or neck).
If the health care provider prefers to change the dressing, he or she assesses the wound at least
daily.
The wound often appears "weepy" because of plasma leakage from
damaged capillaries.
A hematoma near a major artery or vein is ________ because pressure from the expanding hematoma obstructs blood flow.
dangerous
Stage I ulcer may be difficult to detect in individuals with
dark skin tones
tissue ischemia
decreased blood supply to skin
if the erythematous area does not blanch (nonblanching erythema) when you apply pressure,
deep tissue damage is probable
When there is an increase in serosanguineous drainage from a wound, the nurse should be alert for the potential for
dehiscence.
Choose a dressing that controls exudate but does not __________ the ulcer bed.
desiccate
Choose a dressing that keeps the surrounding intact (periulcer) skin ___ while keeping the ulcer bed _____.
dry, moist
Sign of reestablishment of the epidermal layers (partial-thickness would healing): Cells slowly reestablish normal thickness and appear as
dry, pink tissue.
when is hemorrhage normal?
during and immediately after injury
A surgical incision healing by primary intention should have clean, well-approximated
edges
Within 7 to 10 days, a normally healing wound resurfaces with
epithelial cells, and edges close.
An ______ is a slough or piece of dead tissue that is cast off from the surface of the skin, particularly after a burn injury, but also seen in gangrene, ulcer, fungal infections, necrotizing spider bite wounds,
eschar
examples of a stable wound
(e.g., after surgery or treatment)
hydrogel dressing: advantages (4)
Advantages: Is soothing and can reduce wound pain Provides a moist environment Debrides necrotic tissue (by softening the necrotic tissue) Does not adhere to the wound base and is easy to remove
Pressure intensity
Amount of pressure applied to tissue
when do you preform a wound assessment?
Before treatment, at the time of injury, and after therapy when the wound is relatively stable
Psychosocial impact of wounds
Body image changes often impose a great stress on the patient's adaptive mechanisms, self-concept, and sexuality
pressure ulcers are classified by
By the depth of tissue destroyed
Remodeling
Collagen scar continues to reorganize and gain strength for several months
Hematoma
Collection of blood trapped in the tissues of the skin or an organ........ a serious version of a bruise
Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, resulting in tissue ischemia and ultimately tissue ______.
DEATH. Turn your patients every 2 hours.
Inflammatory phase
Damaged tissues secrete histamine, capillaries vasodilate, and serum and white blood cells exudate into damaged tissues
Pressure ulcer assessment
Determine a patient's mobility, nutrition, presence of body fluids, and comfort level
symptoms of stage I pressure ulcer
Discoloration of the skin, warmer, edema, hardness, or pain may also be present
Serous drainage
Exudate composed of clear, watery plasma
Serosanguineous drainage
Exudate composed of serum and blood
Sanguineous drainage
Exudate containing red blood cells, indicates active bleeding
Exudate
Fluid, cells, or other substances that have been discharged from cells through small pores or breaks in membranes
Induration
Hardening of a tissue, particularly the skin, because of edema or inflammation
Complications of wound healing (4)
Hemorrhage, infection, dehiscence, and evisceration
Stages of full-thickness wound healing
Hemostasis, inflammatory, proliferative, and remodeling
A goal frequently identified when working with a patient with a wound is to see wound improvement within a 2-week period. The outcomes of this goal can include the following:
Higher percentage of granulation tissue in the wound base No further skin breakdown in any body location An increase in the caloric intake by 10%
partial-thickness would is stage __ ulcer
II
Until enough slough or eschar or both are removed to expose the base of the wound, the true depth cannot be determined, but it is either a stage
III or IV
the nurse takes wound cultures if
If purulent or suspicious-looking drainage is detected
Stages of partial-thickness wound healing
Inflammatory response, epithelial proliferation and migration, and reestablishment of epidermal layers
Hemostasis
Injured blood vessels constrict, and platelets gather to stop bleeding
how should a nurse assess a wound in an emergency setting?
Inspect for bleeding, foreign bodies or containment, and size to determine care
3 factors of pressure ulcers
Intensity, duration, and tissue tolerance
how to assess wound closures
Look for irritation around the staple or suture site, and note whether closures are intact
how to manage a wound:
Manage infection, remove nonviable tissue, manage exudate, and maintain moist environment
notable characteristics of wound drainage
Note the amount, color, odor, and consistency of drainage
Factors influencing ulcer formation and wound healing
Nutrition, tissue perfusion, moisture, friction, infection, age, and psychosocial impact
effective treatments for atopic pruritus include
Oral and topical steroids
Primary intention
Primary union of the edges of a wound, progressing to complete scar formation without granulation
During this period, the wound contracts to reduce the area that requires healing. Finally, the epithelial cells migrate from the wound edges to resurface.
Proliferative phase
How does an Infection effect the wound healing process?
Prolongs the inflammatory phase (which leads to additional tissue distruction) and delays collagen synthesis
Debridement
Removal of dead tissue from a wound
Surgical debridement: how is it done?
Removal of devitalized tissue by using a scalpel, scissors, or other sharp instrument
Epithelialization
Resurface or repair of a wound
Abrasion
Scraping or rubbing away of epidermis resulting in localized bleeding and weeping of serous fluid
Partial-thickness wounds
Shallow wounds involving loss of the epidermis and possibly partial loss of the dermis
how to prevent pressure ulcers
Skin care and incontinence management, positioning and use of therapeutic surfaces, and education
Shear
Sliding movement of skin and subcutaneous tissue while underlying muscle and bone are stationary
Granulation tissue
Soft, pink, fleshy projections of tissue formed during the healing process. indicates progression toward healing.
Stage III: pressure ulcer
Stage III: Full-thickness skin loss (fat visible). Some slough may be present- may have undermining or tunneling
Stage IV: pressure ulcer
Stage IV: Full-thickness tissue loss (muscle or bone visible) slough may be present- may have undermining or tunneling
Penrose drain
Surgical device that lies under a dressing to remove drainage from wounds
Symptoms of suspected deep-tissue injury
The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler than adjacent tissue. May include a thin blister over a dark wound bed. The wound may evolve further and become covered by thin eschar
Mechanical debridement: how is it done?
The nurse places moistened gauze into the wound and allows the dressing to dry thoroughly before "pulling" the gauze that has adhered to the tissue out of the pressure ulcer. This is a nonselective method of debridement because both devitalized and viable tissues are removed, so it is not used routinely.
initial sign of pressure ulcer
The ulcer is characterized initially by inflammation and usually forms over a bony prominence
In a clean wound, the proliferative phase accomplishes the following:
The vascular bed is reestablished (granulation tissue), the area is filled with replacement tissue, and the surface is repaired (epithelialization).
hydrocolloid dressing is most useful for
This type of dressing is most useful on shallow to moderately deep dermal ulcers
Gauze sponges are used to
To provide moisture to the wound, yet to allow wound drainage to be wicked into the pad
If the red area blanches (turns lighter in color) and the erythema returns when you remove your finger, the hyperemia is
transient, not permanent
Laceration
Torn, jagged wound
what is a tunneling wound? what stage of pressure ulcer can have tunneling?
Tunneling wounds have channels that extend from a wound into and through subcutaneous tissue or muscle. Stage III or IV.
Unstageable/unclassified: pressure ulcer
Unstageable/unclassified: full-thickness skin or tissue loss—depth unknown (necrotic skin)
what should be used to clean a wound?
Use normal saline or commercial wound cleaner to cleanse and remove nonviable tissue. These cleaners are noncytotoxic
Autolytic debridement: how does it work?
Uses synthetic dressings over a wound to allow the eschar to be self-digested by enzymes present in wound fluids
Exposed bone or muscle is visible or directly palpable in what stage ulcer?
VI
Chemical debridement: different types
With the use of a topical enzyme preparation, Dakin's solution, or sterile maggots
Secondary intention
Wound closure with separated edges, granulation tissue in the gap, and epithelium over the tissue
Proliferative phase
Wound fills with granulation tissue, contracts, and resurfaces
Full-thickness wounds
Wounds that extend into the dermis involving both layers of tissue
A strategy to prevent dehiscence is to place a
a folded thin blanket or pillow over an abdominal wound when the patient is coughing. This provides a splint to the area, supporting the healing tissue when coughing increases the intraabdominal pressure.
Dehiscence frequently involves __________ surgical wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed
abdominal
Hydrocolloid dressings are
adhesive.T he wound contact layer of this dressing forms a gel as fluid is absorbed and maintains a moist healing environment. Hydrocolloids are available in various sizes and shapes.
Impairment of healing during the proliferative stage usually results from systemic factors such as
age, anemia, hypoproteinemia, and zinc deficiency.
If the drainage has a pungent or strong odor, the nurse should suspect
an infection.
Because removal of dressings can be painful, the nurse should consider giving an
analgesic at least 30 minutes before exposing a wound.
The first step in prevention is to
assess the patient's risk factors for pressure ulcer development.
Lower numerical scores on the Braden scale indicate that a patient is
at high risk for skin breakdown.
Cellulitis
bacterial skin infection
why is a hematoma near a major artery or vein dangerous?
because pressure from the expanding hematoma obstructs blood flow
why can't you assign a pressure ulcer stage to a wound with necrotic tissue?
because the necrotic tissue is covering the depth of the ulcer
normal reactive hyperemia
blanchable hyperemia
___________ does not occur in patients with darkly pigmented skin
blanching
With total separation of wound layers, _________ occurs.
evisceration
Moisture barriers are cream, gel, ointment or paste preparations formulated to protect the skin from
excessive moisture, due to incontinence, perspiration or wound drainage.
Evacuator units: how do they work?
exert a constant low pressure as long as the suction device (bladder or container) is fully compressed
Crusts often form along the wound edges from
exudate
assess for _____ during your wound inspection
exudate
what supporting structures (3) can a stage IV ulcer extend into?
fascia, tendon, or joint capsule
_______ is responsible for the semisolid character of a blood clot.
fibrin
Clots form a fibrin matrix that later provides a
framework for cellular repair.
example of puncture wound
from knife or from nail
Hemostasis is the first of four phases of healing of a
full-thickness wound
Telfa gauze
has a shiny, nonadherent surface that does not stick to incisions or wound openings but allows drainage to pass through to the gauze topper.
If the wound is covered by a dressing and the health care provider has not ordered it changed, the nurse should not directly inspect it unless
he or she suspects serious complications
Healing occurs quickly, with minimal scar formation, as long as infection and secondary breakdown are prevented.
healing by primary intention
Usually scar tissue contains fewer pigmented cells (melanocytes) and has a lighter color than normal skin. In dark-skinned individuals, the scar tissue may be more
highly pigmented than surrounding skin.
chronic tissue hypoxia is associated with
impaired collagen synthesis and reduced tissue resistance to infection
Deficiencies in any of the nutrients result in
impaired or delayed healing
If fluid accumulates within the tissues, wound healing does not progress at an optimal rate, and this
increases the risk of infection.
Excessive exudate indicates the presence of
infection.
Extreme tenderness during stable wound palpation indicates
infection.
the primary dangers of puncture wounds are
internal bleeding and infection.
Excessive exposure to water, particularly hot water, increases
irritation and scaling
eschar
is dead tissue that can be brown, tan or black in color, and it may also be filled with fluid.
what is an undermining wound? what stage of pressure ulcer can have tunneling?
it's a wider area of wounding that lies beneath the wound opening. Stage III or IV.
The staple provides more strength than nylon or silk sutures and tends to cause
less irritation to tissue
Any factor that interferes with blood flow interferes the function or ____ of the cells
life
The nurse needs to assess and prevent or manage _____ that occurs with debridement.
pain
__________ pressure and __________ pressure can both cause tissue damage.
low-density , high-density
excessive exudate can ________ the skin around the wound
macerate
The nurse should never _________ the reddened (hyperemic) areas. _________ing reddened areas increases breaks in the capillaries in the underlying tissues and the risk of injury to underlying tissue and pressure ulcer formation.
massage, massaging
A major drawback of a staging system is that one cannot stage an ulcer covered with _________ _______ because the __________ ________ is covering the depth of the ulcer
necrotic tissue, necrotic tissue
can you classify a pressure ulcer stage ifs there is necrotic tissue?
no
Wound infection is the second most common _________ infection
nosocomial
Stable (dry, adherent, intact without erythema or fluctuance(can be moved around)) eschar on the heels serves as "the natural (biological) cover of the body" and should
not be removed.
When the evacuator device is unable to maintain a vacuum on its own, the nurse
notifies the surgeon
Pressure ulcer
ocalized injury to the skin and other underlying tissue, usually over a bony prominence
Gauze sponges are the
oldest and most common dressing. 4x4 is the most common size.
Stage IV ulcers can extend into muscle or supporting structures (e.g., fascia, tendon, or joint capsule) or both, making
osteomyelitis or osteitis likely to occur.
When evisceration occurs, the nurse places
sterile towels soaked in sterile saline over the extruding tissues to reduce chances of bacterial invasion and drying of the tissues. If the organs protrude through the wound, blood supply to the tissues is compromised.
fastest method of debridement
surgical debridement
The presence of an evisceration is a
surgical emergency
A deep laceration requires
suturing
When the injury is a result of trauma from a dirty penetrating object, determine when the patient last received a
tetanus toxoid injection
Ischemia develops when
the pressure on the skin is greater than the pressure inside the small peripheral blood vessels supplying blood to the skin.
Partial-thickness wounds heal by regeneration because epidermis regenerates. An example of this is
the repair of a clean surgical wound or an abrasion.
Wound irrigation is
the steady flow of a solution (normal saline) across an open wound surface to achieve wound hydration, to remove deeper debris, and to assist with the visual examination
a deep stage III pressure ulcer occurs in a part of the body where
there is excessive fat
a shallow stage III pressure ulcer occurs in a part of the body where
there isn't a lot of fat
If the patient has reduced sensation and cannot respond to the discomfort of the ischemia- the result of this can be
tissue death
Darkly pigmented skin may not have
visible blanching
When an accurate measurement of the amount of drainage within a dressing is needed, the nurse
weighs the dressing and compares it with the weight of the same dressing when clean and dry
common way skin shearing can occur in health care setting
when transferring a patient from bed to stretcher,
The nurse should ensure that the patient's personal and social resources for adaptation are a part of the
wound assessment.
Calories provide the energy source needed to support the cellular activity of
wound healing.
Other methods of mechanical debridement are
wound irrigation
Suspected deep-tissue injury: pressure ulcer
—depth unknown. Purple or maroon localized area of discolored intact skin or blood-filled blister.
