Skin Integrity and Wound Care

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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


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