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NUR151-WoundCare2
Wound Care and Skin Integrity Part 2
| Question | Answer |
|---|---|
| Serosanguinous or Sanguinous | looks like watery blood - Hemorrhagic - due to capillary damage - Occurs w/severe inflammation/ injury |
| Purulent | Pus Occurs with infection - Thicker, WBCs, dead tissue, & bacteria, Pyogenic – bacteria produced - may be yellow, tan, green, |
| Mucus (mucous) | thick fluid secreted by mucous membranes and glands |
| Phase 4 – Healing | Regeneration and repair - Replacement of lost cells & tissue w/cells of same type |
| What factors may prolong inflammatory phase? | age, autoimmune disease, chronic infections, nutrition deficiencies, immunosuppressants, steroids |
| What might impair granulation or proliferation phase? | dry wound, infection, nutrition (not enough protein or zinc), collagen, anemic (not enough RBCs to get there and heal) |
| Hyperemia | redness due to vasodilation – blanch to see if transient |
| Blanching hyperemia | area blanches and then erythema returns – transient |
| Nonblanching erythema | area does not blanch – deep tissue damage probable |
| In shear, what damage occurs? | deep tissue damage – undermining of dermis |
| In friction, what damage occurs? | epidermis or top layer of skin – sheet burn |
| Skin changes due to age | reduc skin elasticity, decr collagen, slower epithelialization & wound healing, dypodermis decreases in size, less sub Q |
| Primary Intention | Wound closed with sutures, staples, dermabond, Least scarring |
| Secondary Intention | Left open to fill in w/granulation tissue – healing from inside out |
| Why use secondary intention? | To monitor granulation tissue or remove necrotic tissue –adipose tissue takes longer to heal |
| Tertiary Intention or delayed primary closure | wound left open for a period of time & then closed – used w/compartmental syndrome, make sure infection gone before closing |
| Examples of primary intention | surgical incision closed w/suture or staples |
| How does primary intention heal? | by epithelialization – minimal scar formation – by connective tissue deposition |
| How does secondary intention heal? | By granulation tissue formation, wound contraction, and epithelialization |
| Examples of secondary intention | pressure ulcers, burn, severe laceration, surgical wounds w/tissue loss – wound edges not approximated |
| Examples of tertiary intention | contaminated wounds – examining them for inflammation |
| How does tertiary intention heal? | closure of wound delayed until risk of infection, then closed |
| Full thickness wounds heal by | skar formation because deeper structures do not regenerate |
| 3 healing stages of partial-thickness wounds | inflammatory response, epithelial proliferation (reproduction) and migration, and reestablishment of epidermis |
| 3 healing phases of full-thickness wound repair | inflammatory, proliferative, and remodeling |
| How do steroids affect healing? | suppresses the immune system, masks effects of infection |
| How does infection delay healing? | Uses up available resources, damages tissues |
| Inflammatory Phase | hemostasis, fibrin matrix, neutrophils, then monocytes that transform into macrophages – goal is to stop bleeding and remove debris |
| Proliferative Phase | appearance of new blood vessels, granulation tissue, contraction of wound, epithelialization, collagen |
| What can impair healing during proliferation phase? | age, anemia, hypoproteinemia, and zinc deficiency |
| Remodeling phase | collagen scar formation – takes more than year – scar is remodeled and reorganized into original appearance |
| Hemorrhage occurring after hemostasis indicates? | slipped surgical suture, dislodged clot, erosion of blood vessel by drain, etc. |
| Surgical wound doesn’t show infection till when? | 4th or 5th postoperative day |
| Dehiscence | surgical incision has opened - pack w/moist gauze, etc; monitor for signs of infection |
| Increase in serosanguineous drainage from wound could indicate | dehiscence |
| Evisceration | medical emergency – when organ protrudes outside body - dehiscence - cover w/sterile moist gauze over protruding organ & surgery – NPO |
| What can increase incidence of dehiscence and evisceration?Obesity, poor suturing, poor nutrition | |
| Fistula | poor wound healing – abnormal passage between 2 organs or between organ and outside of body |
| How do fistulas occur | poor wound healing or complication of disease, trauma, infection, radiation, cancer – tissue layers don’t’ close properly |
| s/sx of internal bleeding? | hematoma, bruising, distention, BP drop, HR incr due to loss of volume, hypotension, tachycardia |
| Contracture | excessive shortening of muscle or scar tissue leads to deformity – when arm or affected parts are immobilized |
| PRESSURE – 3 factors for pressure wounds | Pressure Intensity, Pressure Duration, Tissue Tolerance |
| Impaired Nutrition that affects wounds | not enough protein, zinc, vitamin C |
| Stage I | Superficial, Intact skin, Non-blanchable erythema, Discoloration of darker skin, Warmth, edema (boggy feeling), induration, hardness |
| Stage II or partial thickness | Partial loss of epidermis & dermis, abrasion, blister, Considered infected even if no sx – heals by regeneration |
| Stage III or full thickness | deep crater, Extends into SQ tissue, but not into muscle, necrosis present - slough or eschar – heals by scar formation |
| Stage IV – Full thickness | through SQ into muscle w/extensive destruction, necrosis – may go down to the bone, possible damage to muscle, bone, supporting structures – scar formation |
| How do stage 3 and 4 wounds heal? | through scar formation |
| How does a stage 2 wound heal? | by regeneration |
| Venous stasis ulcers | necrotic crater-like lesion usually found on lower leg at medial malleoli - slow to heal, poor venous return, varicose veins, incompetent valves, DM, arterioscleosis |
| Arterial ulcers | pale, ischemic base, well defined edges found on toes, heels, lateral malleoli |
| Cap refill in arterial ulcer | Greater than 3sec |
| Cap refill in venous ulcer | Less than 3sec |
| Which type of ulcer condition has no edema in the legs, yet has little or no hair there? | arterial |
| Cool skin temperature occurs in which type ulcer? | arterial – venous is warm |
| Contact Dermatitis | caused by exposure to irritant chemical or allergen - poison ivy, metals – nickel |
| Atopic Dermatitis (Eczema) | tendency is inherited causing chronic inflammation from exposure to allergens |
| Urticaria (hives) | type I hypersensitivity reaction (usually caused by something ingested) causing release of histamines – wheals |
| Psoriasis | Unknown origin - Chronic rapid turnover of epidermal cells resulting in thickening and scaling, silvery plaques |
| Cellulitis | infection of dermis & subcutaneous tissue; may be caused by Staph or Strep, insect bite - MRSA, Red, warm, swollen, painful |
| Furuncles | usually cause by Staph which begins in a hair follicle & spreads into surrounding dermis – boil |
| Carbuncle | collection of furuncles that form a large infected mass – if many furuncles together, they are a carbuncle. |
| Acute Necrotizing Fascitis | highly virulent strain of gram positive, group A, beta-hemolytic Strep, history of minor trauma or infection in skin and subQ - Mortality is 30-60% |
| Herpes Zoster (Shingles) | Caused by activation of varicella-zoster virus - affects one cranial nerve or one dermatome innervated by a spinal nerve |
| Cutoff score for onset of pressure ulcer risk with Braden Scale is | 18 |
| Tinea infections | fungal infection or mycoses |
| Pedis | athlete’s foot |
| Corporis | ringworm of body |
| Capitus | ringworm of head |
| Pediculosis (lice) | contagious parasites that suck blood - head, body, pubic |
| Scabies | contagious, caused by itch mite - Causes burrows, papules, vesicles; very itchy |
| Vitamin A reduces neg effects of | steroids on wound healing |
| Copper is necessary for | collagen fiber linking |
| Best measure of nutritional status is | prealbumin – reflects not only what pt eats but what body has absorbed |
| Basal cell | can be removed. Most common, least likely to metastasize |
| Squamous cell | removal, may require radiation. May metastasize if untreated |
| Malignant Melanoma | Excision & removal of surrounding tissue, Lymph node biopsy, radiation, chemo, immune therapy, A symmetry, B orders irregular, C olor-varied pigmentation brown, black, tan, D iameter > 6mm - pencil eraser |
| Wrinkles – Why? | loss of elasticity |
| Skin tears | lose collagen |
| Senile lentigo or liver spots | areas of discoloration on the skin – tannish - harmless |
| Pruritis | itching due to dry skin |
| Keratosis | overgrowth of horny layer |
| Seborrheic | yellow-brown scales on trunk, face, scalp |
| Macule | frecke, petechia, flat nonpalpable change in skin color – smaller than 1cm |
| Papule | Nevus – palpable, circumscribed, solid elevation in skin – smaller than 1cm |
| Nodule | Wart – elevated solid mass deeper and firmer than papule 1-2 cm |
| Wheal | Hive, mosquito bite – irregularly shaped, elevated areas of superficial localized edema – varies in size |
| Vesicle | Chickenpox, herpes – circumscribed elevation of skin filled w/serous fluid, less than 1cm |
| Pustule | Acne, staphylococcal infection – like a vesicle but filled with pus |
| Ulcer | Venous stasis ulcer – deep loss of skin – extends to dermis – bleeds and scars |
| Atrophy | Arterial insufficiency – thinning of skin w/furrow – skin shiny and translucent |
| Plaque | a patch on the skin or on a mucous surface |
| Fissure | an ulcer or cracklike sore |
| Comedone/comedo | The typically small skin lesion of acne – closed form is a whitehead – papule – open form is a blackhead- rearely inflamed |
| Petichiae | pinpoint purpuric lesions – tiny bruises |
| Purpura | any rash in which blood leaks into skin at multiple sites – associated mostly with coagulation or thrombosis disorders |
| Ischemia (decreased circulation) - disorders causing | PVD, MI, DVT, CVA |
| Causes inflammation without infection | Foreign body, Ischemia, Skin, tissue trauma, Temp extremes (Burns, frostbite), Chemicals, radiation, electricity, Allergies, Neoplasms |
| Differentials measure | WBC count incl. neutrophils, lymphs, monos, eosinophils/basophils |
| Neutrophils increase with | bacterial infections or acute trauma – major inflammatory response |
| Which WBCs are the first to respond? | neutrophils – perform phagocytosis |
| Lymps increase with | viral & chronic bacterial infections |
| Monos change into | macrophages in tissues – phagocytosis |
| Monos increase with | protozoan, rickettsial, & TB infections, fungal |
| Eosinphils/Basophils increase with | allergic rxns, not elevated with infections, release chemical that control histamine & serotonin |
| Which WBCs release chemicals that control histamine & serotonin? | Eosinophils/basophils – due to allergic rxn, not infections |
| Total WBCs | 4000-10000/mm3 |
| Possible critical levels are WBCs | less than 2500 or greater than 30,000 or Absolute neutrophils less than 1000 |
| Elevated sedimentation rate Increase w/ | generalized inflammatory response |
| C-reactive protein increase w/ | inflammation, infection, malignancy |
Created by:
Ladystorm