Wound Care and Skin Integrity
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| Epidermis | Several layers - top layer is dead cells, no blood vessels or nerves – when we bleed, the vessels are down further, Nutrients/fluid diffuse into it
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| Dermis | Appendages consist of hair follicles, sebaceous glands & sweat glands (2 types: Eccrine and Apocrine) - mostly CT which helps w/scar formation, hold hair follicles, sweat glands, & keep us together
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| Skin is useful how? | 1st line of defense, Prevents excess fluid loss, Provides sensory perception – sense pain, Synthesis & activation of Vit D on exposure to sm amounts of UV
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| Skin changes in older adults | FOCUS on Older Adults, Lose adipose tissue – cushion, Sensory perception not as strong, Skin elasticity is reduced –tents easily
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| What is a wound | Break in integrity of skin/mucus membrane caused by surgery, trauma, disease
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| Partial thickness wounds | shallow involving loss of epidermis and possible partial loss of dermis
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| Example of partial thickness wounds | papercut, scrape, blister, abrasion
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| __ can regenerate – scab forms and skin regenerates | Epidermis
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| Full thickness wounds | extend into the dermis or deeper – surgical, gunshot, stabbing, deep laceration, decub ulcer
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| Full thickness wounds heal by | scar formation
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| Inflammation phase of partial thickness wound | Lasts about 24hours, Redness & swelling, serous exudate – clear/watery
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| Epithelial Proliferation of partial thickness | superficial wounds - epithelial cells regenerate & migrate across wound surface from edges –only migrate across moist surface – good tissue looks “red and beefy”
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| Open to air resurfacing | 7 days – moist is 4 days
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| 3 stages of partial thickness wound healing | Inflammation (24 hours), Epithelial proliferation, & Reestablishment of epithelial layers
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| 3 stages of full thickness wound healing | Inflammation (around 3 days), Proliferation (Granulation) phase 3 – 24 days, Remodeling Phase (7 days – mo or years)
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| Reestablishment of Epithelial Layers | Initial resurfacing very thin, appears pink & dry, Must re-establish epithelial layers over time
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| Full thickness inflammation phase | Inflammation phase
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| Fibrin clot serves as | matrix for cellular repair
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| Proliferation (Granulation) phase of full thickness wound repair | 3-24d - fills w/granulation tissue & surface re-epithelialized - Immature CT (fibroblasts) migrate to site & secrete collagen - wound appears pink, grainy - budding capillaries – this a good thing!
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| Remodeling Phase/Scar contracture of full thickness wound repair | 7d- mo. or yrs. - Remodeling of collagen, contraction & strengthening of scar, Appears pale, avascular
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| Scar tissue is not as strong as regular tissue making it | at risk for opening up again due to skin breakdown
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| Assessing wound - note wound appearance | redness, swelling, warmth, tenderness, presence of granulation or necrotic tissue
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| Slough | yellowish & stringy
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| Eschar | black or brown – Necrotic tissue must be removed so that granulation tissue can regenerate.
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| Undermining | when wound descends further under the skin
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| Tunneling | abnormal passageway in the tissue – wound tunnels to an organ like a bowel - Don’t know how deep they go - have to heal by secondary intention- heal from the inside out.
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| Measure Size of wound how often | One a day – Once a week – depends on extent/severity - Most are measured 1 – 2 times per week - measure in cm - use only sterile q-tips in the wounds
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| Measurements of wounds are done how? | head to toe = length, side to side = width, depth at deepest point
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| Gently clean wound w/normal saline or commercial wound cleanser only Why? | Removes debris, toxins, necrotic tissue w/o damaging healthy tissue
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| Chemical debridement | collagenase, papain-urea, Dakin’s solution,sterile maggots
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| Mechanical debridement | Wet to dry dressings - Wound irrigation 8psi w/ 35ml syringe & 19g needle or 18g angiocath – squirt inside wound, Whirlpool
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| Autolytic | occlusive or semi-occlusive dressing promotes body’s softening of Eschar - transparent or hydrocolloid dressings
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| Stable means | it is dry, adherent, intact without erythema or fluctuance -area not stable/mushy
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| stable eschar on the heels serves | as the body’s natural cover and should not be debrided
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| Choose type of dressing based on | purpose, type of wound, amount of exudate – you follow physician’s orders, - choose dressing that allows for proper absorbency
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| Purpose of Dressings | Protects wound from microorganisms, Aids in hemostasis, Provides moist environment, Suports or splints site, Promotes thermal insulation
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| Gauze | woven & non-woven - Wet to moist - Wet to dry – used for packing & delivery of solutions to wound
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| Non-adherent dressings | Adaptic, Vaseline, Telfa – doesn’t pull off the granulation tissue – used a lot on surgical incisions. Shiny
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| Transparent films | Tegaderm, Biocclusive – cover IV sites and wounds – used on partial thickness – minimal exudate
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| Hydrocolloids | Duoderm, Comfeel – used on the coccyx area a long – want to cover the are so it doesn’t become infected – minimal tomoderate exudate – autolysis promoter
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| Absorptive dressings | Kerlix fluffs (using multiple ones together makes a “kluff”), ABDs, Surgipads
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| Foams | Lyofoam, Curafoam – absorbs moderate to heavy exudate – maintains moist environment - semipermeable
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| Hydrogels | Supply moisture to dry wound- Cover w/gauze or hydrocolloid
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| Alginates | Sorban, AlgiDerm – supplied in a dry form – look like filaments of cotton – they turn into jelly when exposed to moisture – absorbs moderate to heavy exudate
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| Antimicrobial | Prisma
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| What would you use to dress Stage I pressure Ulcer? | None, transparent, hydrocolloid – protects from shear – resolves slowly w/o epidermal loss
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| What would you use to dress Stage II pressure Ulcer? | Composite film (limits shear), hydrocolloid, hydrogel (provoids moist environ) – heals through reepithelialization
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| What would you use to dress Stage III pressure Ulcer? | Hydrocolloid, hydrogel w/foam, calcium alginate, gauze, growth factors – Heals through granulation and reepithelialization
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| What would you use to dress Stage IV pressure Ulcer? | Hydrogel, Calcium alginate gauze, growth factors Adherent film, gauze, enzymes – Heals through granulation and reepithelialization
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| Red wound examples | skin tears, pressure ulcers (stage II), partial-thickness or 2-deg burns, surgical allowed to heal by secondary intention
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| Red wound appearance | Clean, pink or red w/ granulating tissue
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| What kind of dressing might be used if red wound is superficial | bandaid, gauze, hydrocolloid (duoderm)
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| If red wound is deeper and has moderate drainage? | gauze dressing – wound vacs are good w/red wounds
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| What does yellow wound look like? | presence of slough – yellowish or greenish in color and necrotic tissue
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| What kind of dressing might be used for yellow wound? | absorption dressing - calcium alginate, foam, hydrogel - absorbs exudate and cleanses the wound surface
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| Thick black necrotic tissue | eschar
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| What type of wounds usually have Eschar? | full-thickness or third-degree burns, pressure ulcers (stages III and IV) and gangrenous ulcers
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| Best way to remove Eschar? | Surgical debridement – other ways – Mechanical, Enzymatic ointments, Dressings to promote softening – Hydrogel, Wet to dry dressings – pull off when dry to debride
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| Protein is important for | wound remodeling and wound healing also helps fight infection – collagen formation
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| Zinc | Collegen Formation, protein synthesis, cell membrane, host defenses
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| Vit C | Collagen synthesis, capillary wall integrity, fibroblast function, immunologic, antioxidant
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| Vit A | Epithelialization, wound closure, inflammatory response, angiogenesis, collagen formation – can reverse steroid effects on skin & delayed healing
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| Inflammatory Response to Cell Injury | Vascular Response – 1 generally occur simultaneously w/cellular, 2 Cellular Response, 3 Formation of exudate, 4 Healing
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| Vascular Response Phase | Hemostasis (vasoconstriction), release of histamine, WBCs & other chemicals (vasodialation), Increased capillary permeability –edema
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| Cellular Response | Specialized WBCs (first neutrophils, then monocytes) move to site of injury to clean debris
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| Leukocytosis is | Increase in white blood count
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| CBC Differential | Part of it is the WBC count and see the specific WBCs to see if they have increased
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| Exudate Formation | Caused by release of chemical mediators, Function of drainage
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| Nature and amount of exudate depends on | tissue involved, type of wound, intensity & duration of inflammation –longer it lasts = more exudate, presence of microorganisms –look for color, amount, consistency
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| Serous | mild inflammation – blister - Serum - watery, low protein
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