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MCC Nursing Unit 3

Wound and Skin Integrity

What are the signs of inflammation? Pain Redness Immobility/ loss of function Swelling Heat
What are the factors that affect skin integrity? Nutrition- poor nutrition less regeneration Hydration- poor hydration reduces turgor Sensation level- diminished sensation leads to increased risk for pressure ulcers & skin break down Impaired circulations-neg effects tissue metabolism (arterial ulcers) Medications- cause side effects itching and rashes Moisture- leads to maceration Fever, Infection, and lifestyle
Why is controlling fever important to skin integrity? Fever depletes the hydration levels in the body. Also increases the bodies metabolic rate, raises the tissues demand for oxygen.
How can our lifestyle choices effect our skin integrity? Thing like tanning, excessive bathing, or not bathing enough, piercings, and tattoos,smoking, exercising(positive effect) can all have lasting effects on our skin.
Name the classification of Wounds. ~Open/Closed ~Acute/Chronic ~Clean/Contaminated/Infected ~Superficial/partial or full thickness ~Penetrating
What are some types of open wounds? Abrasions, Punctures, Compound fractures, surgical incisions
What is the definition of an acute wound? a wound that has a short healing time with out any complications
What is the definition of clean wounds? Uninfected wounds with minimal inflammation, They can be open or closed. Does not include wounds in the: gastrointestional respiratory genitourinary tracts
What is a clean contaminated wound? A surgical incision that enters the gastrointestional, respiratory, or genitourinary tracts. Contains no obvious infection but has a risk of infection.
What is the definition of a contaminated wound? Open traumatic wounds or surgical incisions where a major break in a sepsis occurred.
What are the 4 types of wound drainage? 1.Serous exudate- straw colored 2.Sanguineous- bloody drainage 3.Serosanguineous- mix of bloody and straw colored fluid 4.Purulent yellow- contains pus
What is happening during Regenerative/epithelial stage in the wound healing process. Takes place when the wound only effects the epidermis or the dermis. No scar is formed. New skin can not be distinguished from the intact skin. Partial thickness wounds
What is involved in Primary Intention Healing? Involves minimal or no tissue loss Edges are well approximated. Little scarring is expected Clean surgical incisions
Secondary Intention Healing... The wound has endured extensive tissue loss, edges are not approximated or the wound should not be closed due to infection. The wound heals from the inside out filling in with granulation tissue. Scar is expected. More prone to infection Pressure Ulcers and Infected wounds
Tertiary Intention Healing... Happens when two surfaces of granulation tissue is brought together. Wound initially heals by secondary intentions until there is no sign of edema, infection, or foreign matter. Then the wound edges are closed and held by sutures. Clean contaminated or contaminates wounds Moderate amount of scaring
What are the Phases of Healing? ~Inflammatory ~Proliferative ~Maturation
What happens during the Inflammatory Phase? Cleansing phase and last 1 to 5 days and consists of hemostasis and inflammation.
How long does the proliferative phase last? Starts on day 5 and last until day 21 epithelialization begins to occurs in this stage and seals the wound
What are the 5 major complications of wound healing? 1. Hemorrhage 2.Infection 3.Dehiscence- wound that is close and part ruptures 4.Evisceration- Surgical emergency happens only in the abdomen. 5.Fistula formation- abnormal passage that connects two body cavities
Which scale is used on a focus skin assessment? Braden scale ~ how high of a risk a patient is for skin break down
What is the score for a patient who is at risk for skin break down? Braden score of 18 or less
What is notated in a wound assessment? Dimension length by width in cm Anatomical location Wound depth, edges Drainage- color, amount, odor, consistency Redness Swelling Appearance Eschar (scubbing)
What is the first thing a nurse should do before providing wound care? Check Clinicians orders
Tips for Initial Wound care... IF its dirty, clean it IF its slough, DON'T fluff. IF its deep, fill it. IF its open, cover it. IF its dry, moisten it. IF its wet, absorb it.
What is used to irrigate a wound? Normal Saline Only
What is removed when debriding a wound? foreign materials non functioning cells necrotic tissue exudate and infective tissue
What are the 5 types of debridement? Sharp/surgical- uses sharp instruments to remove devitalize tissue Mechanical- wet to dry dressings or hydrotherapy Enzymatic- using proteolytic agents to break down necrotic tissue Autolytic- body own enzymes are used to break down tissue Biotherapy/ maggot
How does heat and/or cold therapy effect the wound? HEAT ~relieves stiffness and discomfort ~vasodialator and increases blood flow and bring oxygen and WBC to the wound ~Promotes the delivery and removal of waste products ~Moist heat amplifies the intensity of treatment COLD ~Vasoconstrictor ~decreases muscle tension ~reduces inflammation, pain,oxygen requirements, and bleeding ~used to treat fevers
What are the types of wounds? Abrasion, Abscess, Contusions, Crushings, Incisions, Lacerations, Penetrating, Puncture, Tunnel
How does a pressure ulcer develop? when there is unrelieved pressure or combination of pressure and shearing force compromise blood flow to an area resulting in ischemia. Ischemia leads to tissue anoxia and eventually cell death Usually located on bony prominences of the body.
Suspected deep tissue injury Skin is intact but discolored painful and could have blistering
Stage 1 pressure ulcer Localize area of intact skin with non blanchable redness, may be painful, soft, firm , warmer or cooler to adjacent tissue. Discoloration will remain greater than 30 min after pressure is relieved
Stage 2 pressure ulcer Partial thickness loss of dermis open wounds but shallow in depth red/ pink wound bed no slough may have a ruptured or filled blister no bruising
Stage 3 pressure ulcer Deep crater characterized by full thickness skin loss with damage or necrosis of subcutaneous tissue Undermining of adjacent tissue may be present Bone/ Tendon is not visible, or palpable
Stage 4 pressure ulcer Full thickness skin loss Extensive destruction, necrosis,damage to muscle, bone,or support structure Exposed bone/tendon is visible or directly palpable Slough and Eschar may be present
Unstageable pressure ulcer Involves full thickness skin loss Base is obscured by slough, eschar, or necrotic tissue
Nursing Interventions for Pressure Ulcers ~Difficult and Time Consuming ~Utilize Braden Scale ~Frequent repositioning ~Assess patient DAILY ~Maintain moisture control ~Therapeutic mattresses ~Patient/ Family teaching
Which labs would a nurse need for wound care and skin integrity? ~Protein levels ~CBC ~RBC ~Glucose ~Thyroid ~Iron levels ~Wound Cultures ~Coagulation Studies
Why is controlling moisture important to skin integrity? Moisture leads to maceration which is the softening of the skin which in turn leads to skin break down
Created by: MCCGroup5