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Skin Integrity and Wound Care

What are the 3 phases of wound healing? Primary intention, Secondary intention, Tertiary intention
What is primary intention? Wound that is closed; Caused by surgical incision, wound that is sutured or stapled; healing occurs by epithelialization, heals quickly with minimal scar formation
What is secondary intention? Wound edges not approximated; Caused by pressure ulcers, surgical wounds that have tissue loss; heals by granulation tissue formation, wound contraction, and epithelialization
What is tertiary intention? Wound left open for several days, then wound edges are approximated; Caused by wounds that are contaminated and require observation for signs of inflammation; closure of wound is delayed until risk of infection is resolved
Describe methods of assessing wounds and wound healing across the lifespan Inspect the stage, depth, diameter, drainage (if present), blanching, sensation of area, mobility, continence, nutrition status, pain. Children heal more quickly than adults do, as you age it takes longer for wounds to heal.
Describe 3 major factors predisposing patients to pressure ulcers Intensity: how much pressure, duration: how long pressure persists, friction: is patient sliding on bed
Identify risk factors contributing to the formation of pressure ulcers decreased mobility and sensory perception, diabetes, poor nutrition, incontinence, age, poor circulation etc.
Describe stage 1 of pressure ulcer Nonblanchable redness of intact skin; localized area on bony prominence, discoloration of skin, warmth, edema, hardness or pain may be present, visible blanching difficult to see in darker skin patients
Describe stage 2 of pressure ulcer Partial thickness skin loss or blister; shallow open ulcer with red-pink wound bed w/o slough, may also present as a intact or open/ruptured serum-filled or serosangineous filled blister
Describe stage 3 of pressure ulcer Full thickness skin loss (fat visible); subcutaneous fat is visible, but bone, tendon, muscle are NOT visible, some slough may be present, may include tunneling
Describe stage 4 of pressure ulcer Full thickness tissue loss (Muscle, bone, tendon visible) exposed muscle, tendon, and bone, slough of eschar may be present, included undermining or tunneling, can extend into muscle and/or supporting structures
Describe complications of wound healing Smoking delays healing, nutritional status (obesity), age, health status (therapy your on may cause delays), wound condition, circulation/oxygen (varicose veins),
Can you backstage when assessing pressure ulcers? NO!
When using the Braden tool, describe how to identify patients at risk for pressure ulcers The lower the number scored in each category the higher the risk that patient has of developing pressure ulcers
Describe how to assess sites and an existing pressure ulcer Assess bony prominences for formation of pressure ulcers such as: shoulders, occipital portion of head, elbows, heels, coccyx, assess existing pressure ulcers drainage, stage, diameter, and depth
Identify etiologies and defining characteristics for clients at risk for or with impaired skin integrity impaired skin integrity r/t drainage or incision, risk for infection r/t incision, pain r/t pressure ulcer
Describe outcome criteria for clients at risk for developing pressure ulcers No occurrence of skin breakdown, and no formation of pressure ulcers
List guidelines for treating pressure ulcers Different facilities vary in treatment; some cover ulcers, some take pictures of ulcers to track progression, topical skin care provided, moisturizer used PRN, management of incontinence to prevent infection, repositioning of patient to prevent worsening
Created by: amandamarie194