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Wound Care Part 1

What are the functions of the integumentary system? protection, insulation, recieve sensory stimuli, heat regulation, excretion, method of medication administration, displays emotional and physical identity
How much fluid is excreted through our skin daily? 600-900 mL
How does the skin regulate heat? Vasoconstriction to conserve heat and vasodilation to release heat
What is the largest sensory organ? The skin
What are age related changes to the skin? Thinning of dermal layers, decrease in subq tissue, decreased elasticity, decreased sensation, less padding over bony prominences
What skin problem are the elderly at a high risk for? skin breakdown
How does the skin repair itself? Through regeneration and repair
Tissue regeneration replacement of lost cells and tissues with cells of the same type
Tissue repair Healing as a result of lost cells being replaced by connective tissue. Occurs by primary, secondary, or tertiary intention
What are the two differences between tissue repair and regeneration? Regeneration usually occurs with smaller cuts and will not leave a scar. Repair happens with larger/infected wounds and will leave a scar b/c of the connective tissue.
Primary wound healing edges can be brought together, stitched and healed. Mostly medical surgeries
Secondary wound healing wound will heal from bottom up and from the edges in. Mostly pressure ulcers and wounds with infections.
Which nutrients promote wound healing? Protein, zinc, vitamins A and C
What is the building block of new tissue? Protein
What are some factors in delayed wound healing? nutritional deficiencies, inadequate blood supply, corticosteroids, infection, smoking, mechanical friction, obesity, DM, poor general health, anemia
What effect does smoking have on the blood vessels? It causes vasoconstriction
What effect does infection have on the tissues? Inflammation and tissue breakdown
Why does friction pose a problem with wound healing? b/c friction can remove new tissue growth.
Why is anemia a problem with wound healing? B/c there is not enough hemoglobin to carry oxygen to the wound
What are some factors that can promote wound healing? Using precautions to prevent wound infections, drug therapy, nutritional therapy, rest and immobilization, elevation, oxygenation, heat and cold and wound management
How does elevation help wound healing? It prevents edema
How does heat/cold therapy effect the blood vessels? cold causes vasoconstriction; heat causes vasodilation
When taking care of a wound, what is the first thing you need to do? Clean the wound
When you assess the wound, what information do you need to know? location, size, drainage, color of wound and tissue, assess pain associated with the wound
When assessing the size, what information do you need to gather? Length, width, depth, extent of tunneling
When assessing the drainage, what information do you need to gather? color, odor, amount, type (remember COAT, the drainage coats the wound)
When assessing color, what color would indicate healthy tissue? Erythema (red)
Erythema indicates what in wound healing? typically indicates granulation tissue; wound is in the inflammatory or proliferative phase of wound healing
When a wound is erythemic, what do you need to do? protect the wound and keep it most
When a wound is yellow, what does this indicate? infection or fibrous slough and indicates that wound is not ready to heal
eschar scabs or dry crust that result from trauma or infection
eschar is commonly referred to as black wound color
Black wound color indicates the presence of dead tissue that is dehydrated; may be covered w/eschar, the wound can not be assessed when eschar is present and it's an excellent medium for bacterial proliferation.
Why is eschar a good medium for bacterial growth? It's moist and dark
When can a wound not be classified? If the wound contains eschar it can not be properly assessed.
When is the only time that you do not want to remove necrotic tissue? When it's on the heel.
Why do you not want to remove necrotic tissue on the heel? It will increases the risk of osteomyelitis
mechanical debridement wet to moist dressing change
autolytic debridement cover wound and let the body heal by itself
enzymatic debridement creams and ointments that eat unhealthy tissue
biological debridement (maggot therapy) maggots are placed into the wound and eats dead tissue
osteomyelitis infection of the bone
When taking a wound culture, what do you need to do first? Clean the wound
Whose responsability is it to do a tissue biopsy? The doctor
Purulent Pus, yellow, green, tan or brown
serious fluid clear or light pink
sangionous blood
serousangounous blood and serum
What types of medications can you give to treat wounds? oral, IV, and/or topical
What is the cause of pressure ulcers? compression of soft tissue between two hard surfaces causing occlusion of capillaries, the tissue becomes ischemic and dies
What are the factors to consider in the cause of the pressure ulcer? pressure intensity, pressure duration and tissue tolerance
What are the risk factors for development of pressure ulcers? friction and sheer, decreased mobility, decreased sensory perception, fecal and/or urinary incontinence, poor nutrition
What tool do you use to assess risk for pressure ulcers? Braden Scale
What is the braden scale score that indicates your pt is at risk? <18
What are some interventions for prevention of pressure ulcers? assess skin, reposition pt and shift weight every 15 min when sitting, limit time at the HOB, relieve pressure on heels and keep bony prominances from direct contact with each other, consider pressure relieving devices, use a lifting device
The greatest pressure is at which area? The sacral area
What are the two highest risk areas for pressure ulcers? sacral and heels
bogginess/sponginess is an indicator of? Skin breakdown
When do you change the stage of a wound? You can change it going up (from a stage 1 to a stage 4) but never going down.
Whose responsability is it to intervene when a pt is developing a potential pressure ulcer? The nurses
Stage 1 pressure ulcer Skin intact, non-blanching redness
blanching push on red skin and the redness goes away
What do you need to do when you have a stage 1 pressure ulcer? Relieve pressure
Stage 2 pressure ulcer small crater, top layer of skin broken, limited to the dermal skin
What do you do for a stage 2 pressure ulcer? use a hydrocoylloid dressing to protect the skin
Stage 3 pressure ulcer damage goes down to the subQ tissue
Stage 4 pressure ulccer through the fascia and beneath, you may be able to see the bone
When you are dealing with a pressure ulcer, when it is the nurses vs the doctor's responsability? Stage 1 and 2 are usually cared for by a nurse; stage 3 and 4 are usually taken care of by a MD
Why are diabetics predisposed to pressure ulcers? diabetics lose protective sensation, they just don't feel the damage being done and that is why they get their feet inspected at each visit.
When you have a wound, what condition do you want the wound bed to be in? moist (NOT WET)
What is normally used to clean the wound? Normal saline
What is the purpose of wound vac therapy? Remove fluids, promotes moist wound healing environment, helps to draw wound edges together, helps promote perfusion, removes infectious materials, helps protect the wound environment
Created by: mercerw