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N126 Wounds

Wound Assessment and Care r/t Nursing

Regenerative/ epithelial healing Wound effects only epidermis. New skin is formed and no scar is present.
Primary intention healing Wound involves minimal tissue loss with well approximated edges. Minimal scarring. Ex: Clean surgical scar.
Secondary intention healing Wound involves tissue loss. Edges not approximated / wound should not be closed due to infection. Heals slowly by filling with granulation tissue from the bottom up, prone to infection. More scar tissue. Ex: Pressure ulcer, infected wound.
tertiary intention healing Wound is contaminated/ clean-contaminated. Follows secondary intention healing. When there is no edema, infection or debris, two surfaces of granulation tissue are sutured together. Strict aseptic technique - prone to infection. Less scar than secondary.
Inflammatory phase "cleansing" (days 1-5) 1.Hemostasis: vessels constrict limiting hemo. Platelets aggregation & Clotting mechanism. 2.Inflammation:edema, erythema, pain, warmth, WBC migration. macrophages engulf debris & pathogens. Scab formed.
Proliferation Phase "granulation" (days 5-21) New cells fill the wound. Fibroblasts form collagen for strenth. Blood & lymph vessels are re-formed, resulting in formation of granulation tissue. Epithelialization begins.
Maturation phase "epithelialization" (2nd or 3rd week until healed) Collagen fibers are remodeled into an organized structure (scar), increasing tensile strength. Epithelialization continues. *Scar is only 80% as strong as original tissue*
Hemorrhage/Hematoma (major complication) may indicate a clotting issue,infection,slipped suture,internal bleeding
Dehiscence (major complication) separation of one or more layer. RN intervention: Apply a binder & modify activity to prevent evisceration.
Evisceration (major complication) total separation w/ protrusion of viscera. surgical emergency. Cover opening w/ sterile saline soaked sterile towels, notify the surgeon, and prep pt for surgery.
Fistula (major complication) abnormal passage between two body cavities or a body cavity + the skin that is created by an abscess.
Infection (major complication) contaminated/traumatic wound s/sx: 2-3 days; clean surgical wound s/sx: 4-5 day post op. s/sx: edema, erythema, warmth, pain, fever above 100.4, odor, purulent drainage, color change in drainage.
serous exudate consists of serum. Staw colored fluid w/ watery consistency that separates out of blood when a clot is formed. Uusally present in a clean wound.
sanguineous bloody drainage. Indicates damage to capillaries. Usually present with deep wounds or highly vascular areas.
serosanguineous combination of bloody and serous drainage. Common in new wounds.
Purulent exudate yellow (or sometimes blue-green), thick drainage from infected wounds commonly caused by infection of a pyogenic (pus-forming) bacteria such as strep or staph. Possibly malodorous. Contains pus (WBCs, bacteria, and cellular debris)
Predisposing for evisceration/ dehiscence Usually in inflammatory phase before collagen reinforced. Assoc w/ abd. wound, obesity (Fat does not heal quickly), malnutrition, inadq muscle closeure, or infection. Triggered by coughing, vomiting& change in position.
Stage I Pressure Ulcer nonblanchable erythema on intact skin (Dark skin=red/blue/purple hue) that remains for more than 30 minutes after pressure is relieved.
Stage II Pressure Ulcer Involves partial-thickness skin loss of the epidermis, dermis or both. Abrasion, blister, or shallow crater.
Stage III Pressure Ulcer Full-thickness skin loss involving damage or necrosis of sub-q tissue. May extend down to fascia (but not through) Deep crater with poss undermining.
Stage IV Pressure Ulcer Full thickness skin loss with extensive destruction, necrosis, or damage to muscle, bone or support structures. Presence of undermining and sinus tracts common.
Eschar Black, leathery covering of necrotic tissue and plasma proteins that forms when a wound cannot close by epithelialization.
Preventing Pressure Ulcers Daily skincare, warm water(not hot) for high risk pts. Use soap only as needed. Lotion if dry. Keep linen free of wrinkles. Adq calories & protein. Reposition q2h using the rule of 30 degrees. Therapeutic mattresses and cushions. Family teaching.
RYB color code system (wound mgmt) RED Granulation. RN goal=Protect the wound Activites=Keep the wound moist and covered
RYB color code system (wound mgmt) YELLOW Moist, devitalized tissue (slough) RN goal=cleanse the wound Activites=irrigation and dressings. Poss debridement
RYB color code system (wound mgmt) BLACK Eschar Debride the wound Sharp, mechanical, ensymatic, or autolytic debridement.
Sharp debridement use of a sharp instrument to remove devitalized tissue. Provides immediate improvement of the wound bed & preserves granulation tissue.
Wound care with drains Remove one layer at a time carefully to avoid dislodging drains. Monitor drainage. Record amount of drainage as output. Empty container at designated volume to maintain suction.
Mechanical debridement. Lavage:irrigation with a mild amount of force 4-15 psi. Wet do dry dressings: moist dressing is allowed to dry in the wound, then removed providing nonselective debridement. Painful. Hydrotherapy: for wounds w/ lots of nonviable tissue. Avoid water je
Enzymatic Debridement clean wound w/ NS, apply topical enzymatic agent, cover w/ moisture retaining dressing. Apply product only to devitalized tissue.
Autolysis use of an occlusive moisture retaining dressing and the body's own mechanisms for ridding itself of necrotic tissue. Activites: Apply dressing & observe fluid. Change q72h; cleanse wound at dressing changes.
Woven Gauze Fine to coarse mesh. Absorbent. For packing wounds, wicking exudate or debridement.
Nonwoven gauze for cleaning and wiping the skin or providing a layer of protection
Nonadherent gauze (Telfa) Protection
Transparent film clear & semiperm. keep wound moist.For wounds with min/ no drainage. Used to dress IV sites. Good for visual assessment, flexibility (joints)
Hydrocolloids Wafers, pastes, powders. hydrophilic. Adhesive. Keeps wound moist.Moldable for tight spots, absorbant, promote autolysis. Good for stasis ulcers or stge II pressure ulcers. Not for infected wounds. anaerobic bacterial growth.
hydrogels sheets, granules or gels with high water content. Jelly consistency; Nonadhesive. Mimimal absorbtion.. Softens slough or eschar. Can be used in infected wounds. may maserate periwound skin.
Absorption dressings mod-lg exudate.Beads, pwd, paste, ribbon, alg. 2nd dressing req.
Heat therapy Indications stiffness and discomfort r/t mussculoskeletal probmlems, wounds. Increases blood flow and tissue perfusion & relaxation.
Heat therapy assessment Observe for faintness due to drop in BP (vasodilation).
Close observation of heat/cold therapy Very Young Very old Sensory impairment high risk for injury: fingers, hands, face, perineum, feet Application to small area of intact skin is better tolerated
Moist heat amplifies the intensity of the tx.
Cold Therapy Indications decreases blood flow. Produces local anesthesia, decreases muscle tension. slows bacterial growth. limits edema, inflammation, pain, o2 requirements and bleeding. tx of fevers, sports injury & post op swelling.
Cold Therapy Assessment May increase blood pressure. May cause shivering. Prolonged exposure may cause tissue damage.
Temp therapy safety measures Avoid direct contact with skin Apply hot/cold intermittently No more than 15 min at a time check skin for redness, blistering, cyanosis or blanching
abrasion superficial scrape of top layers of the skin
abscess localized collection of pus due to invasion from a pyogenic bacterium or other pathogen. I&D to treat
Contusion Closed wound caused by blunt trauma. AKA bruise/ ecchymotic.
Crushing caused by force leading to compression or disruption of tissues. Assoc w/ fx. Minimal/no break in skin.
incision open, intentional wound caused by a sharp instrument
laceration torn open. Wound w/ jagged margins
penetrating open woudn in which the agent causing the wound lodges in body tissue
puncture open wound caused by a sharp onject. Often a collapse of tissue around entry point. Prone to infection
Tunnel wound with an entrance & exit site
Factors affecting healing age (older=longer healing time) impaired mobility/sensation, nutrition, hydration, poor circulation, medications, moisture, fever (increased metabolism, unavail for wound healing), contamination/infection.
BP meds Healing decreases amt of pressure required to occlude blood flow to an area. Risk for ischemia
Anti-inflammatories inhibit wound healing
Steroids inhibit wound healing
Anticoagulants may cause extravasion of blood into sub q tissue. min pressure/injury can cause a hematoma
chemotherapy delay healing. toxicity
antibiotics, psychotherapeutic drugs, chemotherapy increase sun sens
herbal products (tea tree oil, lavender) dry out the skin.
for aerobic wound culture Use sterile technique and a culturette tube
Low BP & increased arterial pressure are indicative of _______- Internal Bleeding
Preferred dressing for dry yellow slough Tightly adhering hydrocolloid dressing
Tx for fx ankle ice
Nutrient to promote collagen synthesis & capillary wall integrity Vitamin C
Created by: lilredsmiles