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GBCN Skin Integrity

Skin Integrity

Hemostatis when? immediately after the initial injury.blood vessels constrict, blood clotting occurs
Inflammation when? follows hemostasis, lasts about 2 to 3 days. leukocytes and macrophages, move to the wound
Proliferation when? follows inflammation, lasts for several weeks. Tissue is growing (epithelial cells & blood cells)
Maturation when? final stage of healing, begins about 3 weeks after the injury, possibly continuing for months or year. Collagen that was haphazardly deposited in the wound is remodeled
what does the nurse notice during hemostasis? swelling, heat, redness, patient complains of pain
what does the nurse notice during inflammation? redness, swelling, heat, mildly elevated temperature, lab work- elevated WBC's
what does the nurse notice during proliferation? granulation tissue (hamburger)
what does the nurse notice during maturation? closed wound, slowly healing.
Examples of systematic factors affecting wound healing diabetic, age, protein-calorie intake, supressed immune system
Examples of local factors affecting wound healing excessive bleeding, bioburden, pressure, trauma, maseration, adema
serous clear watery
sanguineous bright red
serosanguinous pink to light red.
purulent yellow-green in color. has a foul odor
Hemorrhage External bleeding or internal hematoma
osteomyelitis infection goes to bone
sepsis bacteria in the blood
induration Swelling in and around the wound
Dehiscence Partial or total separation of wound layers as a result of excessive stress on wounds that are not healed.
Evisceration Total separation of wound layers with protrusion of viscera the wound opening
When is a patient at risk for Evisceration days 4 & 5. A sign in the increased serosanguinous drainage
Patients impacted by Evisceration do you feed or avoid? NO FOOD ( NPO- "no food by mouth")
Pressure Injury localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear
Created by: shenderson36