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Wound Care
Ch. 36
| Question | Answer |
|---|---|
| What are pressure ulcers? | impaired skin integrity, pathogenesis, tissue ischemia - occurs when capillary blood flow is obstructed, hyperemia - blanchable/nonblanchable |
| Contributin factors to pressure ulcers | External factors: shear, friction, moisture, Internal factors: nutrition, infection, age, duration of pressure |
| What is shear | force exerted against skin |
| what is friction | two surfaces rub against each other, elbows/heels, looks like abrasion(loss of top layer) |
| What is out of balance with nutrition in pressure ulcers? | fluid/electrolytes, protein balance, low protein cause edema/swelling or hypoalbuminemia Cachexia: malnutrition |
| What is the primary intention of the healing processes of a pressure ulcer? | Primary Intention - little to no loss of tissue, wound edges approximate, minimal scarring, slight risk for infection, surgical incision |
| What is secondary intention healing process? | Secondary Intention - loss of tissue, edges not approximated, granulation forms, great risk of infection, chronic wound, laceration, pressure ulcer, scar, no bleeding/hemostasis phase Provide moist env. for healing |
| What is delayed primary closure or tertiary intention? | a surgical incision where subq and skin layers left open, granulation, wound contraction Ex: ruptured appendix |
| What is partial thickness wound healing? And phases of healing? | shallow wounds with loss of epidermis and part of dermis, wound of primary intention, inflamm response-red/swollen, scab, <24hrs. Epidermal repair-moist hastens healing,epid cells x wound Dermal repair- epid thickens |
| What is Full thickness wound healing | loss of epid/derm/subq/bone/muscle hemostasis phase, inflammatory phase, proliferation phase Remodeling phase |
| Stage 1 pressure ulcer classification? | defined/observable area of intact skin, boggy skin, temp changes, consistency,sensation,nonblanchable Positioning helps |
| Stage II pressure ulcers | partial thickness (abrasian, blister) loss of derm w/o slough Mgmt: moist env, saline, occlusive dressing |
| Stage III pressure ulcers | full thickness with subq tissue,no bone, deep crater (undermining,tunneling), Mgmt: debridement, surgical |
| Stage IV pressure ulcers | full thickness skin loss, extensive destruction, necrosis, bone/muscle, slough, eschar Mgmt: debridement, covered/nonadherent dressing, chg 8-12hrs., skin grafts |
| Unstageable pressure ulcers | full thickness tissue loss where base is covered by slough and/or eshcar covering |
| Baseline assessment for pxts with risk of pressure ulcers | braden scale, visual/tactile, level of mobility, activity tolerance, size, type(viable/non), % of wound tissue, vol and color of drainage, surrounding skin |
| prevention/health promotion for pressure ulcer pxts | topical skin care, positioning - 1-2hrs., support surfaces |
| Complications of wound healing | infection, hemorrhage, dehiscence, evisceration, fistula |
| Types of dressings | gauze(wet to dry, wounds of debridement), Transparent film (traps moisture), Hydrocolloid (protects from surface contamination), Hydrogel(maintains moist env) |
| Wound cleaning | NS is best, least contaminated to most, H202, betadine acetic acid may hinder healing |
| Wound irrigation | solution room temp, flow over least to most contamination |
| Drainage evacuation devices | JP drains, Hemovac |
| what is dehiscences and how to heal it? | partial/total separation of layers of skin/tissue above fascia. Binders (breast,abd,sling) |
| Cold therapy for wounds | acute sprain, fracture, bruise, swelling, inflammation...cold therapies for 20 min, |
| Warm therapy | improve circulation, relieve edema, promote pus concentration, promote muscle relaxation, 20-30 min. NEVER over bleeding or appendicitus, or cardio probs |
| What is tissue ischemia | decr blood flow to tissue, pressure. When pressure relieved = reactive hyperemia, redness in skin |
| What is the inflammatory phase of full thickness healing? | Goal is bacterial balance/clean wound. Brings WBC's. aprox 3+ days |
| What is the proliferation phase in full thickness wound healing? | Production of new tissue, epithelization, contraction. Epith. faster in moist env. Conraction imp in secondary intention, reduces amt of granulation needed to fill |
| what is remodeling phase in full thickness wound healing? | Last up to a year, reorganizes collagen for scar tissue, never more than 80% strength of nonwounded tiss. Same for primary and secondary |
| What is s hematoma | collection of blood underneath tissue internal hemorrhage |
| What is evisceration? | Wound layers separate below fascial layer and visceral organs protrude through wound opening. |
| What is a fistula? | abnormal opening b/n two organs/organ and skin |
| Parts of a braden scale | Sensory perception- 1 limited-4 none Moisture- 1 moist - 4 rarely Activity- 1 bedfast - 4 walks freq Mobility- 1 immobile - 4 no limits Nutrition 1 very poor - 4 excellent Friction/Shear 1 prob - 4 none 24-48 hrs after admission |
| Skin assessment for Dark skin | skin dark (purplish,bluish,eggplant), avoid flourescent lamps, use natural or halogen, warmer/cooler, taut,shiny,indurated(warm red area) |
| Pressure Ulcer preventions | skin barriers, bed below 30 degrees, freq turning, repositioning q2-4h on press reduced mattress or q2h on non-press reduced mattress. Chair bound q1h Nutrition, pxt education |
| How soon should you give pain meds before wound changes? | 30 minutes |
| What is ecchymosis? | skin discoloration |
| Types of drainage | serous: clear, watery plasma Sanguineous: Fresh bleeding Serosanguineous: pale, more waters, combo plasma/red cells, blood streaked Purulent: thick, green/yellow/brown |
| Risk for malnutrition lab results: albumin,transferin, prealbumin | Albumen <2.1, Transferin <100 mg/dL, prealbumin < 7mg/dL, younger 18, older than 64, 5-10% wt loss in 1-6mos |
| How obtain aerobic/anaerobic culture | Aerobic: sterile swab, sterile NS, antiseptic solution Anaerobic: sterile 10-mL syringe |
| What is masceration? | softening of skin due to moisture |
| What is debridement? | remove necrotic tissue, control infection, promote cleansing, eliminate dead space, manage exudate. Clean by irrigation at each dsg change |
| Treatment options for Stage 1 pressure ulcers | Dsg: none, transparent dsg (trap moisture, oxygenates) Protect from shear, turning |
| Treatment options for Stage II | dsg: hydrocolloid(protect from surface contaminates, forms gel), composite film press redistribution mattress |
| Treatment options for Stage III | dsg: hydrocolloid, Hydrogel (moistens),Hydrogel Foam(absorb), Calcium alginate(sig exudate), Gauze |
| Treatment options for Stage IV | dsg: hydrogel,calcium alginate,gauze,hydrocolloid,enzymes for eschar |
| First aid treatments for puncture wounds and penetrating objects | puncture wounds need to bleed. Penetrating object i.e.knife, pressure around, don't remove |
| First Aid cleansing for abrasions, major lacerations | Abrasions: Rinse wound in running water, mild soap Major laceration: brush away surface contaminants, hemostasis, always cover moist dsg with dry outer dsg |
| Purposes for a dressing | protects from microorganisms, promotes hemostasis, promotes healing, promotes thermal insulation and protects from dehydration |
Created by:
palmerag
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