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anatomy of the skin
- epidermis: top layer of the skin
- dermis: inner layer of the skin. contains collagen, blood vessels and nerves
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parts of the epidermis from top to bottom
- stratum corneum (flattened dead keratinized cells. protect from chemical exposure. other layers build to get here)
- stratum lucidum
- stratum granulosum
- stratum spinosum
- stratum basale
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where are melanoytes found
stratum spinosum/stratum basale
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elderly skin differences
- decreased peripheral circulation
- delayed inflammatory response
- less elasticity
- more vulnerable to tears
- decreased subQ fat
- less layers so more prone to breakdown
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wounds
- injury to the skin
- etiology dictates how we will manage it
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onset and duration of wound
- can be acute- sudden onset, heals quickly
- or chronic- gradual, lasts longer
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how to classify wounds
- can be by onset and duration (acute/chronic)
- can be by the phase of healing
- can be by extent of tissue injury (partial or full thickness)
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acute wounds
- occur suddnely
- result from accidents/surgery
- heal within 8-12 weeks as long as no secondary infection/condition
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what does heal time of acute wound depend on
- size
- depth
- extent of damage
- patient's underlying physical condition
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example of acute wound
trauma/surgical wound
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Phases of wound healing
- hemostasis
- inflammatory phase
- proliferative phase
- remodeling phase
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full thickness wound
- epidermis and dermis are affected
- extends into the durmis and even subcutaneous tissue sometimes
- heals by fibrous (scar) tissue
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partial loss wound
- epidermis and superficial dermis affected
- heals by regeneration of epidermis
- more shallow
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Wound healing processes
- primary intention
- secondary intention
- tertiary intention
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primary intention wound healing and example
- wound edges are approximated
- heals quickly with minimal scarring
- wound that is closedÂ
- heals by epithelial generation
- ie: clean surgical insicion or abrasion
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secondary intention wound healing and example
- heals by build up of granulation tissue
- takes longer to heal so higher chance of infection
- open wound, not approximated
- example: pressure ulcer
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tertiary intention wound healing
wound that is intentially left open to resolve an infection then they close it
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factors affecting wound healing
- wound type
- nutrition - certain nutrients help heal (vitamin C and zinc)
- tissue perfusion
- immunosuppression- immune cells cant get to site delays healing
- infection- lengthens healing
- age- more comprimised skin integrity/healing process
- psychosocial impact- may not be caring for themselves, pick at it or affects body image
- hydration- bc of fluid loss
- caloric intaie= you need more energy to heal
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Complications of wound healing
- hemorrhage
- infection
- dehiscence
- evisceration
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hemorrhage
- highest risk is 24-48hrs after injury
- can be internal (ie sutures come out, hematoma- looks blue or swelling) which can affect perfusion or external (ie frequent dressing saturation)
- monitor vital signs and patient
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infection
- bacteria gets into the wound tissue
- delays healing
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dehiscence
- partial or full separation of layers
- collagen supplies tension strength
- if it hasnt had time to heal it this can happen
- whos at risk for this: elderly, infected, immunocompromised, those who are too active after wound
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evisceration
- organ is protruding from the wound
- EMERGENCY
- keep them calm and NPO
- cover with sterile dressing and call provider
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what is splinting
putting pressure on a wound when coughing, sneezing, etc
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when to do wound assessment
- on admission
- everytime you do wound care
- anytime pt condition changes
- on interview
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things to look for in wound assessment
- location and appearance: be very descriptive
- measurement: length, diameter, depth
- wound closure: and whats been used to close it
- wound drainage: color volume smell
- drains: type condition, quality
- dressings: and frequency of their change
- when, where how it happened: and any associated symptoms
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Wound appearance colors
- Red: granulation tissue which is healthy regeneration of tissue. protect this. the budding blood vessels and new tissue that is generating
- Yellow: purulent drainage and slough. cleanse this for healing
- Black: eschar that hinders healing and requires removal. debride this
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slough
dead keratinized cells and debri
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why do we measure wounds
- to detect changes that occur and assess how the wound is healing
- length, width and depth
- is it tunneling, undermining, etc
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types of wound closures
- staples
- sutures
- wound adhesives (dermabond for ex. to approximate edges)
- steri-strips (help with closure and speed healing)
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what if there is pink around wound edges
- this is the inflammatory process and normal. it will slowly dissappear over time
- be concerned if its bright red
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what to note about drainage (exudate)
- note and document drainage on/in: wound itself and areas of induration, dressings, and drains
- amount: scant, moderate, copious, or mLs
- color
- consistancy
- odor: foul, earthy
- frequency of dressing change
- assess integrity of surrounding skin and the periwound area
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Serous drainage
- light and pink
- thin and watery
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purulent drainage
- yellow, thick
- may have an odor
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serosanguineous drainage
mix of serous and blood
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sanguineous drainage
blood
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why drain wounds
accumulation of drainage delays healing and provides a medium for growth of microorganisms
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Placing and assessing drains
- placed into or near wound if large amount of drainage
- evacuation of drainage using a drain alone or a tube with suction
- may be sutured in place to prevent dislodgement
- caution with dressing change around not sutured ones to prevent dislodgement
- asses number and type and document which number has how many mL
- monitor skin integrity around drain insertion site- for leakage
- ensure patency-
- measure volume and assess characteristics of drainage
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what does it mean to ensure patency of a drain
- that its draining
- if it suddenly slows the wound could be drained or there could be a blockage
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types of drains
- jackson pratt (jp): has tubing, emptying cap and port and collection reservior. you squeeze the balloon to creat negative pressure to pull the drainage out
- penrose drain: drain put in the wound. a saftey pin stops the flow from going back
- hemovac (accordion) drain: circular. accordion squeezed flat again to create suction from hold more volume than the JP but similar to it.
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why do we use dressings
- applied to promote healing by absorbing drainage and to protect wound from microorganisms
- they keep pressure to slow/stop bleeding
- they establish a warm moist environment
- the dressing type is determined by wound type
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types of dressings
- gauze
- transparent film
- hydrocolloid (have gel forming agents)
- hydrogel
- foam
- alginate
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packing a wound
- promotes wound healing by providing a moist wound environment
- uses sterile technique
- assess size, shape depth of wound
- use prescribed packing material
- dont pack too tightly because you dont want to put pressure on healthy granulation tissue
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wound vac
negative pressure wound therapy
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application of wound vac
- black sponge to clean wound
- cover with dressing
- attach suction to hole in dressing
- sucks drainage out
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how to secure dressings
- tape: paper for skin as its breathable and hypoallergenic. silk is much more adhesive, shouldnt be used on skin. foam stretchy marshmallow tape- good for wounds in areas of mobility
- ties: big bulky ties can secure dressing and avoid taping/retaping
- bandages: ie elastic bandages. for pressure, prevent edema
- binders: secure dressings
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cleaning incisions
- follow providers orders
- can be basic or involve irrigation
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basic incision cleaning
from inside (cleanest) to out (dirtiest)- center of wound to surrounding skin
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irrigation
- done to remove exudate and debri
- only do if ordered
- isotonic solutions are preferred (ie normal saline) or a specific antiseptic solution may be ordered
- employ proper irrigation pressure
- allow solution to flow from least to most contaminated area
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employing proper irrigation pressure
- 8-15 PSI
- done to ensure that you dont disrupt the healthy tissue
- syringe size and catheter size affects irrigation pressure
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irrigation order
- from least to most contaminated area- inside to out
- solution flows from inside the wound out
- if sutures/staples, drain still clean outwards s
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when does wound infection usually develop
4th day and after
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suspecting wound infection
- look at incision appearance and surrounding skin
- note- temp, swelling, color (bright red), purulent drainage, tenderness on palpation, extension of erythema (red streaking)
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wound cultures
- done if you suspect infection to identify the offending organism
- dont culture from old drainage
- make sure wound is clean from external flaura that may give false result
- swab inside
- do aerobic and anaerobic cultures
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promoting comfort in wound care
- adminster analgesics 30-60min before dressing changes
- carefully remove tape- provide counter traction to skin
- gently clean wound edges
- carefully manipulate dressings and drains to minimize stress on underlying tissues
- turn and position patient carefully before and after dressing change
- provide privacy
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common Nursing dx for wounds
- infection risk
- imbalanced nutrition (less than)
- acute/chronic pain
- impaired mobility
- impaired skin integrity
- risk for manipulated skin integrity
- ineffective perfusion
- impaired tissue integrity
- deficient knowledge
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know potter and perry table 48.5
:)
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