-
Classify Ulcer: Non-blanchable redness of a localized area, usually on a bony prominence
Stage 1 ulcer
-
Classify Ulcer: partial-thickness skin loss involving epidermis, dermis, or both?
Stage 2 pressure ulcer
-
Classify Ulcer; full-thickness tissue loss
Stage 3 pressure ulcer
-
Classify ulcer: full-thickness tissue loss with exposed bone, tendon, or muscle, slough or eschar may be present
Stage 4 pressure ulcer
-
Definition:
Red moist tissue composed of new blood vessles, the presence of which indicates progression toward healing?
Granulation tissue
-
Definition:
Stringy substance attached to wound bed?
Slough
-
Definition:
Black or borwn necrotic tissue?
Eschar
-
Definition:
The amount, color, consistency and odor of wound drainage and is part of wound assessment?
Wound exudates
-
Wound healing:
surgical wound (a wound with little tissue loss, clean incision; skin edges are approximated/close/little risk for infection)?
Primary intention wound healing
-
Wound healing:
burn, pressure ulcer, severe laceration (wound involving loss of tissue; left open until becomes filled with scar tissue. Skin edges not approximated/longer healing time/greater chance for infection)?
Secondary intention wound healing
-
Wound healing:
contaminated wounds (wound left open for several days, then wound edges are approximated)?
Tertiary intention wound healing
-
Pressure ulcers are also known as:
1.
2.
3.
And defined....?
- pressure sores
- decubitus ulcers
- bed sores
- defined = impaired skin integrity due to unrelieved prolong pressure
-
What can cause pressure ulcers? Risks?
- age-related skin changes (reduced elasticity, decreased skin turgor...)
- Medical conditions and polypharmacy
- Flattened attachment between dermis and epidermis
- Diminished inflammatory reponse, slow wound healing
- Little subcutaneous padding over bony prominences
- Reduced nutritional intake
-
Factors that contribute to pressure ulcers include:
1.
2.
3.
?????
- Pressure intensity
- - pressure ischemia
- -blanching
- Pressure duration
- -low pressure over prolonged time
- high pressure over short time
- Tissue tolerance
- -shear/friction/moisture - brkdwn skin
- -integrity of skin to start with
-
Three phases to partial thickness wound repair are?
- 1. Inflammatory response
- -Hemostasis- blood vessels constrict
- -Fibrin - clotting
- 2. Epithelial proliferation
- -wound fills with granulation tiss.
- -Contraction of wound occurs
- -REsurfacing of wound by fibroblasts
- 3. Reestablishment of epidermal layers
- -Remodeling; collagen scare continues to reorganize
-
Three phases to full-thickness wound repair?
- 1. Inflammatory
- -begins w/in minutes and lasts approx. 3 days
- 2. Proliferative
- -lasts 3-24 days
- -appearance of new blood vessels
- fibroblasts and granulation begin
- 3. Remodeling
- -final stage
- -can take more than a year sometimes
- -collagen scar continues to reorganize
-
Complications of wound healing: Definition:
bleeding from a wound site; poor clotting factor so bleeding doesn’t stop?
Hemorrhage
-
Complications of wound healing: Definition
second most common healthcare issue/concern?
Infection
-
Complications of wound healing: Definition:
wound fails to heal properly; partial or total rupture (seperation) of a sutured wound usually with separatioin of underlying skin layers?
Dehiscence
-
Complications of wound healing: Definition
protrusion of visceral organs through wound opening occurs?
Evisceration
-
Complications of wound healing: Definition:
abnormal passage between two organs or between an organ and the outside of the body?
Fistulas
-
Wound drainage;
Clear, watery plasma - normal?
Serous fluid
-
Wound drainage:
thick, yellow, green, tan or brown fluid/appearance on wound?
Purulent
-
Wound drainage:
Pale, red, watery - mixture of clear and red fluid?
Seosanguineous
-
Wound drainage:
bright red - indicates active bleeding/
Sanguineous
-
Definition:
Superficial wound with little bleeding; considered partial-thickness wound?
Abrasion
-
Definition:
Wound bleeds more profusely depending on wound depth/location (e.g., head wound)?
laceration
-
Definition:
Wound bleeds in relation to the depth and size of the wound (nail puncture vs. knife wound)?
Puncture
-
Seperates the dermis (inner layer) and epidermis (top layer) of skin?
dermal-epidermal junction
-
Pathogenesis of pressure ulcers - cause of pressure ulcers may include?
- pressure intensity of skin to causative agent
- blanching of skin - red tones absent
- pressure duration of skin to causative agent
- Tolerance of skin tissue to causative agent
-
Risk factors for pressure ulcer develpment include?
- impaired skin integrity
- impaired mobility
- friction
- shear
- moisture
- alterations in LOC
-
What are things to consider/do to keep skin intact?
- Hydration
- Nutrition
- Keep glucose levels at 70-110
- Know what patient is at risk for
- Know what kind of patient is at risk
- Know how to prevent wound from further injury
-
Factors influencing pressure ulcer formation and wound healing?
- nutrition
- tissue perfusion
- infection
- age
- psychosocial impact of wounds
-
What to assess for, related to wound(s), upon client enterance to hospital?
- skin
- presence of ulcers
- mobility
- nutrition and fluid status
- pain
- exisitng wounds, apearance, location, character
- wound culture
-
What are some health promotion techniques to implement to ensure proper wound healing and prevention from further injury?
- topical skin care - barrier cream
- change position every 1-2 hours
- provide support surfaces
- -get client off bony prominence
- -tents to raise sheets
- -special mattresses
- -boots for feet
- -increase circulation back to heart - SCD's
-
Wound definition:
Removal of non-vialbe necrotic tissue?
Debridement
-
A wound will not heal if you do not remove causative agents - list some?
- Friction
- Shearing
- Pressure
- Moisture
-
Type of debridement (there are 4)
Wound irrigation or whirl pool, wet to dry saline gauze dressing?
Mechanical debridement
-
Type of debridement (there are 4)
Synthetic dressing over wound allow eschar to be self-digested by the action of enzymes that are present in wound fluids?
Autolytic debridement
-
Type of debridement (there are 4)
Topical enzyme prep; dankins solution or maggots?
Chemical debridement
-
Type of debridement (there are 4)
Removal of devitalized tissue w/scalpel, scissors, sharp instrument?
Sharp/surgical debridement
-
Acute care for wound management includes?
- debridement
- nutrition - I's and O's
- client education
-
Types of dressings:
Absorbant and wicks away wound exudates? Oldest and most common dressing type.
Gauze dressings
-
Types of dressings:
Does not stick to wound - Telfa?
Non-adherent gauze
-
Types of dressings:
Traps wounds moisture over the wound providing appropriate mositure environment for the wound/
Self-adhesive/transparent film
-
Types of dressings
Absorbs drainage through use of exudate absorbers in dressing? Protects wound from surface contamination?
Hydrocolloid dressings
-
Types of dressings:
Maintains a moist surface to support healing; soothing and reduces pain in wound?
hydrogel
-
Types of dressings:
You should not use this dressing on dry wounds, requires a secondary dressing when using this form of dressing/
Foam dressings
-
Types of dressings:
This dressing uses negative pressure to support healing/
Wound V.A.C.
-
When changing dressings, what should you know first?
- Type of dressing that is on client
- Whether this is first or second changing (surgeon likes to change first time)
- Any drainage tubes present
- type of supplies needed for wound care
- always to use aseptic technique
- providing comfort measures for client before doing ANY kind of care to wound - PRIORITY
-
1. When removing a dressing you use a clean OR sterile technique?
2. When applying a dressing you use a clean OR sterile technique?
CLEAN
STERILE
-
When using heat/cold therapy what should you assess for?
- observe area - any changes
- tolerance for temp
- condition(s) that may contraindicate therapy
- edema
- bleeding
- LOC - inability to feel the temp
- condition of heat/cold equipment
- ** remember, RN responsible for safe administration of this therapy
-
Name some types of wound binders?
-
When packing a wound you should assess for?
- Size, depth, shape of wound
- appropriate material being used for wound
- not to pack to tightly
- vacuum assisted closure is needed
-
What should you know about wound irrigation? Why do you irrigate the wound?
- Doctors/Wound care specialists orders
- Irrigation is to cleanse, keep free from debris/infection, and prevent, manage infection (this is also why you irrigate)
- pg. 1307 P&P
-
What is blanching?
it is when the normal red tones of a light-skinned client are absent. Blanching does not occur in dark-skinned clients - they are more at risk for pressure ulcers as they are harder to identify.
|
|
