Wound Healing

what can cause skin breakdown?

Items left in prolonged contact with the skin.

For example: if a patient lays on a bed for too long, bedpans, support boots

Friction

skin slides against objects

shear

the skeleton moves but the skin stays

how often should someone be repositioned?

every two hours

how much of a position change should occur when repositioning

at least 30 degrees

what can help prevent shearing and friction?

limiting the amount of time the head of the bed is elevated

(recommended height of bed is less then 30 degrees or as low as tolerated)

chair bound individuals should reposition how often? and shift weight how often?

every hour and shift their weight every 15 minutes

what can be used to support positioning with boney prominences?

pillows or wedges

friction causes damage to the ______?

superficial skin layers

shearing causes _______ to the skin that causes injury

diminished blood flow

slide sheet

a special fabric sheet that makes moving immobile or obese patients easier

why should we NOT use donut rings for pressure reduction? what should we use instead?

the ring of the donut ring can cause intense pressure which causes additional damage. Instead, we should use a waffle mattress

waffle mattress

helps relieve pressure

partial wound

extend through the epidermis but not through the dermis

full thickness wound

the dermis, epidermis, and subcutaneous tissue are penetrated; muscle and bone may be involved

incision

A cut made in order to get inside something

Abrasion

Scrape of the skin

contusion

bruise

penetrating

entering into, going through, or piercing

laceration

a cut

Primary intention healing

tissue surfaces are approximated (closed) and there is minimal or no tissue loss, formation of minimal granulation tissue and scarring

examples of primary intention healing

closed surgical incision and minimal tissue is lost

Secondary intention healing

a considerable amount of issue is lost, repair time is longer and more scarring

Tertiary intention healing

Wound is left open for 3-5 days to allow edema or infection resolve then later closing with sutures

the three phases of wound healing

inflammatory, proliferative, maturation

inflammatory phase

follows hemostasis and lasts 4-6 days, white blood cells move to wound, macrophages enter wound and remain extended time, they ingest debris and release growth factors, pt has generalized body repsonse

Proliferative phase of wound healing

begins to synthesize collagen

granulation tissue forms (fragile and bleeds easy)

capillary network is developing

maturation phase

the third phase of wound healing, in which scar tissue forms

scar tissue is

never as strong as the original tissue

Complications of wound healing

hemorrhage, infection, dehiscence, evisceration

Dehiscence

Bursting open of a wound, especially a surgical abdominal wound

Evisceration

The displacement of organs outside of the body.

internal hemorrhaging is indicated by

swelling

dishiscene can lead to

evisceration

how can a patient help their wound heal?

While the patient lays in bed, they can bend the knees so there is less pull on the incision

dishiscene and evisceration means the nurse must

notify the surgeon immediately

how does saline clean a wound

Normal sterile saline is regarded as the most appropriate and preferred cleansing solutionbecause it is a nontoxic, isotonic solution that does not damage healing tissues.

Passive dressings

Dressings that serve a protective function only.

Interactive dressings

Dressings that create a moist environment and interact with the wound they cover to stimulate cell activity and growth

active dressings

improve healing process/decrease healing time-skin grafts, biologic skin substitutes

what two dressings create a moist environment?

active and interactive

Undermining wound

dead space under the edges of the wound

Wicker dressings

roselike dressings used to manage wounds that have undermining injuries.

wicker dressings are affective at

absorbing drainage

wicker dressings can be

plain or have antimicrobial properties

filler dressings

best for deeper wounds;

these fill the contour of the wound, allowing the wound to heal by secondary intention

cover dressings

best of surface wounds and can be used as a secondary dressing over filler dressings. they can be absorbing, hydrating, plain, or antimicrobial

necrotic tissue

dead tissue that usually presents as black or brown and is hard or leathery in texture

debridement

removal of foreign material and dead or damaged tissue from a wound

slough tissue

YELLOW, GREEN, OR GREY

DEAD TISSUE

THIN

WET STRINGY

granulating tissue

pink, healthy, healing tissue

Epithelialising

pink blush tissue

advancing wound edge

very fragile tissue

acute infection tissue

acute inflammatory response

heat

pain

erythema

infected tissue

chronic inflammatory response

dull beefy tissue

friable

what phase of healing is necrotic tissue

inflammatory

what phase of healing is slough tissue

inflammatory

what phase of healing is granulating tissue

proliferative

what phase of healing is epitheliaising tissue

remodeling

what phase of healing is granulation tissue

proliferative

Silver dressings

antimicrobial dressings used for infected wounds

bacteria can not grow where silver is

venous ulcers

Injury to poor venous return, blood pools or collects and causes edema and poor circulation

arterial ulcers

Injury and underlying ischemia, resulting from underlying conditions, such as atherosclerosis or thrombosis

Neuropathic/Diabetic Ulcers

Due to Pressure in Numb Areas, Such as Feet

Deep

Painless

Heads,Areas Where Shoes Rub

pressure ulcer

any lesion caused by unrelieved pressure that results in damage to underlying tissue

stage one pressure ulcer

has intact with non blanchable redness of a small area of skin usually over a bony prominence

stage two pressure ulcer

partial thickness skin loss

shallow open ulcer

red/pink wound bed

stage 3 pressure ulcer

full thickness tissue loss with visible fat

bone muscle and tendon is not exposed

may included tunneling

stage 4 pressure ulcer

Full-thickness tissue loss with exposed bone, muscle, or tendon

slough mat be present

undermining and tunneling

eschar

dead matter that is sloughed off from the surface of the skin, especially after a burn

unstageable ulcer

Full thickness tissue ulcer where the extent of the tissue damage can not be confirmed because its covered by slough or eschar

deep tissue pressure ulcers (DTPI)

the skin is intact but the tissue beneath is damaged and appears purple or dark red

Braden Scale for Predicting Pressure Sore Risk

19-23 not at risk

15-18 low risk

13-14 moderate risk

10-12 high risk

Less than or equal to 9 very high risk

Braden Scale

sensory perception, moisture, activity, mobility, nutrition, friction and shear

when moving a patient, you should

LIFT not pull

risk factors for pressure ulcers

aging skin

immobility

altered LOC

moisture

obesity

poor nutrition

dehydration

sedation

anemia

impaired circulation

edema

sensory deficits

chronic diseases

friction

shear

sinus tracts

narrow openings or passageways underneath the skin that results in dead space with potential for abscess formation

most common areas for a pressure ulcer include

sacrum and coccyx

heels

ankles

hip bones

shoulders

elbows

risks for pressure ulcers

bed ridden

incontinent

what should you monitor for pressure ulcers

monitor stage, size, color

if a patient has a urine output of 30 mL or less that means they have

kidney distress! It is a problem

incontinence associated dermatitis is usually located where?

perianal areas

perineal

inner thighs

buttocks

groin

how deep is incontinent associated dermatitis

superficial

partial thickness

what does incontinence related dermatitis look like on the skin?

in lighter people it can range from pink to red. in darker skinned people It can be blue or purple. The affected area usually has poorly defined edges and may be patchy or continuous over large areas.

what does floating heels mean?

float heals off of a block or a pillow so they dont touch the bed