U2 W6: tissue integrity

Risk factors: for impaired tissue integrity

Age, immobility, impaired sensory perception, chronic disease, Malnutrition, Incontinence

Blurb: wound assessment

Location, stage, size, tunneling, undermining, exudate, odor, surrounding tissue, pain

Serous exudate

Clear fluid coming from a wound

Serosanguineous exudate

Clear with a little red coming from a wound, this is normal after a surgery

Sanguineous

Bright red exudate coming from the wound, this is not normal

Purulent exudate

Green/yellow exudate that indicates an infection coming from the wound

Moisture associated skin damage

Incontinence associated dermatitis

Intertriginous dermatitis

Peri wound moisture- associated skin damage

Peristomal moisture - associated skin damage

Arterial chronic wound

Venous chronic wound

Blurb: Pressure ulcers: risk factors

Immobility, malnutrition, reduced perfusion, altered sensation, decreased LOC, moisture, friction/shearing

Braiden scale

A scale used to determine risk of developing pressure ulcers the lower the number the higher the risk

What is the risk if a wound bed is too wet?

Maceration, infection risk

What is the risk of a wound bed being too dry?

Inability for cells to proliferate

film dressings

transparent dressing for superficial wounds

hydrocolloids dressing

gel like dressing to maintain a moist wound bed. can sometimes look purulent, it is not infected

alginate dressing

a highly absorbent dressing derived from seaweed that helps manage a lot of exudate and supports a moist healing environment. it also establishes hemostasis

foam dressing

usually a dressing for the sacrum. it may need frequent changes

hydrogel

is a moisture-retentive dressing that provides hydration to wound beds and supports autolytic debridement.

Jackson Pratt drain

an active drain that looks like a grenade. it uses negative pressure to such the exudate out

hemovac

a larger active wound drainage

how much should a drain, drain exudate

30-100mL/ 24 hours

document

type of exudate, amount, consistency, color

if a pt is incontinent when should rounds happen to ensure client is clean/dry?

every 2 hours

HOB should be at what degree to minimize skin breakdown?

30 degrees

primary intention

A method of wound healing where the edges of the wound are brought together, like sutures or staples, allowing for minimal tissue loss and scarring.

secondary intention

A method of wound healing where the wound is left open and fills with granulation tissue, resulting in more tissue loss and potential scarring.

delayed primary (tertiary intention)

A wound healing method where the wound is initially left open to reduce the risk of infection and later closed surgically once the risk has subsided.

Dehiscence

separation of a wound edge, might be due to an infection, or poor closure. notify MD and cover wound

evisceration

organs popped from a surgucal wound.

an emergency! cover with sterile saline gauze and notify MD

a wound healing compliation can be bleeding

hematomas and seromas, increased risk with anticoagulants or infection