ATI Chapter 55: Pressure Ulcers, Wounds, and Wound Management

A wound

Is a result of injury to the skin

A pressure ulcer is caused by

Unrelieved pressure that results in ischemia and damage to the underlying tissue

Suspected deep tissue injury

Discolored but intact skin caused by damage to

underlying tissue

Stage I Pressure Ulcer

Intact skin with an area of persistent, nonblanchable redness, typically over

a bony prominence, which may feel warm or cool to touch. The tissue is swollen and

congested, with possible discomfort at the site. With darker skin tones, the ulcer may

appear blue or purple.

Stage II Pressure Ulcer

Partial-thickness skin loss involving the epidermis and the dermis. The ulcer

is visible and superficial and may appear as an abrasion, blister, or shallow cavity.

Edema persists, and the ulcer may become infected, possibly with pain and scant

drainage.

Stage III Pressure Ulcer

Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue.

The ulcer may reach, but not extend thorough the fascia below. The ulcer appears as

a deep crater with or without undermining of adjacent tissue and without exposed

muscle or bone. Drainage and infection are common

Stage IV Pressure Ulcer

Full-thickness tissue loss with destruction, tissue necrosis, or damage to

muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of

infection, tunneling, undermining, eschar (black scab-like material), or slough (tan,

yellow, or green scab-like material).

Unstageable Pressure Ulcer

Ulcers whose stages cannot be determined because eschar or slough

obscures the wound.

Intact skin with an area of persistent, nonblanchable redness

Stage I

may feel warm or cool to touch

Stage I

The tissue is swollen and

congested

Stage I

Possible discomfort at the site.

Stage I

darker skin tones, may appear blue or purple

stage I

Partial-thickness skin loss involving the epidermis and the dermis

Stage II

is visible and superficial and may appear as an abrasion, blister, or shallow cavity

Stage II

Edema persists

Stage II

possibly with pain and scant

drainage

Stage II

Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue

Stage III

may reach, but not extend thorough the fascia below

Stage III

appears as

a deep crater with or without undermining of adjacent tissue and without exposed

muscle or bone

Stage III

Drainage and infection are common

Stage III

Full-thickness tissue loss with destruction, tissue necrosis, or damage to

muscle, bone, or supporting structures

Stage IV

be sinus tracts, deep pockets of

infection, tunneling, undermining, eschar, or slough.

Stage IV

Eschar

Black scab-like material

Slough

Tan, yellow, or green scab like material.

The Stages of Wound Healing

1. Inflammatory stage

2. Proliferative stage

3. The maturation or remodeling stage.

The inflammatory stage

occurs in the first 3 days after the initial trauma

Control bleeding with clot formation

The inflammatory stage

Deliver oxygen, WBC, and nutrients to the area via the blood supply

The inflammatory stage

The proliferative stage

lasts the next 3 to 24 days

Replacing lost tissue with connective or granulated tissue

The proliferative stage

Contraction of the wound's edges

The proliferative stage

Resurfacing of new epithelial cells

The proliferative stage

Maturation or remodeling stage i

strengthening of the collagen scar

and the restoration of a more normal appearance. It can take more than 1 year to

complete, depending on the extent of the original wound.

Primary intention

Little or no tissue loss

Edges are approximated, as

with a surgical incision

• Heals rapidly

• Low risk of infection

• Minimal or no scarring

Secondary intention

• Loss of tissue

• Wound edges widely

separated, as with pressure

ulcers and stab wounds

• Increased risk of infection

• Scarring

Tertiary intention

• Widely separated

• Deep

• Spontaneous opening of a

previously closed wound

• Risk of infection

• Extensive drainage and tissue

debris

• Closes later

• Long healing time

Little or no tissue loss

Primary intention

Edges are approximated, as

with a surgical incision

Primary intention

Heals rapidly

Primary intention

Low risk of infection

Primary intention

Minimal or no scarring

Primary intention

Increased risk of infection

Secondary intention

Scarring

Secondary intention

Loss of tissue

Secondary intention

Wound edges widely

separated, as with pressure

ulcers and stab wounds

Secondary intention

Widely separated

Tertiary intention

Deep

Tertiary intention

Spontaneous opening of a

previously closed wound

Tertiary intention

Risk of infection

Tertiary intention

Extensive drainage and tissue

debris

Tertiary intention

Closes later

Tertiary intention

Long healing time

Tertiary intention

Serous drainage

is the portion of the blood (serum) that is watery and clear

or slightly yellow in appearance.

Sanguineous drainage

contains serum and red blood cells. It is thick and

appears reddish

Serosanguineous drainage

contains both serum and blood. It is watery and

appears blood streaked or blood tinged.

Purulent drainage

is the result of infection. It is thick and contains white blood

cells, tissue debris, and bacteria. It may have a foul odor, and its color reflects

the type of organism present (green may indicate a pseudomonas infection).

lack of protein

puts the client at greater risk for

delayed wound healing and infection

Woven gauze (sponges)

Absorb exudate from the wound

Nonadherent material

Does not adhere to the wound bed

Self-adhesive, transparent film

A temporary "second skin" ideal for small,

superficial wounds

Hydrocolloid

An occlusive dressing that swells in the presence of exudate

Used to maintain a granulating wound bed

Hydrocolloid

May be left in place up to 5 days

Hydrocolloid

May be used on infected, deep wounds

Hydrogel (Aquasorb)

Provides a moist wound bed

Hydrogel (Aquasorb)

Dehiscence

is a partial or total rupture (separation) of a sutured wound

Evisceration

dehiscence that involves the

protrusion of visceral organs through a wound opening

Reposition the client how often?

Bed at least every 2 hr and every 1 hr in a chair

Suspected deep tissue injury and Stage I Interventions

• Relieve pressure.

• Encourage frequent turning/repositioning.

• Use pressure-relieving devices (air-fluidized beds).

• Implement pressure-reduction surfaces (air mattress,

foam mattress).

• Keep the client dry, clean, well-nourished, and

hydrated.

Stage I Pressure Ulcer Interventions

• Maintain a moist healing environment (saline or

occlusive dressing).

• Promote natural healing while preventing the

formation of scar tissue.

• Provide nutritional supplements as prescribed.

• Administer analgesics as prescribed.

Stage III Pressure Ulcer Interventions

• Clean and/or debride:

◯ Prescribed dressing

◯ Surgical intervention

◯ Proteolytic enzymes

• Provide nutritional supplements as prescribed.

• Administer analgesics as needed.

• Administer antimicrobials (topical and/or systemic) as

prescribed.

Stage IV Pressure Ulcer Interventions

• Clean and/or debride:

◯ Prescribed dressing

◯ Surgical intervention

◯ Proteolytic enzymes

• Perform nonadherent dressing changes every 12 hr.

• Treatment may include skin grafts.

• Provide nutritional supplements as prescribed.

• Administer analgesics as prescribed.

• Administer antimicrobials (topical and/or systemic) as

prescribed.

Unstageable

• Eschar should cover wound as protective barrier.

• Provide nutritional supplements as prescribed.

• Administer analgesics as prescribed.

• Administer antimicrobials (topical and/or systemic) as

prescribed.

1. An adolescent client who has diabetes mellitus is recovering from an appendectomy. This is the

third postoperative day. The client has been prescribed a regular diet and is tolerating it well. He

has ambulated successfully around the unit with the help of his parents and is requesting pain

medication every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to 10 after medication is given.

His incision is approximated and free of redness with scant serous drainage noted on the dressing.

What type of healing process should the nurse expect this wound to be undergoing? Explain.

This wound is healing by primary intentions because it is a surgical incision.

2. Which of the following diagnostic tests is relevant for assessing the risk of developing a pressure ulcer

for an older adult client who has no major health issues?

A. Serum albumin

B. WBCs

C. RBCs

D. Serum potassium

Serum albumin would provide information regarding the adequacy of protein intake.

Inadequate protein poses a great risk for altered skin integrity and ineffective healing. The

other options are not indicative of this finding.

3. Which of the following findings may negatively impact wound healing? (Select all that apply.)

1. Type 2 diabetes mellitus

2. Strict vegetarian

3. Cigarette smoker

4. Long-term use of glucocorticosteroids

5. Family history of pressure ulcers

1,2,3,4.

Diabetes mellitus negatively impacts the immune response. A strict vegetarian may not have

adequate protein intake, which would negatively impact wound healing, as would smoking

(because it impairs oxygenation) and the use of glucocorticosteroids (because they depress

the immune response). A family history is not indicative of developing pressure ulcers.

4. Which of the following term describes wound drainage that is thick and yellow?

A. Serous

B. Sanguineous

C. Serosanguineous

D. Purulent

D. Purulent

Wound exudate depends on the presence or absence of infection - Uninfected wounds have

serous (clear, thin, maybe slightly yellow) or serosanguineous exudate (thin, blood tinged),

and infected wounds have purulent exudate. Purulent drainage is thick and contains white

blood cells, tissue debris, and bacteria. The color varies among infective organisms (yellow

with Staphylococcus and green with Pseudomonas).

6. What risk factors for poor healing does this client exhibit?

The client is obese, has diabetes mellitus, smokes, and adequate nutritional intake is

impaired.

7. Later that day, the client becomes confused and pulls off her surgical dressing. The nurse enters

the room and finds the client with an extensive dehiscence. Which of the following nursing

interventions are appropriate? (Select all that apply.)

1. Repack the wound.

2. Call for help.

3. Assist the client to a chair.

4. Cover the wound with a sterile dressing moistened with normal sterile

saline.

5. Stay with the client.

2, 4, 5.

It is appropriate for the nurse to call for help, stay with the client, and cover the wound with

a sterile dressing that is moistened with normal sterile saline. The nurse should not attempt

to reinsert the organs and repack the wound. The client should be placed in the supine

position with hips and knees bent.

8. What placed this client at risk for a wound dehiscence/evisceration?

Age

Obesity

Abdominal surgery 6 days ago

Recent vomiting

An adolescent who has diabetes mellitus is 2 days postoperative following an appendectomy. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain medication every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to 10 after receiving the medication. His incision is approximated and free of redness, with scant serous drainage on the dressing. Which of the following risk factors for poor wound healing does this client have? (Select all that apply.)

A. Extremes in age

B. Impaired circulation

C. Impaired/suppressed immune system

D. Malnutrition

E. Poor wound care

B, C

A nurse is assessing a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following assessment findings should the nurse expect? (Select all that apply.)

A. Increase in incisional pain

B. Fever and chills

C. Reddened wound edges

D. Increase in serosanguineous drainage

E. Decrease in thirst

A, B, C

A nursing instructor is reviewing the wound healing process with a group of nursing students. They should be able to identify which of the following alterations as a wound or injury that heals by secondary intention? (Select all that apply.)

A. Stage III pressure ulcer

B. Sutured surgical incision

C. Casted bone fracture

D. Laceration sealed with adhesive

E. Open burn area

A, E

A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the client's surgical wound and finds the wound separated with viscera protruding. Which of the following interventions is appropriate? (Select all that apply.)

A. Cover the area with saline-soaked sterile dressings.

B. Apply an abdominal binder snugly around the abdomen.

C. Use sterile gauze to apply gentle pressure to the exposed tissues.

D. Position the client supine with his hips and knees bent.

E. Offer the client a warm beverage, such as herbal tea.

A, D

A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that apply.)

A. Keep the head of the bed elevated 30 degrees.

B. Massage the client's bony prominences frequently.

C. Apply cornstarch liberally to the skin after bathing.

D. Have the client sit on a gel cushion when in a chair.

E. Reposition the client at least every 3 hr while in bed.

A, D