W12 Tissue integrity

U never want a wound too wet (exudate or water) ot too dry. Meds b4 wound care

What are the 4 factors that can effect skin intergrity? Please provide examples

Age → dec in skin elasticity

Health status → immobility can lead to skin breakdown

Nutrition → vit.c and protien promotes healing

Hydration → promotes healing

A nurse is reviewing the medical record of a client who has a surgical incision and a puncture wound from a fall. Which of the following correctly classifies these wounds?

a. Surgical incision – unintentional; puncture wound – intentional
b. Surgical incision – intentional; puncture wound – unintentional
c. Surgical incision – contaminated; puncture wound – clean
d. Surgical incision – unintentional; puncture wound – unintentional

b. Surgical incision – intentional; puncture wound – unintentional

A nurse is caring for a client who has a surgical incision closed with sutures and another client who has a venous ulcer on the lower leg. Which of the following best classifies these wounds?

a. Surgical incision – chronic; venous ulcer – acute
b. Surgical incision – contaminated; venous ulcer – clean
c. Surgical incision – acute; venous ulcer – chronic
d. Surgical incision – partial-thickness; venous ulcer – full-thickness

c. Surgical incision – acute; venous ulcer – chronic

What are the phases of wound healing and what the characteristics of each phase?

Hemostatsis and inflammatory

• - Bleeding stops (vasoconstriction + clot formation)

• - WBCs (neutrophils/macrophages) clean the wound

• - Signs of inflammation: redness, swelling, warmth, pain

Proliferation

• - Granulation tissue forms (new capillaries + fibroblasts)

• - Collagen strengthens wound

• - Re-epithelialization begins (skin cells migrate to cover wound)

Maturation/Remodeling

• - Stronger collagen replaces earlier tissue

• - Scar forms and wound contracts

• - Final strengthening and restoration of skin integrity

Why does these factor effect wound healing

• Desiccation

• Maceration

• infection

• Necrosis

Desiccation

• - No grandulated tissue will form since cells die from dehydration

Maceration

• - Overhydration can lead to molecular breakdowns of cells (Grand cayon) and bacteria love wet dark places.

• - This incules urine, feces , and sweat

Infection

• - Cells can’t heal if there being attack by bacteria

Necrosis (Slough and eschar)

• - Occupies space and prevents granulated tissue formation

What are some wound complications? (5)

Please explain why these are wound complications

Infection

• - Cells can’t heal if there being attack by bacteria

Hemorrhage

• - To much bleeding to form a blood clot and start the healing process

Fistula Formation

• - Caused by maceration; a tunnel connecting two areas of the body

Dehiscence

• -Inscions line opens up

Evisceration

• -Inscions line opens up and organs are spilling out

A nurse walks into a patient’s room and finds that the client’s abdominal surgical wound has opened, and internal organs are protruding. Which of the following actions should the nurse NOT do?

a. The nurse covers the organs with a sterile moistened gauze.
b. The nurse calls for help.
c. The nurse stops the client from consuming any food or fluids
d. The nurse attempts to push the protruding organs back into the abdominal cavity.

d. The nurse attempts to push the protruding organs back into the abdominal cavity.

A nurse is caring for a client 14 days after abdominal surgery. The provider has ordered the removal of surgical staples. The client refuses, stating, "They don’t hurt, and I’d rather leave them in just to be safe." Which of the following responses by the nurse is most appropriate?

a. "Keeping them in longer won’t cause any harm."
b. "It’s your choice, but we can remove them at your next visit."
c. "Leaving staples in too long can cause the skin to grow over them, making removal more painful and increasing the risk of infection."
d. "Staples are only removed if they fall out on their own or look infected."

c. "Leaving staples in too long can cause the skin to grow over them, making removal more painful and increasing the risk of infection."

How long should the steri-strips be on the inscion line? Why is this important

1.5 - 2 in

This is important because it allows the steri-strips to grinp the skin tight

Differnce between pressure and shearing?

Pressure → Compressing blood vessels

Friction/ shearing forces → Tearing or injuring blood vessels

What are the 6 things nesscary to document in pressure ulcer assessment?

Record length(↕︎︎), width, depth

Describe the condition of the wound tissue

• Beefy red, yellow, black %

Note any pain

Note tunneling or undermining

• Clock format

Note surrounding tissue

• Discolaration

Describe the drainage (amount/type)

• Serous (clear) - Sanguineous (bloody) - Serosanguineous - Purulent (green.yellow, brown pus)

Define undermining

the tissue under the edges of a wound becomes eroded, resulting in a pocket or space beneath the skin

Define these terms that pertain to amount of drainage

None

Scant

small

Monderate

Large

None - Competely dry dressing and wound bed

Scant → Competely dry dressing and moist wound bed

small → Dressing is 25% wet / wound be is wet

Monderate → Dressing is 50% wet / wound be is wet

Large → Dressing is 75-100% wet / wound be is wet

Name and describe the stage of this pressure uncler

Stage II: partial-thickness skin loss; superficial ulcer

involving epidermis or dermis

Name and describe the stage of this pressure uncler

Stage IV: full-thickness skin loss with extensive destruction; damage to muscle/bone

Name and describe the stage of this pressure uncler

Stage I: persistent (nonblanchable) redness

Name and describe the stage of this pressure uncler

Stage III: full-thickness skin loss; involving subcutaneous tissue

What makes a wound unstageable?

When Escar or slough covers the wound bed

what are the 4 ways to remove necrotic tissue? Please provide examples of each

Autolytic debridement

• - Bodies' enzymes breaking down the necrotic tissue

Mechanical debridement

• - Wet to dry dressing

• - Maggots

• - Saline irrigation

Enzymatic debridement

• - Ointment

• - Cream

Sharp debridement

• - Scalpel

What are the 7 Wound Dressings/Treatments

Gauze dressing (can be it impreg w/ Petrolatum, Saline, Hydrogel)

Hydrogels (add moisture)

Anglintaes (take away moisture )

Transparent Flims

Antimicrobials

Enzymatic Debriders

Non-Stick Pads

Which system is at a higher risk for infection, open or closed? Why and please provide examples

Open since it open to the environment

• - Penrose

Closed

• - Jackson-Pratt drain

• - Hemovac drain

What situiation would a nurse use a open or closed system?

Open → little to no fluid leak

Closed → Large amount of fluid leak

Inc HR, Blood sugar, Temp, and WBC, Change in mental status, and N&V are signs of …. and explain why

Infection

Inc HR → The body tries to circulate immune cells faster.

Inc BS → Stress hormones (like cortisol) raise glucose for quick energy.

Inc Temp → The body raises its core temp to inhibit bacterial growth.

Inc WBC → More white blood cells are produced to attack invading pathogens.

Change in mental status (confusion/lethgary) → The body is overworking itself.

N&V → inflammation affects the gastrointestinal system.