Wound Healing LG

The top layer of the skin

Epidermis

The inner layer of the skin that provides tensile strength and mechanical support

Dermis

Tough, fibrous protein

Collagen

Localized injury to the skin and underlying tissue over a body prominence

Pressure injury

Normal red tones of light-skinned pts are absent

Blanching

Skin that does not blanch

Darkly pigmented skin

What are the 3 pressure factors contributing to pressure injury development?

1. pressure intensity

2. pressure duration

3. pressure tolerance

What is pressure intensity

amount of pressure needed to occlude a vessel (can lead to tissue ischemia)

What is pressure duration

the length of time the pressure is exerted on the skin (even low pressure over a long period can cause damage)

What is pressure tolerance

the ability of the skin and its underlying structures to endure pressure (influenced by the integrity of the tissue and supporting structures)

What are 6 risk factors that predispose a pt to pressure injury formation?

1. Immobility

2. advanced age

3. nutritional status

4. moisture/incontinence

5. altered mental status

6. chronic conditions

How is immobility a risk factor for pressure injury

Inability to reposition to relieve pressure

- cannot independently relieve pressure on bony prominences

How is advanced age a risk factor for pressure injury

Skin becomes thinner and loses elasticity/collagen.

- making it more susceptible to mechanical forces

How is nutritional status a risk factor for pressure injury

Malnutrition, specifically protein-calorie deficiency.

- the body lacks the resources to maintain tissue integrity or repair damage

How is moisture/incontinence a risk factor for pressure injury

Exposure to body fluids softens skin (maceration).

- reduces its resistance to other physical factors like friction and shear

How is an altered mental status a risk factor for pressure injury

Inability to perceive or respond to discomfort.

- this prevents pts from realizing they need to move

How are chronic conditions a risk factor for pressure injury

Diabetes and vascular disease impair circulation and healing.

- increase the likelihood that pressure will result in a non-healing injury

How many stages for pressure injuries are there?

Stage I, II, III, and IV

- based on the depth of tissue destroyed

Stage I

Intact skin with non-blanchable redness

Stage II

Partial-thickness skin loss involving the epidermis, dermis, or both; often appears as an abrasion or blister.

Stage III

Full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, and muscle are not

Stage IV

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

What is a deep tissue pressure injury (DTPI)

A localized area of persistent non-blanchable deep red, maroon, or purple discoloration on intact or non-intact skin. It can also appear as a blood-filled blister and results from damage to underlying soft tissue from pressure and/or shear.

Granulation tissue meaning

Pink or red, moist tissue composed of new blood vessels; indicates progression toward healing.

Slough meaning

Soft, stringy yellow or white necrotic tissue; must be removed for healing to occur.

Eschar meaning

Black, brown, or tan leathery necrotic tissue.

Exudate meaning

Fluid, such as pus or serum, that leaks out of blood vessels or organs due to inflammation.

What does the physiological process of wound healing involve?

Primary intention, Secondary intention, Tertiary intention

What is primary intention

Healing of a wound with neatly approximated margins, such as a surgical incision.

What is secondary intention

Healing from the bottom up; used for wounds with significant tissue loss where edges cannot be approximated.

What is tertiary intention

Delayed primary closure; a contaminated wound is left open deliberately and closed later after infection is resolved.

What are the three components of healing a partial-thickness wound

1. inflammatory response: initial reaction

2. epithelial proliferation and migration: cells begin to reproduce and move across the wound bed

3. reestablishment of epidermal layers: final stage where skin surface is restored

What are the four phases of healing a full-thickness wound

1. hemostasis

2. inflammatory phase

3. proliferative phase

4. remodeling and maturation

What happens in hemostasis phase

Blood vessels constrict and platelets gather to stop bleeding and form a clot.

What happens in inflammatory phase

WBCs move to the wound to clean it and release growth factors.

What happens in proliferative phase

The wound fills with granulation tissue and the surface is repaired by epithelialization.

What happens in remodeling and maturation phase

Collagen scars continue to gain strength and reorganize for months.

What are some complications of wound healing

internal hemorrhage, external hemorrhage, hematoma, wound infection, dehiscence, evisceration

Unseen bleeding into the tissues; may cause swelling or shock.

Internal hemorrhage

Visible active bleeding from the wound site.

External hemorrhage

A localized collection of blood underneath the skin

Hematoma

Invasion by microorganisms; second most common HAI (healthcare-associated infection)

Wound infection

Partial or total separation of wound layers

Dehiscence

Total separation of wound layers with protrusion of visceral organs

Evisceration

What is the Braden Scale and how does it work

- The Braden Scale is a highly reliable and validated risk assessment tool used to predict pressure injury risk.

- It scores patients in six areas: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.

- A lower total score indicates a higher risk for developing a pressure injury; for example, a score of 16 or less typically signals the need for intensive prevention interventions

What are factors that influence pressure injury formation and wound healing?

Advanced age, malnutrition, malnutrition, obesity, smoking, drugs, infection, anemia, mechanical friction, diabetes

How does advanced age influence pressure injury formation/wound healing

Aging slows collagen synthesis by fibroblasts, impairs circulation, and results in a longer time for epithelialization

How does malnutrition influence pressure injury formation/wound healing

A lack of protein and calories prevents tissue repair, as protein is essential for collagen formation and immune function

How does obesity influence pressure injury formation/wound healing

Adipose (fatty) tissue has a poor blood supply, which slows the delivery of nutrients and oxygen needed for healing

How does smoking influence pressure injury formation/wound healing

Nicotine is a potent vasoconstrictor that impedes blood flow to the healing area

How do drugs influence pressure injury formation/wound healing

Corticosteroids are particularly damaging because they inhibit the inflammatory response and slow collagen synthesis

How does infection influence pressure injury formation/wound healing

Infection prolongs the inflammatory phase, increases tissue destruction, and consumes the body's energy stores

How does anemia influence pressure injury formation/wound healing

A low red blood cell count reduces oxygen delivery to the tissues, which is critical for all phases of repair

How does mechanical friction influence pressure injury formation/wound healing

Physical forces like friction and shear can destroy new granulation tissue and damage fragile skin

How does diabetes influence pressure injury formation/wound healing

Hyperglycemia impairs phagocytosis (the ability of WBCs to kill bacteria) and significantly slows the synthesis of collagen

How does motility put a pt at risk for a pressure injury development

Inability to shift weight results in prolonged pressure on bony prominences.

How does nutritional status put a pt at risk for a pressure injury development

Severe protein deficiency (hypoalbuminemia) increases the risk of edema and breakdown.

How do body fluids put a pt at risk for a pressure injury development

Constant exposure to urine or feces leads to chemical irritation and maceration.

How does pain put a pt at risk for a pressure injury development

Can lead to immobility and a decreased appetite, further delaying healing.

What role do calories play in wound healing

Fuel for cell energy; 30-35 kcal/kg/day.

What role does protein play in wound healing

Needed for collagen formation and immune function; 1.25-1.5 g/kg.

What role does Vitamin C play in wound healing

Critical for collagen synthesis and antioxidant protection.

What role does Vitamin A play in wound healing

Aids in epithelialization and wound closure.

What role does Zinc play in wound healing

Essential for protein synthesis and cell membrane integrity.

What role do Fluids play in wound healing

Provides the essential environment for all cellular functions

A superficial scrape with little bleeding

An abrasion

A jagged, torn wound

A laceration

A small, deep hole caused by a sharp pointed object

A puncture

How should wound appearance be assessed

Evaluate color (red, yellow, black), edge approximation, and signs of dehiscence.

How should the character of wound drainage be assessed

Assess amount, color, consistency, and odor.

How should measurement of a wound be assessed

Measure length (head-to-toe), width (side-to-side), and depth. Note tunneling or undermining using a "clock" orientation.

Characteristics of Serous drainage

Clear, watery plasma.

Characteristics of Purulent drainage

Thick, yellow, green, or brown; indicates infection.

Characteristics of Serosanguineous drainage

Pale, pink, watery; mixture of clear and red fluid.

Characteristics of Sanguineous drainage

Bright red; indicates active bleeding.

What is the nurse's responsibility when assessing and managing drains (JP/Hemovac)?

- The nurse must assess the patency of the drain, the volume of output, and the character of the drainage. - Drains should be emptied when half full to maintain suction and the volume must be recorded.

Describe the procedure for removing sutures and staples

- Removal requires a provider's order. (This is a interdependent nursing intervention)

- The nurse cleans the site and typically removes every other suture or staple first.

- For staples, a specialized extractor is used to avoid pulling on the tissue.

Three major areas of nursing interventions for pressure injury prevention

a. Skin care and early management of incontinence: frequent inspection, cleansing, moisture barriers

b. Mechanical loading and support devices:(turning/positioning-at least q 1-2 hrs), use specialty beds

c. Education and nutrition support: educate on high-calorie, high-protein diet to maintain skin integrity

Explain the rationale for debriding a wound.

Debridement removes necrotic (dead) tissue, which interferes with healing, prevents the nurse from seeing the wound bed, and provides a breeding ground for bacteria.

4 methods of debridement

1. Autolytic

2. Chemical/Enzymatic

3. Mechanical

4. Surgical/Sharp

Uses synthetic dressings to allow the body's own enzymes to digest necrotic tissue.

Autolytic

Topical enzymes are applied to break down dead tissue.

Chemical/Enzymatic

Use of wet-to-dry dressings or wound irrigation.

Mechanical

Removal of nonviable tissue using instruments like a scalpel.

Surgical/Sharp

What are some purposes that dressings provide?

a. Protect from microorganisms.

b. Promote hemostasis.

c. Absorb drainage and debride.

d. Support or splint the wound.

e. Provide thermal insulation.

f. Maintain a moist environment for healing.

How does a wound vacuum-assisted closure (wound VAC) device work?

A Negative-Pressure Wound Therapy (NPWT) device that uses a vacuum pump to apply suction to a specialized foam dressing. It removes excess fluid, reduces bacterial load, and stimulates blood flow and granulation tissue formation.

What are three important principles when cleaning an incision

1. Clean from the least contaminated area (the incision) to the most contaminated (surrounding skin).

2. Use a new swab for each cleaning stroke.

3. Clean from the top of the incision toward the bottom. (flow of gravity, standard sterile technique)

What are the principles of wound irrigation

- Use a nontoxic solution (e.g., normal saline)

- Delivered via a 35-mL syringe and a 19-gauge needle to achieve a pressure of 4 to 15 psi.

- This pressure effectively cleans the wound without damaging new granulation tissue.