BOOK / TISSUE INTEGRITY

tissue integrity based on the book

chronic wounds

chronic wounds

develop when the normal wound healing process is disrupted
often due to underlying conditions such as poor blood flow, diabetes, venous insufficiency.

venous disease wound

often located on the lower legs and result from poor blood return to the heart.

a patient with varicose veins who develops an open sore on their lower leg that is slow to heal due to poor circulation

arterial disease wounds

tend to form on the toes or feet and are painful, especially when the legs are elevated.

a diabetic patient with PAD develops a deep, painful ulcer on their foot due to restricted blood flow.

neuropathic disease wounds

often associated with diabetes. a client’s sensation is reduced, leading to unnoticed pressure on injury. typically on the feet.

a diabetic patient with nerve damage steps on a sharp object but doesnt feel the injury. over time, the wound becomes infected and develops into a chronic ulcer

serious drainage

clear, watery drainage that is typically a sign of a healthy healing wound.

example: post operative incision that is healing well.

serosanguineous exudate

mixture of fluid and blood. gives a pinkish color
often seen in wounds that are healing properly with SLIGHT trauma to blood vessels.

sangeuineous exudate

mostly composed of blood. may indicate an active bleeding site.
can be bright red or dark red.

purulent exudate

thick, yellow, green or brown fluid containing pus. indicates infection. SMELLY!!!

a nurse treating a large, irregularly shaped pressure ulcer might use this method to ensure accurate tracking of the wound size over time.

wound circumference tracing

a nurse measuring a surgical incision from a recent appendectomy might use this method to record dimensions

ruler measurements

tunneling

a wound that goes deep into the body, creating a curved tunnel through layers of tissue

skin remains in tact, but there is a localized area of non-blanchable redness.
sensation, temperature and consistency changes may precede visible color changes.

stage 1 pressure injury

partial thickness loss of skin with visible pink or rest moist tissue. no deeper tissues are exposed. it may also present as an open or ruptured serum-filled blister

stage 2 pressure injury

full thickness loss of skin, with visible adipose tissue. granulation tissue is often present, the wound may have rolled edges. undermining or tunneling might also occur.

stage 3 pressure injury

full-thickness skin and tissue loss with muscle, tendon, ligament, cartilage or bone. undermining and tunneling are often present, dead tissue may be visible.

stage 4 pressure injury

the wound is covered with slough (yellow or stringy tissue) or eschar (black, brown hard tissue) making it impossible to determine the depth. once the slough or eschcar has been removed, it reveals either a stage 3 or 4 injury.

unstageable

the skin may be intact or broken, but the area shows persistent, non-blanachable, deep red, maroon, or purple discoloration due to intense or prolonged pressure.

example: a client who sat in the same position for hours develops a dark purple area on their buttock, indicating a deep tissue injury that may worsen

deep tissue pressure injury

a client wearing oxygen tubing develops a pressure injury shaped like the tubing on their cheeks.

device related pressure injury

a client with a long term nasogastric tube develops irritation and injury inside their nostril and upper throat from the tube’s pressure

mucosal membrane pressure injury

involves using a scalpel or scissors to remove necrotic tissue and debris from a wound. reduces risk of infection and promotes healing.

surgical debridement

involves flushing a wound with sterile saline or another cleaning solution to reduce bacteria and remove debris

irrigation

enzymatic agents like collagenase or larvae therapy can be used to break down and remove necrotic tissue

biological debridement

applied immediately after surgery and changed with sterile technique to reduce infection risk.

sterile dressing

used for wounds with minimal drainage

dry dressing

gauze moistened with saline and used for packing wounds that require debridement. primarily used to keep wound moist.

wet dressing

dressings that allow moisture evaporation but maintain a moist wound bed. ideal for superficial wounds with minimal exudate.

semi-occlusive

gel like dressing, used for small abrasions, superficial burns, pressure injuries and postoperative wounds
are comfortable, have less of a risk of maceration, bacteriostatic properties.
can cause contact dermatitis and produce a foul smelling, yellow film

hydro-colloid

made from seaweed, dressings are super absorbent, used for moderate to heavily exudative wounds. provide homeostasis and require less frequent changes.

aliginate dressings

highly absorbent, causes less maceration to the surrounding skin, ideal for moderate to heavily exudative wounds

hydrofiber dressing

used for wounds with mild to moderate exudate. require more frequent changes. reduce hospital acquired pressure injuries. may produce malodorous discharge.

foam dressings

used for mildly exudative wounds and stimulate epithelial growth without sticking to the wound bed
can be used for partial thickness wounds that are starting to epithelialize.

polymeric membrane

available in gel or sheet form, can be used to debride necrotic tissue and eschar, or for dry wounds in need of moisture
cooling effect with little trauma to the wound bed, versatile
requires secondary dressing

hydrogel

used as an antiseptic to clean wounds

iodine

used to manage infections and reduce odor

honey

effective against bacteria in moist or exudative wounds

silver

sutures

provide more precision and are often used for smaller or more delicate areas where cosmetic outcomes are important

staples

used for large areas such as the abdomen because they are faster to place.
often used in surgeries than involve large incisions or where speed is important for closing the wound

skin adhesives

act as a protective waterproof covering
suitable for small wounds with straight edges
applied in layers, peel off within 5-10 days.

negative pressure wound therapy

uses a foam dressing with suction to reduce edema and promote granulation tissue formation. suction is applied intermittently or constantly.
may be used on large, chronic wound to enhance healing by reducing fluid accumulation.

relies on gravity to remove fluid from wound

passive drain

uses negative pressure to actively remove fluid from wound, might be used in a postoperative client with significant fluid accumulation

active drain

drains fluid into the air
example: used after knee replacement to collect wound drainage in a sterile container.

open drains

drains fluid into a closed system to reduce contamination risk

closed drains

passive, open drain that allows fluid to drain from a wound. is flat, flexible, and lacks a collective chamber

penrose

active, closed system that uses negative suction to drain fluid
bulb is compressed to create suction and should be emptied when half full or every 8 hours

jackson pratt drain

for wounds expected to produce large amounts of fluid
change when half full

large bottle drain

this type of drain provides low vacuum suction to remove fluid from a wound. it has a spring that flattens to create suction.

hemovac drain

these things can cause complications in drains

clot formations, tissue fragments, accidental removal

when are drains typically removed?

when the output is less than 30 to 100 mL per day.

doing this regularly helps the client redistribute pressure and prevent injury

repositioning

encourages early movement, such as sitting up or ambulating as soon as tolerated. helps improve circulation and skin integrity

early mobilization

how many degrees should the head of the bed be kept to reduce risk of sliding?

example: a client recovering from surgery should have their knees flexed and supported with pillows under their arms to prevent sliding.

30 degrees, this helps prevent shearing forces on the sacral area

a client with limited mobility due to a stroke should be placed on an __________ to reduce pressure on heels and sacrum

alternating pressure mattress

a ______ placed under the legs of a client with a catheter helps reduce pressure on the skin and avoid injury.

foam cushion

A malnourished client with pressure injuries may benefit from ________supplements to promote wound healing.

protein and calorie supplements

decreased peripheral perfusion and sensation can delay wound healing

diabetes mellitus

breaks down collagen, hindering tissue repair

infection

increase the risk of infection and delay healing

foreign bodies

______ inhibit collagen formation and fibroblast production

steroids

lack of ______ impairs the healing process

essential nutrients

_____ results in dead tissue, which blocks blood flow and delays healing.

tissue necrosis

low oxygen levels due to ________ or other factors can impede healing

vasoconstriction

________ compete for nutrients and slow down overall healing

multiple wounds

clean surgical incisions or lacerations that are closed with sutures, staples, or skin adhesives. fastest healing method.

primary healing / first intention

wounds left open to heal by granulation tissue from the wound bed up. this process takes longer and has a higher risk of infection

secondary healing / second intention

wound is initially left open and later closed with sutures to reduce infection risk

delayed primary closure / tertiary intention

begins at the moment of injury. blood vessels constrict to stop bleeding and clotting factors activate. histamine release increases blood flow to the wound, allowing white blood cells to clean the area and promote tissue formation.

hemostatic/inflammatory phase (days 0-6)

blood supply to the wound increases, then granulation tissues (fibroblasts and collagen) form, strengthening the wound and beginning the re epitheliazation process

proliferative phase (3-24)

collagen is replaced by stronger collagen, the wound matures and contracts as myofibroblasts pull the edges of the wound together

remodeling phase (day 21-1 year)

local infection may present as

redness
cellulitis
warmth to the touch
foul odor and exudate

if the infection becomes systemetic, signs may include

fevers
chills
nausea
vomiting
hypotension
high blood sugar
increased WBC
changes in mental status

are commonly caused by staph, a bacteria found on the skin or acquired during hospitalization.

surgical site infections

reduce risk of surgical site infections by lowering bacterial colonization

clorhexidine gluconate wipes

occurs when a wound reopens due to poor healing. occurs usually 7-10 days post surgery and can be identified by SEROSANGUINEOUS DISCHARGE

dehiscence

complete separation of the wound , where abdominal organs protrude through the incision

evisceration

accumulation of blood under the skin

hematoma

collection of serous fluid

seroma

complications of hematoma and seroma

blood clots and fluid collections can increase pressure on blood vessels, leading to wound ischemia and tissue necrosis. cllients on anticoagulants or those with obesity are at higher risk for these complications

muscle strength is rated from

zero-five

completely flaccid, person cannot move a MUSCLE

level zero muscle strength

a twitch in the muscle

level one muscle strength

very slight movement against gravity only

for example, youre testing the ability of someone who is sitting to move their leg forward, if they are at this level they can barely move it without the help of your hand

level two muscle strength

movement against gravity, nothing is helping the movement of the muscle

level three muscle strength

moving muscle against resistance, but there is some trace weakness

level four muscle strength

completely normal, full strength against resistance

level five muscle strength

the ability for muscles to contract, which means the muscle is shortening

contractability

when the muscle fibers can receive and respond to nerve and hormonal stimulation.
affected by electrolyte imbalances or any other malfunctions

exciteability

ability for the muscle to stretch and extend

estensibility

only located in the heart

cardiac muscle

found in blood vessels and between organs, operates involuntarily
example: intestines performing peristalsis

smooth muscle

attached to bones by tendons, operates voluntarily
we want to always build this type of muscle

skeletal muscle

long bone injuries are associated with

pulmonary embolisms or deep vein fat embolisms

damaged bones, especially long ones, release ________ into the blood stream

bone marrow

post-menopausal females and those who experience hormonal changes are at high risk for ______

osteoporosis

back significantly turns inwards
pregnant women: belly out and back curving inward

lordosis

older patients with a hunched back

kyphosis

you see this with older men who have undergone some kind of lumbar surgery, no curvature in the back

flat back

hip displacement, misaligned shoulders

scoliosis

patients who are immobile are at risk for developing DVTs because they have increased ______ in the blood stream

calcium

bones are rebuilding even though patient is immobile, all that calcium which is supposed to be used for bone strengthening is going around in the blood stream. patients who are immobile are at risk of

hypercalcemia