NUR350 midterm 2 - therapeutic skills

acute wound

wound follows an orderly and timely reparative process that restores anatomical and functional integrity

- e.g. surgical incision

chronic wound

wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity

- e.g. pressure injury

- does not heal easily

wound healing (2 types)

1. primary intention

2. secondary intention

wound healing: primary intention

wound with little tissue loss

- skin edges are closed/approximated

- healing takes place over small area = fine scar

- low risk of infection

- e.g. clean surgical wound

wound healing: secondary intention

wound involving tissue loss

- wound is not approximated

- area fills with scar tissue as it heals (heals from wound base)

- e.g. burn, pressure injury

partial vs full thickness wound healing

partial thickness:

- wounds that occur mostly within epidermis

full thickness:

- wounds that extend down into dermis

- take longer to heal

process of wound healing: partial thickness (3 steps)

1. inflammatory response (first 24 hours)

- increases blood flow to area (causes swelling and colour change)

2. epithelial proliferation (reproduction) and migration across wound bed

- new epithelial layer is not very thick

3. reestablishment of epidermal layers (normal thickness)

process of wound healing: full thickness (3 steps)

1. inflammatory phase (reaction)

- goes on for 3 days

- controls bleeding, delivers blood and cells to area

- epithelial cells form at site

2. proliferative phase (regeneration)

- lasts for 3-24 days

- filling in wound with granulation tissue (including collagen)

- contraction of wound

- resurfacing of wound by epithelialization

3. remodelling (maturation)

- may take up to 2 years

- collagen fibers (scar tissue) continue to gain strength

assessment of acute wounds (6 components)

1. wound appearance

2. character of wound drainage

3. presence of drains

4. wound closures

5. wound palpation

6. pain

wound appearance (4 characteristics)

1. edges

- separated or closed (approximation)

2. size

- measure

3. shape

- e.g. linear, circular, puncture-like

4. colour

- wound and peri-wound area

wound drainage (4 characteristics)

1. amount

2. colour

3. consistency

4. odour

- foul odour may indicate infection

types of wound drainage (4)

1. serous

- clear, pale, watery

2. serosanguinous

- mixture of clear fluid and blood

- light red or dark pink

3. sanguinous

- bloody drainage

- may indicate active bleeding

4. purulent

- thick, yellow/brown/green

- may indicate infection

wound drains: nurse's responsibilities (4)

1. assess insertion site

2. care for insertion site

3. monitor output and character of drainage

4. prevent dislodgement

types of wound drains (3)

1. jackson-pratt (JP)

- uses bulb to create suction

- often sutured in place

2. hemovac

- uses spring to create suction

3. penrose

- drains by gravity

- uses pin to prevent slipping back into wound (open dressing carefully to avoid pulling out)

- soft and floppy

penrose drains are slowly pulled out as ___ to prevent ___

volume of drainage decreases;

fluid buildup in the healing wound

(allows wound to heal and avoids creating a pocket of fluid from the drain being removed too quickly)

types of wound closure (4)

1. sutures

2. staples

3. adhesive skin closures (steri-strip)

4. tissue adhesive (glue)

how to remove sutures and staples

both by medical order

sutures:

- cut close to skin, away from knot

- pull up on knotted side

- careful to not pull contaminated part of stitch back through skin

staples:

- slide device under staple and compress

wound palpation (inspection and palpation)

inspection:

- observe swelling or separation of wound edges

palpation:

- lightly palpate wound edges to detect areas of tenderness or warmth (may indicate infection)

- may cause fluid to be expressed

___ tenderness may signify infection

extreme

- some pain is expected at incision site

assessment of wound pain (2 steps)

1. minimize discomfort (if needed: administer analgesic 30-45 mins before dressing change)

2. ask pt to rate pain before and after wound care (e.g. numerical rating scale)

complications of wound healing (5)

1. hemorrhage

2. infection

3. dehiscence

4. evisceration

5. fistula

complications of wound healing: hemorrhage (2 types)

some bleeding is expected with surgical wounds

1. external

- visible on inspection

- circle area of drainage on dressing with a pen (note date and time; monitor)

2. internal

- assess for: swelling or distention, increased drainage in drain reservoir, decreased BP, increased HR

- may progress to hypovolemic shock

risk of hemorrhage is greatest in first ___

24-48 hours

complications of wound healing: infection

surgical site infections = most common HAI in surgical pts

complications of wound healing: infection (8 signs)

1. edema

- increased inflammation increases blood flow to area (hyperemia)

2. skin colour changes

- compare to pt's baseline

3. pain/tenderness

4. purulent discharge

5. foul odour

6. warmth, fever, chills

7. increased WBC count (body is fighting off infection)

8. delayed healing

complications of wound healing: dehiscence

partial or total separation of wound layers

- opening up of incision line or wound

complications of wound healing: dehiscence - risk behaviours

coughing, vomiting, sitting up in chair (abdominal wounds)

- actions that increase pressure in abdomen and on skin

complications of wound healing: dehiscence - risk factors

obesity, smoking, poor nutrition, multiple traumas, failure of suturing, excessive coughing, vomiting, dehydration

complications of wound healing: dehiscence - nursing intervention to reduce risk

splinting the area with blanket or pillow if pt has to cough or is sitting up

- can decrease effect of pressure building under skin

complications of wound healing: evisceration

protrusion of visceral organs through a wound opening = medical emergency

complications of wound healing: evisceration - steps to take if this happens (4)

1. place sterile towels (soaked in sterile saline) over the area

2. pt is NPO

3. prepare pt for emergency surgery

4. monitor pt closely (e.g. vital signs, LOC)

complications of wound healing: fistula

passage that develops between two spaces where there shouldn't be one

- between two organs or between an organ and the outside of the body

- can result from poor wound healing, disease complication, trauma, or infection

- may require surgery

interventions to promote wound healing (6)

1. wound dressings

2. principles of dressing changes

3. debridement

4. irrigating and packing wounds

5. culturing wounds

6. application of bandages

interventions to promote wound healing: wound dressings (6 purposes/benefits)

1. protect wound from microorganisms

2. aid in hemostasis (by stopping bleeding)

- pressure dressings

3. promote healing by absorbing drainage

4. provide moist environment for wound bed

5. support/splint wound

6. protects pt from seeing the wound (if perceived as unpleasant)

traditional surgical dressings have 3 layers:

1. contact or primary layer

- covers the incision

2. absorbent layer

- reservoir for additional secretions

3. outer protective layer

- prevents external contaminants from reaching wound surface

(all 3 layers may come as one bandage)

types of wound dressings (2)

1. dry

- e.g. surgical wound that is well-approximated with minimal drainage

2. moist wound healing

- e.g. larger wound with large wound bed that requires packing (packed gauze wicks drainage from wound bed to absorbent layer)

interventions to promote wound healing: principles of dressing changes (2 components)

1. preparation of pt

2. basic skin cleansing

how to prepare a pt for a wound dressing change (4 steps)

1. administer required analgesics

- so that peak effects occur during dressing change (30-40 mins before)

2. describe the steps of procedure to lessen pt anxiety

3. gather all supplies

4. answer pt questions

basic skin cleansing principles (4)

1. cleanse wound with normal saline (NS)

2. cleanse from least contaminated area (wound site) to most contaminated (surrounding skin = peri-wound area)

3. use gentle friction to clean

- helps with removal of microorganisms

4. use each cleansing gauze only once

2 methods of wound (incision) cleansing

1. perpendicular to incision

2. parallel to incision

(least to most contaminated)

interventions to promote wound healing: debridement (4 purposes/benefits)

1. removes necrotic, nonviable tissue

2. removes infection source

3. enables visualization of wound bed

4. makes clean base for healing

wet to dry and moist to dry dressings (are / are not) recommended because...

not recommended

- they inadvertently mechanically debride the wound

- the wet/moist gauze can dry out and adhere to the wound bed

when to use dry vs moist wound healing dressings

dry:

- for wounds with minimal drainage

moist wound healing:

- for wounds where we want to maintain a moist wound bed

interventions to promote wound healing: irrigating wounds (4 considerations)

1. can use NS, water, or antiseptic solutions (for infections)

2. solution should flow out so would bed is not further damaged (position pt to allow gravity to assist)

3. solution should flow from least to most contaminated

4. use low pressure to cleanse without trauma to wound bed

interventions to promote wound healing: irrigating wounds - what size syringe?

larger syringe (35 cc)

- to provide lower pressure

interventions to promote wound healing: packing wounds (purpose)

to eliminate dead space

- open areas in wound can heal over and become pockets for infection or cause dehiscence

interventions to promote wound healing: packing wounds (4 steps/considerations)

1. packing should be loose, contacting all wound surfaces, and not mounding above the skin surface

2. assess for undermining and tunneling

3. measure and record wound depth and amount of packing used

4. protect integrity of skin around wound to prevent maceration

undermining

area of tissue destruction extending under intact skin along periphery of a wound

tunneling

tract or extension deep into soft tissues

interventions to promote wound healing: culturing wounds (reason to do)

purulent drainage noted at wound site or other signs of possible infection

interventions to promote wound healing: culturing wounds (6 steps/techniques)

1. cleanse wound thoroughly with NS

2. do not culture pus or exudate (may contain microorganisms from skin)

3. swab healthiest looking tissue

- do not swab over scab or eschar

4. rotate the swab in 1 cm x 1 cm of clean tissue in the open wound

5. apply pressure with swab to elicit fluid

6. insert tip of swab into appropriate sterile container

gold standard of wound culture

tissue biopsy

interventions to promote wound healing: application of bandages (reason to use and 5 uses)

bandages create pressure

1. immobilizing a body part (e.g. sprained ankle)

2. supporting a wound (e.g. abdominal binder)

3. reducing or preventing edema

4. securing a splint

5. securing a dressing

relation of nutrition to wound healing

facilitates wound healing, maintains immune function, decreases risk of infection

- poor nutrition has been associated with delayed wound healing

eschar

thick, dry, black necrotic tissue covering a wound

slough

viscous yellow layer which often covers a wound

maceration

skin breakdown due to fluid contacting healthy skin (when skin is consistently wet)

- skin softens, turns white, and can easily get infected with bacteria or fungi

types of chronic wounds (4)

1. arterial and venous ulcers

2. diabetic ulcers

3. skin tears

4. pressure injuries

arterial and venous ulcers

result from poor circulation

- occur in lower extremities

arterial ulcers

inadequate blood supply

- deeper and smaller than venous ulcers

- often on feet

- necrotic or pale wound beds (little blood supply)

- legs may appear shiny, skin is taut and without hair

- quite resistant to healing

venous ulcers

inadequate blood return

- superficial, irregular shape

- large amount of exudate

diabetic ulcers

result from neuropathic changes related to diabetes

- common over bony prominences on foot and heels

- pt may experience decreased ability to feel pain or temp change

skin tears

separation of skin layers as a result of injury (shear, friction, trauma)

- opportunity for microorganisms to enter body and cause infection

- take care during position changes; protect area and promote healing (keep covered)

risk factors for skin tears

aging skin = greatest risk factor (thinning of epidermis)

others:

- dehydration

- poor nutrition

- steroid use

- sensory and cognitive impairment

pressure injuries

result from pressure, shear, and/or friction

- affected by moisture, nutrition, perfusion, mobility/activity, and comorbidities

- highly prevalent in healthcare settings

- significant impact on quality of life

degree of pressure injury caused by pressure depends on... (3 factors)

1. intensity (amount of pressure)

2. duration

3. tissue tolerance (how well skin and vessels can redistribute pressure)

risk factors (5) and related interventions to prevent pressure injuries

1. decreased sensory perception

- assess pressure points

- provide pressure redistribution surface

2. moisture

- incontinence management

- keep skin clean and dry

3. friction and shear

- reposition pt using drawsheet

- devices to assist with independent movement (e.g. trapeze bar)

- 30 degree lateral positioning (optimal position to relieve pressure)

4. decreased mobility

- turning schedule

- pressure reducing devices

5. poor nutrition

- assess dentures

- mouth care

- assist with intake

- consult dietician/SLP

pressure injury risk assessment: most widely used assessment tool

braden scale

- 6 subscales (sensory perception, moisture, activity, mobility, nutrition, friction/shear)

- total score = prediction of risk

- subscale scores can guide interventions

braden scale (pressure injury risk assessment tool): interpretation of score

lower score = higher risk

- can target interventions in areas (of subscale) where score is lower

key components of pressure injury risk assessment (4)

1. use preventively

- on admission

2. use consistently

- ideally daily (depends on type of unit/setting)

3. reevaluate

- whenever there is a change in pt's condition

4. work collaboratively with other HCPs

- e.g. dietitian, OT/PT

staging of pressure injury is based on...

description of the amount of tissue damage

stages of pressure injury formation (NPIAP)

suspected deep tissue injury

stage 1

stage 2

stage 3

stage 4

unstageable

stage of pressure injury formation (NPIAP): suspected deep tissue injury

results from intense or prolonged pressure and shear

- skin may be intact or not

- may assess a blood-filled blister

- localized areas of non-blanchable red or purple discolouration (light skin) or a darkening (dark skin)

- pain and temp change often precede colour changes

stage of pressure injury formation (NPIAP): stage 1

intact skin with damage to the underlying tissues

- signs of inflammation: changes in colour, sensation, temp, and firmness

stage of pressure injury formation (NPIAP): stage 2

partial thickness loss of dermis presenting as a shallow open ulcer

- red-pink wound bed

- without slough

stage of pressure injury formation (NPIAP): stage 3

full thickness tissue loss

- subcutaneous fat may be visible (bone, tendon, or muscle are not exposed)

- slough and/or eschar may be present

stage of pressure injury formation (NPIAP): stage 4

full thickness tissue loss

- exposed bone, tendon, or muscle

- undermining and/or tunneling often present

stage of pressure injury formation (NPIAP): unstageable

full thickness tissue loss

- extent of damage cannot be confirmed (base of wound is covered in slough and/or eschar)

wound assessment (7 characteristics)

1. staging of pressure injury

2. measurement of size (depth, width, length, area)

3. character and amount of exudate

4. wound bed characteristics (e.g. granulation, necrotic tissue)

5. pain

6. edge

- condition of wound edge and surrounding skin

7. evidence of tunneling or undermining

wound measurement: use ___

cotton swab

- use second swab to determine depth of undermining

management of pressure injuries (4 methods)

1. cleansing, irrigation, and packing

2. debridement

3. dressing selection

4. advanced therapies

benefits of maintaining a moist wound bed with moistened gauze (4)

1. faster healing of both acute and chronic wounds

2. promotes growth of new tissue

3. better tissue quality (less scarring)

4. reduced pain

packing of a wound is done with ___ gauze

moist

wound debridement (5 techniques)

1. surgical/sharp

- cutting away dead tissue

2. autolytic

- uses body's natural enzymes to digest necrotic tissue

3. enzymatic (chemical)

- uses proteolytic enzymes to loosen necrotic tissue

4. biologic

- e.g. maggot therapy

5. mechanical

- uses force (can happen incidentally with wet to dry dressings)

gold standard wound debridement technique

surgical/sharp

- fastest and most efficient

many chronic wounds require use of ___ debridement technique

more than one

purpose/benefits of chronic wound dressings (8)

1. optimizes healing

2. protects wound from contamination

3. supports/splints the wound

4. hemostasis (by applying pressure)

5. contains exudate and supports autolytic debridement

6. keeps wound bed slightly moist

7. protects peri-wound skin

8. prevents trauma to fragile tissue

types of chronic wound dressings (5)

1. transparent films and membranes

2. hydrogel

3. hydrocolloids

4. foam dressing

5. calcium alginate dressing

types of chronic wound dressings: transparent films and membranes

thin, transparent polyurethane

- permits exchange of water vapour and CO2

- not absorbent

- useful for protecting skin

types of chronic wound dressings: hydrogel

semitransparent, non-adherent gel (contains 90-95% water)

- used in wound beds with slough or eschar to accelerate autolysis

- recommended for wounds that are dry to mildly exudating

types of chronic wound dressings: hydrocolloids

interact with wound bed to hydrate the wound

- semi-occlusive; non-permeable to water vapour and O2

- can be left on for 5-7 days

- does not absorb exudates very well (not used on heavily infected or draining wounds)

types of chronic wound dressings: foam dressing

draws exudates into core of the dressing

- can absorb large amount of exudate

- protects peri-wound skin from maceration

- easily shaped to fit wounds

types of chronic wound dressings: calcium alginate dressing

made from seaweed

- used for highly draining wounds (absorbs a lot of exudate)

- needs another dressing to cover

additional chronic wound therapies (1)

1. negative pressure wound therapy

- for large wounds

- assists wound closure by applying localized negative pressure

inspiration and expiration are under the control of ___ and ___ processes that respond to levels of...

neural;

chemical;

O2, CO2, and hydrogen ion concentrations in the blood

pathway of air

nose or mouth -> pharynx -> larynx -> trachea -> bronchi (splits into two main bronchi at carina) -> bronchioles -> alveoli

respiratory physiology: oxygenation (3 parts)

1. ventilation

- moving gases into and out of the lungs

2. perfusion

- oxygenated blood to the tissues

- deoxygenated blood to the lungs

3. diffusion

- movement of molecules (O2 and CO2) from high to low concentrations

- takes place across alveolar capillary membranes

if any of the 3 factors of respiratory physiology are compromised...

respiratory status is compromised

factors affecting oxygenation (4)

1. physiological

2. developmental

3. lifestyle

4. environmental

factors affecting oxygenation: physiological (5 examples)

1. cardiac conditions

- impaired blood flow = decreased ability to move O2 within body

2. anemia

- decreased hemoglobin = decreased O2 carrying capacity

3. pregnancy

- can decrease inspiratory capacity

4. fever and infection

- increased metabolic rates and tissue O2 demand

5. chest wall movement

- CNS conditions or MSK trauma/injury/disease can affect innervation of inspiratory muscles