wound healing

risk factors for pressure injury

- Impaired sensory perception

- Impaired mobility

- Alteration in LOC

- Shear

- Friction

- Moisture

- Elevated body temperature

- Incontinence

- Diabetes

- Prolonged surgery

- Poor nutrition

- Advanced Age

- Anemia

stage 1 classification

intact skin with nonblanchable redness

usually over a bony prominence

stage 2 classification

partial thickness skin loss involing epidermis, dermis, or both

Can present as an intact or ruptured serum-filled blister

stage 3 classification

Full-thickness tissue loss with visible fat

deep crater

stage 4 classification

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

Epibole, undermining and tunneling may occur

epibole

rolled wound edges

undermining

shelf, pocket, or lip is formed

separation of the wound edges from the surrounding healthy tissue

tunneling

narrow, tube-like channel extending in one specific direction

deep tissue injury

Purple or maroon localized area of discolored intact skin or blood-filled blister

unstageable pressure injury

Full-thickness tissue loss in which actual depth of Injury is completely obscured by slough or eschar

healing process of full thickness wound repair

1. hemostasis

2. inflammation

3. proliferative

4. maturation

Medical-device related pressure injury

The resultant pressure injury generally conforms to the pattern or shape of the device.

The injury should be staged using the staging system.

Mucosal membrane pressure injury:

localized damage to mucous membranes caused by prolonged pressure, usually from medical devices like endotracheal tubes or nasal cannula

common in ICU patients

wound classification

- cause of wound (abrasion, laceration, puncture, skin tear)

- cleanliness of wound

- Descriptive qualities of the wound tissue such as color

- acute vs. chronic

- extent of tissue loss (full vs. partial)

secondary intention wound healing

not enough issue to bring together

tertiary intention

delayed healing of a wound that can be closed with sutures

wound healing for partial thickness

1. Inflammatory response

2. Epithelial proliferation and migration

3. Reestablishment of the epidermal layers

Complications of wound healing

- hemorrhage

- infection (likely 3-5 days post op)

- fistula formation

- dehisence

- evisceration

Factors influencing pressure injury formation and wound healing

Tissue perfusion

Inadequate blood supply

Anemia

Corticosteroid drugs

Infection

Smoking

Advanced Age

Obesity - adipose tissue is not vascularized, doesn't get nutrients

Diabetes

Psychosocial impact

nutrients necessary for wound healing

- calories (cell energy)

- protein (fibroplasia)

- vitamin C (collagen)

- vitamin A (epithelization)

- zinc (collagen formation, protein synthesis)

- fluid

braden scale

- Sensory perception

- Moisture

- Activity

- Mobility

- Nutrition

- Friction and shear

Low score = high risk for injury developing

High score = lower risk