TISSUE INTERGRITY

allures (demo)-sterolab

risk factors for impaired tissue integrity

age (thin, non-elastic, frail skin), immobility (patients can’t move themselves, high pressure wound risk), malnutrition (lack of protein or albumin disrupts healing), moisture/incontinence (contact dermatitis, acidity of urine breaks down skin), impaired sensory perception, and chronic illnesses (diabetes, CKD, and other conditions that cause impaired blood flow).

factors of wound assessment

location (common in coccyx and heels), staging, size (LxWxD), exudate type, odor, surround skin. condition, and patient response (did they tolerate? have pain?)

serous exudate

normal; a clear watery fluid that is usually present in the later stages of wound healing

serosanguineous exudate

normal; a watery and bloody or “blood-tinged” fluid present before serous drainage

sanguineous exudate

normal; bloody fluid, usually present post-op

purulent exudate

abnormal; yellow or green fluid w/ odor, signifies infection

braden scale

numeric scale determining risk for skin breakdown; assessed every shift in high risk patients. a lower number indicates a higher risk. sub scales include sensory perception, moisture, activity, mobility, nutrition, and friction/shear. score of less than 9 is a very high risk.

stage 1

redness in a localized area that can be indicated with a temperature change. skin is nonblanchable and intact. usually occurs over bony prominences.

stage 2

partial thickness skin loss with visible skin loss or a fluid filled blister

stage 3

full thickness loss of skin into subQ tissue without exposed muscle or bone. tunneling and undermining is possible.

stage 4

full thickness loss of skin with exposed bone or muscle, sometimes with eschar or slough. undermining and tunneling is possible.

unstageable

eschar or slough obscures the wound, preventing assessment

deep tissue injury

an area of discoloration; a persistent nonblanchable area. happens due to ischemia from damage to underlying tissue.

debridement

the removal of devitalized tissue. can be surgical (using a surgical instrument), biological (using enzymes or larvae), or mechanical (done during cleansing or via wet-to-dry dressing).

film dressing

transparent; used in superficial wounds with minimal to no exudate. maintains moisture.

hydrocolloid dressing

gel like dressings that maintain moist wound beds. used for small wounds, burns, peptic ulcers, or surgical wounds. can look purulent, but is not infected.

alginate dressing

used in moderately to highly exudative wounds. works to remove moisture; requires a secondary dressing to cover.

hydrofiber dressing

used in moderately to highly exudative wounds for wounds with less maceration (breakdown due to moisture) than wounds with alginate dressings.

foam dressing

used in mild to moderate drainage, requires frequent changes

polymeric membranes

used with mild exudate wounds; stimulates cell growth; non stick

hydrogel dressing

used in dry wounds; requires frequent changes. causes debridement of necrotic tissue and provides/adds moisture.

JP drains

a closed system bulb, must charge to maintain suction, uses a compression suction

hemovac drain

a larger closed system with a disc shaped reservoir. much charge to maintain function

penrose drain

a passive drain with an open system, a plastic tube, and absorbent dressing that is applied to collect drainage. can have inaccurate drainage measurements and pose a higher risk for infection.

wound vac drain

negative pressure wound therapy that assists in wound contraction, debridement, and removal of exudate. applies suction and speeds up wound healing.

preventing skin breakdown

reposition client q2h if client is unable to do so independently, keep the client clean/dry by performing incontinence checks q2h, keep them hydrated, mobilize the patient, keep bed below 30º, use supportive surfaces such as heel protectors and wedges.

primary intention

all surgical wounds; wound site is approximated (edges meet together). heels from the top down.

secondary intention

chronic or acute wounds; left open to be filled with granulation tissue/epithelialization. heal from bottom to top. usually requires suturing/stapling.

tertiary intention

takes longer to heal and involves more scar tissue. a combination of primary and secondary

dehiscence

wound edges separate usually due to infection, foreign particles, or poor closure. can occur 7-10 days post surgery. notify MD and cover the wound.

evisceration

when bowels protrude; an emergency. cover organs with a sterile soaked saline gauze.

hematoma/seroma

bleeding of wound. increased risk with those on anticoagulants or those who are obese. has a risk of infection and tissue ischemia. monitor swelling pain, drainage, s/s of infection, and output.