Unit 1

Stages of Wounds:

• Stage 1:

  • Localized, non-blanchable erythema

  • Early sign of poor blood flow

  • Ischemia: no or poor blood flow to tissues

  • Dark pigmentation of the skin

• Stage 2:

  • Partial thickness skin loss

  • Wound bed is viable, appears intact like a ruptured blister

  • Sourroungind tissue is painful, swollen, discolored

• Stage 3:

  • Full thickness loss, fat visible

  • Undermining or erosion of wound edge

  • Tunneling

  • Slough/ eschar may occur

• Stage 4:

  • Full thickness loss with exposed cartilage (tendons, ligaments, muscle, or bones)

  • Extends through all layers of the skin

• Unstageable wounds:

  • When there is full thickness loss, but can’t be identified due to slough or eschar covering the entire wound bed

Pressure injury risk factors:

• Immobility

• Age

• Incontinence

• Poor nutrition

• Perfusion issues

• Smoking

• Corticosteroids

• Braden scale less than or equal to 18

Pressure injury prevention:

• Braden scale assessments every shift

• Repositioning every 2 hours

• HOB less than or equal to 30 degrees

• Waffle seat cushion when sitting

• Redistributing weight

• Elevate feet so heels are dangling freely

• Pad bony prominences

• Adequate nutrition, especially protein

• Moisture barriers

Phases of wound healing:

• Hemostasis:

  • Blood vessels constrict

  • Clotting factors activate to stop bleeding

  • Platelet release of growth factors that alert cells to start repair process

  • Can last about 60 min

• Inflammation:

  • Vasodilation

  • White blood cells reach wound and start cleaning

  • Symptoms: redness, warmth, swelling, edema, exudate, and fluid accumulation

• Proliferation:

  • Epithelization: new epidermis and granulation tissue

    • Healthy tissue: pink or red, beefy, moist

    • Unhealthy: Painful, bleeding, white/yellow fibrous tissue or biofilm

• Maturation:

  • Remodeling skin tissue

  • Collagen production to strengthen wound

  • Strong scar tissue

Stages of wound healing:

• Primary intention:

  • Wound is sutured,stapled, or glued

  • Heals beneath the closure

• Secondary intention:

  • Edges cannot be approximated, like pressure injuries

  • Heals from inside out

• Tertiary intention:

  • Wound is left open or reopened due to severe swelling or infection

Complications of wound healing:

• Dehiscence: a previously closed wound reopening

• Evisceration: dehiscence with organs protruding

  • Put saline-moistened gauze over open area

Wound drainage:

• Sanguineous: fresh bloody drainage

• Serous: Clear, thin, watery plasma

• Serosanguineous: Combo of blood and plasma, pink color

• Purulent: Thick, opaque, yellow/green color, NEVER NORMAL

Signs of an infection:

• Fever

• Redness

• Inflammation

• Pain

• Swelling

• High white blood cell count

Chain of infection:

• Infectious agent: bacteria, virus, fungi

• Reservoir: body of water, inside a creature

• Portal of exit: in blood, fecal, cough

• Mode of transmission: how it goes from to the reservoir and spread to another person

• Portal of entry: broken skin, inhalation, ingestion

• Susceptible host: individual who is at risk of infection due to weakened immune system or lack of immunity

Prevention of infection:

• Hygienic practices

• Precautions (PPE):

  • Standard:

    • Hand hygiene

    • Clean gloves

    • Sharps safety

    • Aseptic technique

    • Respiratory etiquette

  • Contact:

    • EX: C-diff, MRSA

    • Gloves

    • Gown

    • Dedicated equipment

  • Neutropenic:

    • No live plants/flowers

    • Mask

  • Droplet:

    • EX: Flu, pertussis, meningitis

    • Gown

    • Gloves

    • Surgical mask

  • Airborne:

    • EX: TB, Varicella, Measles

    • N-95 mask

    • Gown

    • Gloves

    • Door closed, pressurized room

• Aseptic and sterile techniques

Nursing process:

• Assess: collecting objective and subjective data

• Diagnosis: how is the patient responding to conditions

  • NANDA aaproved

• Outcome identification: Identifies expected outcomes for the plan

• Plan: SMART goals and interventions tailored to the patient

• Implement: Carry out the interventions (Meds, teaching, repositioning)

• Evaluate: Assess the effectiveness and determine if care need to be revised and improved

SMART goals:

• Specific

• Measurable

• Achievable/attainable

• Relevant/realistic

• Timely

Braden Scale:

• Sensory perception: Can they feel discomfort and tell you about it

• Moisture: How often are they exposed to moisture

• Activity: How much are they physically moving around

• Mobility: Change and control body position in a bed/chair

• Nutrition: Food and fluid intake

• Friction/shear: Damage that happens when skin gets dragged against a surface, like sliding down a bed