Wound Healing and Pressure Injuries

Wound Healing

• Differentiate among healing by primary, secondary, and tertiary intention.
• Intact skin is the first defense against infection.

Nursing Process

• Explain the nursing process in caring for individuals with wounds.
• Factors affecting wound healing include advanced age, poor nutrition, anemia, circulatory problems, irritation, bleeding, and infection.

Pressure Injury Etiology

• Pressure injuries are caused by pressure, shear, and friction, resulting in tissue ischemia and injury.
• Use the Braden Scale to assess risk for pressure injuries.

Pressure Injury Prevention

• Frequent turning (every 2 hours).
• Get patients out of bed and into chairs.
• Keep vulnerable areas clean and dry.
• Keep bed coverings off feet (use pillows to "float heels").
• Reposition every 2 hours.
• Use support devices (pillows, gel pads, mattress pads).

Pressure Injury Management

• Perform passive range of motion (PROM).
• Clean wounds with each dressing change.
• Do not use harsh products on sensitive skin.
• Avoid agents that delay wound healing (topical corticosteroids, hydrogen peroxide, iodine).
• Avoid massage over bony areas.

Pressure Injury Definition

• A localized injury to the skin and/or underlying tissue due to pressure.
• Causes tissue necrosis, usually over bony prominences.

Tissue Necrosis

• Tissue necrosis is a common outcome of pressure injuries.

Oxygenation in Pressure Injuries

• Adequate oxygenation is critical for wound healing. Is the tissue receiving enough oxygen?

Duration of Pressure

• Length of time pressure is exerted.

Tissue Tolerance Factors

• Ability of tissue to tolerate external pressure, influenced by age, density, collagen and co-morbidities.

Shearing Force

• Pressure exerted on the skin when it adheres or sticks to the bed linen and the layers of skin slide, resulting in injury.

Friction

• Two surfaces rubbing against one another, like bed sheets and skin, can cause injury.

Moisture

• Excessive moisture from diaphoresis, urine, or stool can damage skin.

Pressure Ulcer Staging

• Pressure ulcers are graded from Stage 1 to 4, based on the depth of tissue damage.

Slough

• Stringy, yellow dead tissue.

Eschar

• Black, brown necrotic issue; a vascular, biologic cover.

Stage 1 Pressure Ulcer

• Partial-thickness loss of dermis, shallow open ulcer with red or pink wound bed, possibly an intact or ruptured serum-filled blister.

Stage 2 Pressure Ulcer

• Full-thickness skin loss, damage or necrosis of subcutaneous tissues, may extend to underlying fascia. Wound color may include yellow.

Stage 3 Pressure Ulcer

• Full-thickness skin loss with damage to subcutaneous tissues, may extend to underlying fascia, possibly visible fat, and wound color may include yellow.

Stage 4 Pressure Ulcer

• Full-thickness loss that extends to muscle, bone, or supporting structures, possible bone, tendon, or muscle visualization or palpation.

Unstageable Pressure Ulcer

• Full-thickness tissue loss, covered by slough and/or eschar (dead tissue). The depth and stage cannot be determined until the slough or eschar is removed.

Clinical Manifestations of Wound Infection

• Signs and symptoms of infections include: leukocytosis, fever, increased ulcer size, odor, drainage, necrotic tissue, and pain. Untreated ulcers can lead to cellulitis, chronic infection, sepsis, and potentially death.

Braden Scale Total Score

• A total score of 23 is possible; an 18 or less indicates high risk for skin breakdown.

Tissue Injury in Patients with Deep Pigmentation

• Look for areas of skin darker than surrounding skin, may appear red, blue, or purple.

Skin Temperature Assessment

• Assess skin temperature using your hand.

Nursing Problem

• Impaired skin integrity related to skin breakdown secondary to pressure ulcers.

Risk for Impaired Skin Integrity

• Risk for impaired skin integrity related to immobility as evidenced by prolonged sitting.
• Evidenced by pressure sores.

Impaired Skin Integrity

• Skin infection evidence by open sores.

Osteomyelitis

• Bone infection, from bloodstream or nearby tissue.

Nutritional Deficiencies

• A lack of nutrients impairs tissue healing.

Corticosteroid Drugs

• Inhibit inflammatory response; impair healing.

Diabetes Mellitus

• Elevated blood glucose increases infection risk, and reduced oxygen delivery to cells and tissues.

Anemia

• Reduced oxygen delivery to cells and tissues.

Wound Care

• Prevent infection and promote healing.

Pressure Relief

• Reduce pressure on vulnerable skin areas.

Debridement

• Removal of necrotic tissue from wounds.

Surgical Debridement

• Removal using a scalpel, scissors, or other sharp instrument.

Mechanical Debridement

• Wet-to-dry or moist dressings, removing moisture and then removing them.

Enzymatic Debridement

• Topical drugs to dissolve necrotic tissue, containing collagenase and papain, and/or urea.

Autolytic Debridement

• Occlusive dressings to soften dry eschar by autolysis.

Primary Intention

• Wound healing with neatly approximated edges.

Secondary Intention

• Extensive tissue loss with exudate.

Tertiary Intention

• Delayed suturing after infection resolution.

Complications of Healing

• Issues like dehiscence and hypertrophic scars.

Dehiscence

• Bursting open of a wound, particularly surgical abdominal wounds.

Evisceration

• Displacement of organs outside the body.

Post-Op Infection

• Infection starts after surgery. 3-5 days after surgery, swollen and red. Includes purulent drainage. localized to the wound.

Hypertrophic Scar

• Excessive amounts of collagen, tumor-like mass.

Keloid Scars

• Thick, raised scars caused by excessive amounts of collagen and tumor-like mass.

Wound Measurements

• Measured in centimeters of length, width, and depth.

Negative-Pressure Wound Therapy

• Reduces drainage, speeds healing.

Culture and Sensitivity

• Identifies organisms for effective antibiotic treatment.

Levine's Technique

• Rotating a culture swab over a 1-cm2 cleansed wound area to extract wound fluids from deep layers.

Psychological Implications

• Concerns about scars and odor during patient care. Increase calories and protein for healing, use enteral feedings, maintain moisture with moist wound healing, prevent skin issues, use positioning devices, monitor daily weight.

Caloric Intake

• Increase calories and protein for healing.

Enteral Feedings

• Nutritional support via tubes for healing.

Moist Wound Healing

• Maintain moist wound bed for better healing.

Skin Care Prevention

• Avoid moisture and pressure on skin.

Positioning Devices

• Use pillows and protectors for pressure relief.

Daily Weight Monitoring

• Track weight to assess nutritional status.

Healing Process

• Includes initial, granulation, and maturation phases.

Healing Stages

• Initial, granulation, and maturation stages for tissue regeneration and repair.

Exudate Management

• Control drainage to promote wound healing.

Undermining Wound

• Wider at the base than the surface of the wound.

Tunneling Wound

• Track underneath the skin, tunnel-like.