Wound Healing and Pressure Injuries

Podcast

Play an AI-generated podcast conversation about this lesson

Questions and Answers

What is a key factor in healing by primary intention?

The presence of a large wound area

Involvement of granulation tissue

Formation of a significant scar

Edges of the wound are approximated (correct)

How does advanced age contribute to delayed wound healing?

Increased cellular division

Reduced mitosis and skin elasticity (correct)

Enhanced immune response

Greater blood circulation

Which of the following factors can lead to the development of pressure injuries?

Pressure, shear, and friction causing ischemia (correct)

Regular movement and proper nutrition

Excessive moisture and skin integrity

Weight loss and increased mobility

What does the Braden Scale assess?

Risk of pressure injuries Signup and view all the answers

Which factor is NOT typically associated with delayed wound healing?

Adequate hydration Signup and view all the answers

What influences the ability of tissue to tolerate externally applied pressure?

Age, density, collagen, and co-morbidities Signup and view all the answers

What is a characteristic of Stage 1 Pressure Ulcer?

Shallow open ulcer with a red pink wound bed Signup and view all the answers

Which of the following best describes eschar?

Dead tissue that is black or brown and avascular Signup and view all the answers

What defines shearing force in the context of skin pressure?

Skin layers sliding in the direction of body movement Signup and view all the answers

Which stage of pressure ulcer involves full-thickness skin loss with damage to subcutaneous tissue?

Stage 3 Signup and view all the answers

What is a common contributor to moisture on the skin leading to pressure injuries?

Excessive diaphoresis, urine, or stool Signup and view all the answers

What characterizes slough in wound healing?

Stringy, yellow, dead tissue that is avascular Signup and view all the answers

Which of the following is NOT a potential indicator of pressure injury?

Consistent skin moisture Signup and view all the answers

What distinguishes a Stage 4 Pressure Ulcer from a Stage 3 Pressure Ulcer?

Stage 4 has muscle and bone visible. Signup and view all the answers

What is a key indication that a pressure ulcer may be unstageable?

Coverage by slough or eschar Signup and view all the answers

What is commonly associated with untreated pressure ulcers?

Chronic infection Signup and view all the answers

Which of the following is NOT a clinical manifestation of wound infection?

Decreased ulcer size Signup and view all the answers

What does a total score of 18 or less on the Braden Scale indicate?

High risk for skin breakdown Signup and view all the answers

What would you expect in skin temperature assessment over time for an ulceration?

Initially warm, then cooler Signup and view all the answers

What visual sign may indicate tissue injury in patients with darker skin tones?

Areas darker than surrounding skin Signup and view all the answers

Which of the following symptoms suggests an advanced infection of a pressure ulcer?

Fever Signup and view all the answers

Which method of debridement involves the use of drugs to dissolve necrotic tissue?

Enzymatic Debridement Signup and view all the answers

What is the primary goal of surgical debridement?

To remove necrotic tissue Signup and view all the answers

Which type of wound healing involves delayed suturing after infection resolution?

Tertiary Intention Signup and view all the answers

In which method of debridement are occlusive dressings used?

Autolytic Debridement Signup and view all the answers

What complication occurs when a surgical wound bursts open?

Dehiscence Signup and view all the answers

Which method of debridement relies on moisture to facilitate tissue removal?

Mechanical Debridement Signup and view all the answers

Which term describes the displacement of organs outside of the body?

Evisceration Signup and view all the answers

Which type of wound healing primarily involves neatly approximated edges?

Primary Intention Signup and view all the answers

What is a recommended practice to prevent pressure injuries?

Reposition the patient every 2 hours. Signup and view all the answers

Which of the following is NOT recommended for cleaning a wound?

Hydrogen peroxide. Signup and view all the answers

What is the purpose of using gel pads in pressure injury prevention?

To provide support and relief of pressure. Signup and view all the answers

Which of the following best defines a pressure injury?

A localized injury due to pressure on skin and underlying tissue. Signup and view all the answers

What factors can cause tissue necrosis in pressure injuries?

Length of time pressure is applied. Signup and view all the answers

Which of the following agents should be avoided as they can delay wound healing?

Topical corticosteroids. Signup and view all the answers

Which surface is recommended to help prevent pressure injuries?

A gel-infused mattress pad. Signup and view all the answers

What should be done with bed coverings to avoid pressure injuries?

Keep bed coverings off the feet using pillows. Signup and view all the answers

What is a characteristic symptom of a post-operative infection?

Purulent drainage Signup and view all the answers

What distinguishes keloid scars from hypertrophic scars?

Keloids can grow larger than the original wounds Signup and view all the answers

What is the purpose of utilizing negative-pressure wound therapy?

To remove drainage and speed healing Signup and view all the answers

How is the culture and sensitivity test performed?

By rotating a culture swab over a cleansed area using pressure Signup and view all the answers

What is a primary benefit of maintaining a moist wound environment?

Promotes better healing outcomes Signup and view all the answers

What role does caloric intake play during the healing process?

Supports increased energy expenditure for repair Signup and view all the answers

Why are position devices important in preventing skin damage?

They alleviate pressure on vulnerable areas Signup and view all the answers

What is an implication of psychological factors in wound care?

Concerns about scars can affect patient compliance Signup and view all the answers

Study Notes

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.

Studying That Suits You

Use AI to generate personalized quizzes and flashcards to suit your learning preferences.

Description

This quiz covers essential concepts of wound healing, including the differences between primary, secondary, and tertiary intention. It also discusses the nursing process in caring for wounds, the etiology of pressure injuries, and prevention and management strategies. Test your knowledge on these critical components of nursing care!