Wound Healing and Pressure Injury Management

Wound Healing

• Differentiate among healing by primary, secondary, and tertiary intention.
• Describe wound healing principles.

Nursing Process

• Explain the nursing process in caring for individuals experiencing a wound.
• Describe factors that delay healing or result in complications.

Pressure Injury Etiology

• Explain the etiology and clinical manifestations of pressure injury.
• Discuss using the Braden Scale to assess for pressure injury risk.

Pressure Injury Prevention

• Identify measures used to prevent pressure injury development.
• Explain the nursing and collaborative management of pressure injury with or without infections of the integument.

Pressure Injury Definition

• A localized injury to the skin and/or underlying tissue due to pressure.

Tissue Necrosis

• Cause tissue necrosis, usually over bony prominence.

Oxygenation in Pressure Injury

• If tissue is under pressure against the bone, are the cells receiving oxygen?

Duration of Pressure

• Length of time pressure is exerted (duration).

Tissue Tolerance Factors

• Ability of tissue to tolerate externally applied pressure, influenced by age, density, collagen, and comorbidities.

Shearing Force

• (Not Further Defined)

Friction

• Pressure exerted on the skin when it adheres or sticks to the bed linen and the skin layers slide in the direction of body movement.
• Two surfaces rubbing against each other (sheet and skin when pulling a patient up in bed).

Moisture

• Excessive diaphoresis, urine, or stool.

Pressure Ulcer Staging

• Pressure Ulcers are graded and staged according to the deepest area of tissue damage, from Stage 1 (minor) to Stage 4 (severe).

Slough

• Appearance: Stringy, yellow texture; dead tissue, a vascular.

Eschar

• Black/brown necrotic tissue; a vascular; biologic cover.

Stage 1 Pressure Ulcer

• Intact skin with non-blanchable redness; possible indicators include skin temperature, tissue consistency, pain.

Stage 2 Pressure Ulcer

• Partial-thickness loss of dermis; shallow open ulcer with red/pink wound bed; presents as an intact or ruptured serum-filled blister.

Stage 3 Pressure Ulcer

• Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia; the wound color includes yellow.

Stage 4 Pressure Ulcer

• Full-thickness loss can extend to muscle, bone, or supporting structures; bone, tendon, or muscle may be visible or palpable.

Unstageable Pressure Ulcer

• Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar; the depth and stage cannot be determined until the slough and eschar are removed.

Clinical Manifestations of Wound Infection

• Signs/symptoms include leukocytosis, fever, increased ulcer size, odor, or drainage, necrotic tissue, and pain.
• Untreated ulcers may lead to cellulitis, chronic infection, sepsis, and possibly death.

Braden Scale Total Score

• Total Score of 23 possible; 18 or less indicates High Risk for skin breakdown.

Tissue Injury

• Look for areas of skin darker than surrounding skin; may appear with red, blue, or purple hues in darker skin tones.

Skin Temperature Assessment

• Assess skin temperature using your hand; an ulceration may feel warm initially, then become cooler.

Nursing Problem

• Impaired Skin Integrity related to skin breakdown secondary to pressure ulcer, as evidenced by pressure sore on the sacrum.

Risk for Impaired Skin Integrity

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

Impaired Skin Integrity

• Skin infection evidenced by open sore.

Osteomyelitis

• Bone infection from bloodstream or nearby tissue.

Nutritional Deficiencies

• Lack of nutrients impairs tissue healing.

Corticosteroid Drugs

• Inhibit inflammatory response, impair healing.

Diabetes Mellitus

• Elevated blood glucose increases infection risk.

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.

Primary Intention Wound Healing

• Wound healing with neatly approximated edges.

Secondary Intention

• Healing with extensive tissue loss and exudate.

Tertiary Intention

• Delayed suturing after infection resolution.

Complications of Healing

• Issues like dehiscence and hypertrophic scars.

Wound Measurements

• Measured in centimeters: length, width, depth.

Negative-Pressure Wound Therapy

• Suction removes drainage, speeds healing.

Culture and Sensitivity

• Identifies organisms for effective antibiotic treatment.

Levine's Technique

• Method for obtaining wound culture samples.

Psychological Implications

• Concerns about scars and odor during care.

Caloric Intake

• Increased calories and protein for healing.

Enteral Feedings

• Nutritional support via feeding tubes.

Surgical Debridement

• Surgical removal of necrotic tissue.

Moist Wound Healing

• Keeps ulcer bed moist for better healing.

Skin Care Prevention

• Avoid moisture and pressure on skin.

Positioning Devices

• Use pillows and protectors to relieve pressure.

Daily Weight Monitoring

• Track weight to assess nutritional status.

Healing Process

• Includes regeneration and repair of tissues.

Healing Stages

• Initial, granulation, maturation phases of healing.

Exudate Management

• Control drainage to promote healing.