Pressure Injuries: Wound Healing PDF

Understanding Pressure Injuries and Wound Healing Study online at https://quizlet.com/_g55869 Differentiate among healing by primary, Wound Healing secondary, and tertiary intention....

Understanding Pressure Injuries and Wound Healing Study online at https://quizlet.com/_g55869 Differentiate among healing by primary, Wound Healing secondary, and tertiary intention. Intact skin is first defense against infec- Wound Healing Principles tion. Explain the nursing process in caring for Nursing Process individuals experiencing a wound. -Advanced age, reduced mitosis -Poor nutrition -Anemia Factors Delaying Healing -Circulatory problems -Irritation, bleeding -Infection Caused by pressure, shear, and friction, Pressure Injury Etiology resulting in tissue ischemia and injury Discuss using the Braden Scale to as- Braden Scale sess for pressure injury risk. frequent turning (every 2 hours), get per- son out of bed and into chair, keep vul- Pressure Injury Prevention nerable areas clean and dry, keep bed coverings off feet (use pillows to "float heels") reposition q2h provide relief of pressure on wound -use support devices -pillows -gel pads -mattress pads perform passive range of motion Pressure Injury Management (PROM) clean wound with each dressing change do not use harsh products on sensitive skin avoid agents that delay wound healing (topical corticosteroids, hydrogen perox- ide, iodine) avoid massage over bony areas 1/7  Understanding Pressure Injuries and Wound Healing Study online at https://quizlet.com/_g55869 use the appropriate type of dress- ing: hydrocolloid, transparent adhesive, wet-to-moise, etc A localized injury to the skin and/or un- Pressure Injury Definition derlying tissue due to pressure. Cause tissue necrosis, usually over Tissue Necrosis boney prominence. If tissue is under pressure against the Oxygenation in Pressure Injury bone are the cells receiving oxygen? Length of time pressure is exerted (dura- Duration of Pressure tion). Ability of tissue to tolerate externally ap- Tissue Tolerance Factors plied pressure, influenced by age, densi- ty, collagen, and co-morbidities. Pressure exerted on the skin when it ad- heres or sticks to the bed linen and the Shearing Force skin layers slide in the direction of body movement. Two surfaces rubbing against each other: Friction Sheet and skin when pulling a patient up in bed. Moisture Excessive diaphoresis, urine, stool. Pressure Ulcers are graded and staged according to the deepest area of tissue Pressure Ulcer Staging damage, from Stage 1 (minor) to Stage 4 (severe). Appearance: Stringy, yellow texture; Slough dead tissue, a vascular. Black/brown necrotic tissue; a vascular; Eschar biologic cover. Intact skin with non-blanchable redness; possible indicators include skin tempera- ture, tissue consistency, pain. 2/7 Understanding Pressure Injuries and Wound Healing Study online at https://quizlet.com/_g55869 Stage 1 Pressure Ulcer Partial-thickness loss of dermis; shal- low open ulcer with red pink wound bed; presents as an intact or ruptured serum-filled blister. Stage 2 Pressure Ulcer Full-thickness skin loss involving dam- age or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia; the wound color in- cludes yellow. Stage 3 Pressure Ulcer Full-thickness loss can extend to mus- cle, bone, or supporting structures; bone, Stage 4 Pressure Ulcer tendon, or muscle may be visible or pal- pable. 3/7  Understanding Pressure Injuries and Wound Healing Study online at https://quizlet.com/_g55869 Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar; the depth and stage can- not be determined until the slough and eschar are removed. Unstageable Pressure Ulcer Signs/Symptoms include leukocytosis, fever, increased ulcer size, odor, or drainage, necrotic tissue, and pain. Clinical Manifestations of Wound Infec- tion Untreated ulcers may lead to cellulitis, chronic infection, sepsis, and possibly death Total Score of 23 possible; 18 or less Braden Scale Total Score indicates High Risk for skin breakdown. Look for areas of skin darker than sur- Tissue Injury in patients with deep pig- rounding skin; may appear with red, blue, mentation or purple hues in darker skin tones. Assess skin temperature using your Skin Temperature Assessment hand; an ulceration may feel warm initial- ly, then become cooler. Impaired Skin Integrity related to skin Nursing Problem breakdown secondary to pressure ulcer, 4/7  Understanding Pressure Injuries and Wound Healing Study online at https://quizlet.com/_g55869 as evidenced by pressure sore on the sacrum. Risk for impaired skin integrity related Risk for Impaired Skin Integrity to immobility as evidenced by prolonged sitting. Impaired Skin Integrity Skin infection evidenced by open sore. Bone infection from bloodstream or near- Osteomyelitis by tissue. Nutritional Deficiencies Lack of nutrients impairs tissue healing. Inhibit inflammatory response, impair Corticosteroid Drugs healing. Elevated blood glucose increases infec- Diabetes Mellitus tion risk. Reduced oxygen delivery to cells and Anemia tissues. Wound Care Prevent infection and promote healing. Reduce pressure on vulnerable skin ar- Pressure Relief eas. Removal of necrotic tissue from wounds. Debridement Methods include: Surgical, Mechanical, Enzymatic, Autolytic Removal of necrotic tissue or eschar by Surgical Debridement using a scalpel, scissors, or other sharp instrument wet to dry or moist dressings with gauze Mechanical Debridement moisten with NS allowed to almost dry and then it is removed topically applied drug to dissolve necrotic Enzymatic Debridement tissue contains collagenase and papain and urea (Panafil or Gladase or Elase) occlusive dressings used to soften dry autolytic debridement eschar by autolysis (Aquacel, Comfeel, DuoDerm, Tegasorb) 5/7  Understanding Pressure Injuries and Wound Healing Study online at https://quizlet.com/_g55869 Wound healing with neatly approximated Primary Intention edges. Healing with extensive tissue loss and Secondary Intention exudate. Delayed suturing after infection resolu- Tertiary Intention tion. Issues like dehiscence and hypertrophic Complications of Healing scars. Bursting open of a wound, especially a Dehiscence surgical abdominal wound The displacement of organs outside of Evisceration the body. · Infection: starts to occur 3-5 days after, Post-Op Infection s/s swelling, redness, purulent drainage Excess production of scar tissue that is localized to the wound Hypertrophic Scar thick raised scars caused by excessive amounts of collagen tumor like mass Keloid Scars Measured in centimeters: length, width, Wound Measurements depth. Suction removes drainage, speeds heal- Negative-Pressure Wound Therapy ing. 6/7 Understanding Pressure Injuries and Wound Healing Study online at https://quizlet.com/_g55869 Identifies organisms for effective antibiot- Culture and Sensitivity ic treatment. rotating a culture swab over a cleansed 1-cm2 area near the center of the wound, using sufficient pressure to ex- Levine's Technique tract wound fluid from deep tissue layers Method for obtaining wound culture sam- ples. Concerns about scars and odor during Psychological Implications care. Increased calories and protein for heal- Caloric Intake ing. Enteral Feedings Nutritional support via feeding tubes. Moist Wound Healing Keeps ulcer bed moist for better healing. Skin Care Prevention Avoid moisture and pressure on skin. Use pillows and protectors to relieve Positioning Devices pressure. Daily Weight Monitoring Track weight to assess nutritional status. Includes regeneration and repair of tis- Healing Process sues. Initial, granulation, maturation phases of Healing Stages healing. Exudate Management Control drainage to promote healing. Wider at the base than the surface of the Undermining Wound wound Tunneling Wound Track underneath the skin. Tunnel like 7/7