Wound Management SLO - Week 4 PDF

SLO- Wound Management Di erentiate between di erent types of wounds and be able to describe the pressure injury classi cation stages. Two major types: ◦ Open wound: skin is split, incise or cracked, and the underlying tissue are exposed to the outside environment. ◦ Closed wound: skin is intact, but...

SLO- Wound Management Di erentiate between di erent types of wounds and be able to describe the pressure injury classi cation stages. Two major types: ◦ Open wound: skin is split, incise or cracked, and the underlying tissue are exposed to the outside environment. ◦ Closed wound: skin is intact, but underlying tissue may be damaged. ‣ Ex: contusion, hematoma, stage 1 pressure injury. Wound Classi cation: ◦ Acute: wound that proceeds through an orderly and timely, reparative process that results in sustained restoration of anatomical and functional integrity. ‣ Causes: surgical incision, trauma ◦ Chronic: wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity. ‣ Causes: vascular compromise, chronic in ammation, repetitive insults to tissue Classi cation stages of pressure injury: ◦ Stage 1: intact skin with a localized area of nonblanchable erythema, which may appear di erently in darkly pigmented skin ‣ Presence of blanchable erythema or changes in sensation, temperature, or rmness may precede visual changes. Color changes do not include purple or maroon discoloration. ◦ Stage 2: partial-thickness skin loss with exposed dermis ‣ Partial-thickness of loss of skin with exposed dermis. ‣ The wound bed is viable, pink or red, and moist and may also present as an intact or ruptured serum- lled blister. ‣ Adipose tissue is not visible, and deeper tissues, granulation tissue, slough, and eschar are not visible. ◦ Stage 3: full-thickness skin loss. ‣ Full-thickness loss of skin, in which adipose tissue is visible in the ulcer and granulation tissue and epibole (round wound edges) are often present. ‣ Slough and/or eschar may be visible. ‣ Undermining and tunneling may occur. ‣ Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. ‣ If slough or eschar obscures the extent of tissue loss, this is classi ed as an unstageable pressure injury. ◦ Stage 4: full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon,, ligament, cartilage, or bone in the ulcer. ‣ Slough and/or eschar may be visible. ‣ Epibole, undermining, and/or tunneling often occurs. ‣ If slough or eschar obscures the extent of tissue loss, this is classi ed as an unstageable pressure injury. ◦ Unstageable pressure injury: ‣ Obscured full-thickness skin and tissue loss. ‣ Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be con rmed because it is obscured by slough or eschar. ‣ If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. ◦ Deep-tissue pressure injury: ‣ Intact or non-intact skin with localized area of persistent nonblanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood- lled blister. ‣ Pain and temperature change often precede skin color changes. ‣ This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. ‣ The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. Utilizes the nursing process to assess, identify major nursing diagnosis, plan, implement, and evaluate care for a client experiencing pressure injury. ◦ Assessment: ‣ Admission: thorough head-to-toe to identify and document any pressure injuries present. ‣ Asses with every dressing change ‣ Periodic reassessment per facility ‣ Pressure ulcer scale for healing (PUSH) ‣ Size, Location, Wound base, Drainage, Margins, Palpation (lightly press wound edges to check for tenderness and drainage collection. ‣ Tunneling vs Undermining ‣ Wound Cultures: never collect sample from old drainage and cultures must be obtained before starting antibiotics. ◦ Assessing patients with dark skin: ‣ look for areas of skin darker (purplish, brownish, bluish) than surrounding skin. ‣ Use natural or halogen light for accurate assessment ‣ Assess skin temperature using the back of your hand. ‣ Ask about pain or an itchy sensation. ◦ Nursing Diagnosis: ‣ Risk for infection ‣ Acute or chronic pain ‣ Impaired mobility ‣ Impaired peripheral tissue perfusion ‣ Impaired tissue integrity ◦ Planning: ‣ no wound deterioration ‣ no infection development within the pressure injury ‣ promote wound healing ‣ no recurrence ‣ Interventions based on severity and stage of pressure injury along with existing complications. ◦ Implementation: ‣ Wound care: Dressings: dependent on stage, tissue and dressing function. Debridement Wound vacuum-assisted closure (VAC) ‣ Inter-professional expertise: Wound-care nurse Physical/occupational therapist Nutritionis Pharmacist ◦ Evaluation: ‣ Pressure injury healing with restoration to skin integrity ‣ No further breakdown of intact skin ‣ Patient response to nursing therapies ‣ Did we meet the goals for this patient? Comprehension of the healing process. Partial-thickness wound repair: there are 3 components. ◦ In ammatory response: ‣ Causes redness and swelling to the area with a moderate amount of serous exudate. ‣ This response generally is limited to the rst 24 hours after wounding. ‣ The epithelial cells begin to regenerate, providing new cells to replace the lost cells. ◦ Epithelial proliferation (reproduction) and migration: ‣ It starts at both the wound edges and the epidermal cells lining the epidermal appendages, allowing for quick resurfacing. ‣ Epithelial cells begin to migrate across a wound bed soon after the wound occurs. ◦ Reestablishment of the epidermal layers: ‣ The cells slowly reestablish normal thickness and appear as dry pink tissue. Full-thickness wound repair: there are 4 phases involved. ◦ Hemostasis phases: ‣ Controls blood loss, establish bacterial control, and seal the defect that occurs when there is an injury. ‣ During this phase, injured blood vessels constricts and platelets gather to stop bleeding. ‣ Clots form a brin matrix that later provides a framework for cellular repair. ◦ In ammatory phases: ‣ In this phase, damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and movement or migration of serum and white blood cells (WBCs) into the damaged tissues. ‣ Leukocytes (WBCs) reach a wound within a few hours. The primary-acting WBC is the neutrophil, which begins to ingest bacteria and small debris. ‣ Monocyte (second leukocytes), these cells transform into macrophages. The macrophages are the “garbage cells” that clean a wound of bacteria, dead cells, and debris by phagocytosis. ‣ Collagen appears as early as the second day, and is the main component of scar tissue. ‣ Establishes a clean wound bed ◦ Proliferation phase: (new tissue formation) ‣ This phase begins 3 to 4 days after injury and can last as long as 2 weeks. ‣ The main activities during this phase are the lling of a wound with granulation tissue, wound contraction, and wound resurfacing by means of epithelialization. ‣ Fibroblasts are present in this phase and are the cells that synthesize collagen, providing the matrix for granulation. ‣ Collagen provides strength and structural integrity to a wound. ‣ During this phase, a wound contracts to reduce the area that requires healing. ‣ Finally, the epithelial cells migrate from the wound edges to resurface. ‣ Vascular bed is reestablished (granulation tissue), area is lled with replacement tissue *collagen, contraction, granulation), surface is repaired (epithelialization) ◦ Maturation: (remodeling): ‣ This phase begins several weeks after injury and continues for more than a year. ‣ The collagen scar continues to reorganize and gain strength for several months. ‣ Collagen bers undergo remodeling or reorganization before assuming their normal appearance. Discuss complications of healing. ◦ Hemorrhage: bleeding from a wound site, is normal during and immediately after initial trauma. ‣ Hemorrhage occurring after hemostasis indicates a dislodged surgical suture, a clot, infection, or erosion of a blood vessel by a foreign object (ex: drain) ‣ You detect internal hemorrhaging by looking for distention or swelling of the a ected body part, a change in the type and amount of drainage from a surgical drain, or signs of hypovolemic shock. A hematoma is a localized collection of blood underneath the tissues. ‣ External hemorrhaging is obvious. ◦ Infection: one of the most common health careassociated infections. ‣ Wound infection develops when microorganisms invade the wound tissues. ‣ The local signs of wound infection include erythema; increased amount of wound drainage; change in appearance of a wound drainage (thick color change, presence of odor); and peri wound warmth, pain, or edema. ‣ Some contaminated or traumatic wounds show signs of infection early, within 2-3 days. ‣ SSIs occur within 30 days of surgery; risk factors include hyperglycemia, smoking, untreated peripheral vascular disease, cancer, obesity, age, and emergency and abdominal surgery. ‣ If an SSI occurs, the patient will have a fever, tenderness, and pain at the wound site and an elevated WBC count. ◦ Dehiscence: when a surgical incision fails to heal properly, the layers of skin and tissue separate. ‣ This usually occurs before collagen formation. ‣ A patient who is at risk for poor wound healing (ex. Poor nutritional status, infection, or underlying diseases such as diabetes mellitus or peripheral vascular disease. ‣ Half of dehiscence occurrences are associated with wound infection. ‣ It can also occur if a person is obese and patients with abdominal surgical wounds. ◦ Evisceration: occurs with the total separation of wound layers, and protrusion of visceral organs through wound opening. ‣ When evisceration occurs, place sterile gauze soaked in sterile saline over the extruding tissues to reduce chances of bacterial invasion and dying of the tissues. ‣ If the organs protrude through the wound, blood supply to the tissues can be compromised. ‣ When this happens, contact surgical team, make patient NPO and prepare for emergency surgery. Discuss collaborative and nursing management for clients with wound and or pressure injury to include various dressing and treatments for wounds. ◦ Health care team: ‣ RN ‣ WOC Nurse ‣ Plastic surgeon ‣ Dietician ‣ Physical therapist ‣ Occupational therapist Understand the local and systemic clinical manifestations of in ammation. ◦ Local manifestation: ‣ pain ‣ redness ‣ swelling ‣ heat ‣ pain ◦ Systemic manifestation: ‣ Fever ‣ Headache ‣ Fatigue ‣ Increased heart rate ‣ Increased respiration ‣ Increased WBC