Nursing Theory A2

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bhe2xjo
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Nursing Theory A2
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2013-01-25 02:38:59
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Nursing Theory A2
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Nursing Theory A2- Integumentary and Wound
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  1. Skin
    • Largest organ of the body
    • 1/6 of total body weight
    • 3 layers (epidermis, dermis, subcutaneous tissue)
    • Open or closed
    • Infant skin structurally the same but not as functionally developed
    • Elderly have structural and functional changes
  2. Skin Injuries
    • Abrasion (superficial damage to the skin)
    • Laceration (open wound)
    • Puncture
    • Penetrating
    • Incision
    • Hematoma
    • Contusion/bruising
    • Ulcer/wound
  3. Wound Types/Etiologies
    • Cancer
    • Trauma (injury is a physiological wound caused by an external source)
    • Burns
    • Pilonidal cysts (often contains hair and skin debris)
    • Abscess (collection of pus in any part of the body)
    • Skin tears
    • Surgery
    • Pressure, friction and shear
    • Diabetes Arterial disease
    • Venous insufficiency (condition in which the veins have problems sending blood from the legs back to the heart)
    • Mixed vascular disease
  4. Phases of wound healing: Hemostasis
    • Constriction of blood vessels
    • Clot formation
  5. Phases of wound healing: Inflammation
    • Increase vascular permeability
    • WBC phagocytosis
  6. Phases of wound healing: Proliferation (Regeneration)
    • Filling/coverage of wound bed
    • New blood vessels
  7. Phases of wound healing: Maturation (remodeling)
    Collagen forms, make take 1 year to complete depending on depth/extent of wound
  8. Healing Process/Types of wound closures:Primary
    • Intentional
    • Wound that is closed
    • No tissue loss
    • Edges well approximated
    • Cause: Surgical incision, wound that is sutured or stapled
    • Implications for Healing: healing occurs by epithelialization;heals quickly with minimal scar formation
  9. Healing Process/Types of wound closures: Secondary
    • Not intentional
    • Tissue loss
    • Edges not well approximated
    • Wound heals from bottom up
    • Cause: pressure ulcers, surgical wounds that have tissue loss
    • Implications for healing: Wound heals by granulation tissue formation, wound contraction and epithelialization
  10. Healing Process/Types of wound closures: Tertiary
    • Intentional or not intentional
    • Wound left open and to be sutured at a later date
    • High risk for scarring
    • Cause: Wound that contaminated and required observation for signs of inflammation
    • Implications for healing: Closure of wound is delayed until risk of infection is resolved
  11. Factors affecting wound healing:
    • Age
    • Nutritional Status
    • Mobility
    • Comorbidities
    • Oxygenation
    • Smoking
    • Infection
    • Medications
    • Obesity
    • Wound stress
  12. Principles of wound management:
    • Conduct a comprehensive wound assessment
    • Cleanse the wound
    • Remove necrotic debris
    • Fill the dead space
    • Manage exudate
    • Maintain a moist wound environment
    • Provide thermal insulation
    • Identify and treat Infection
    • Protect the healing wound
  13. Guidelines for Staging Pressure Ulcers: Suspected Deep Tissues Injury
    Purple or maroon localized area of discolored intact skin or blood-field blister due to drainage of underlying soft tissue from pressure or shear or both.

    • The are may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue


  14. Guidelines for Staging Pressure Ulcers: Stage 1
    • Intact skin with nonblanchable redness of a localized area usually over a bony prominence.
    • Darkly pigmented skin may not have visible blanching - its colour maybe differ from the surrounding area
  15. Guidelines for Staging Pressure Ulcers: Stage II
    • Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.
    • May also present as intact or an open ruptured serum-filled blister
  16. Guidelines for Staging Pressure Ulcers: Stage III
    • Full thickness tissue loss
    • Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed
  17. Guidelines for Staging Pressure Ulcers: Stage IV
    • Full thickness tissue loss with exposed bone, tendon, or muscle.
    • Slough or eschar may be  present on some parts of the wound bed
    • Often includes undermining and tunnelling
  18. Guidelines for Staging Pressure Ulcers: Unstageable
    • Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, grey or brown) or eschar ( tan, brown, or black) or both, in the wound bed.
  19. Wound Complications:Infection
    Commonly by staphylococcus aureus
  20. Wound Complications:Dehiscence
    Disruption of incisional edges
  21. Wound Complications:Evisceration
    Protrusion of internal contents/ structures
  22. Wound Complications:Scarring
    Related to poor healing and tertiary closure
  23. The assessment of tissue type includes:
    • Amount (%)
    • Appearance (colour) of viable or non-viable tissue
  24. Skin Assessment
    • Colour
    • Moisture
    • Texture& thickness
    • Temperature
    • Turgor
    • Mobility
    • Vascularity and edema
    • Lesions/rashes
  25. Describe changes and assessment findings in the skin for the older adult
    • Changes:
    • Decrease subcutaneous fat, muscle laxity, degeneration of elastic fiber, collagen stiffening
    • Decrease extracellular water, surface lipids, and sebaceous gland activity
    • Increase capillary fragility and permeability
    • Increased melanocytes in basal layer with pigment accumulation
    • Diminished blood supply
    • Assessment Findings:
    • Increased wrinkling, sagging breast and abdomen
    • Redundant flesh around eyes
    • Slowness of skin to flatten when pinched
    • Dry to no perspiration
    • flaking
    • uneven skin colour
    • evidence of bruising
    • Decrease rosy appearance of skin and mucous membrane
    • skin is cool to touch
    • diminished awareness of pain, touch, temperature and peripheral vibration
    • Diminished rate of wound healing
  26. Hair & scalp Assessment
    • Colour
    • Texture
    • Distribution
    • Lubrication
    • Lesions
    • Pest inhabitants
  27. Describe changes and assessment findings in the hair for the older adult
    • Changes:
    • Decreased melanin and melanocyte
    • Decreased oil
    • Decrease density of hair
    • Cumulative androgen effect;
    • decreasing estrogen leves
    • Assessment Findings:
    • Grey or white hair
    • Dry
    • coarse
    • scaly scalp
    • Thinning and loss of hair
    • facial hirsutism
    • baldness
  28. Nail Assessment
    • Shape/contour
    • Thickness
    • Colour
    • Capillary refill
    • Cuticles
    • cleanliness
  29. Describe changes and assessment findings in the Nails for the older adult
    • Changes:
    • Decreased peripheral blood supply
    • Increase keratin
    • Decreased circulation
    • Assessment Findings:
    • Thick
    • brittle nails with diminished growth
    • longitudinal ridging
    • Prolonged return of blood to nails on blanching
  30. Wound Assessment
    • Size - Length, width, depth, tunneling,
    • undermining
    • Base - Granular, necrotic, bone, muscle, tendon
    • Drainage - Serous, serosanguineous, sanguineous, purulent, (colour, amount, consistency)
    • Odour - Foul, sweet, pungent
    • Edges - Smooth, defined, jagged, unattached
    • Periwound - Intact, colour, moisture, texture
    • Pain - Scale 1-10, quality, intensity, onset,
    • location, duration, aggravating/alleviating factors
  31. Terms Used in Wound Care
    • Partial thickness - Depth of wound into dermis/epidermis
    • Full thickness - Depth of wound into subcutaneous tissue
    • Acute - Has normal predictable/timely healing
    • Chronic - Failed to progress through sequence of repair-not restored structure & function
    • Eschar - Black/ brown dry adherent necrotic tissue
    • Slough - Yellow or white wet stringy/loose tissue
    • Granulation - Red-pink connective tissue on wound base
    • Epithelialization - Epithelial cell formation/migration-wound edge contraction
    • Maceration - White wrinkled skin from excessive moisture
    • Induration - Increased firmness of tissue
    • Erythema - Redness of skin due to inflammation, injury
    • Hyperkeratosis - Thickening of skin- callous formation
    • Hemosiderin Staining - Discoloration due to release of iron containing pigment from disintegration of red blood cells- indicator of venous disease
    • Lipodermato- sclerosis - Thickening of tissues under the skin of the leg resulting in hard, woody texture
  32. Surgical asepsis (sterile technique)
    • Used to eliminate all micro-organisms from an object or area.
    • When working with a sterile field or with sterile equipment, any break in technique results in contamination.
  33. Principles of Medical Asepsis
    • Use practices of personal grooming
    • Wash hands frequently
    • Keep soiled items and equipment from touching clothing
    • Do not place soiled linen or other items on the floor
    • Clean least soiled areas first (clean to dirty)
    • Dispose of soiled or used items in appropriate containers
    • Avoid leaning against equipment or touching eyes, nose, mouth after immediate use
  34. Principles of Surgical Asepsis
    • All objects used in or over a sterile field must be sterile
    • Sterile items out of vision or below the waist level are considered unsterile
    • Sterile objects become unsterile by prolonged airborne exposure
    • Sterile objects become contaminated when touched by unsterile objects
  35. Types of Wound Care Products: Wound Hydration
    Hydrogels (intrasite, duoderm gel)
  36. Types of Wound Care Products: Moisture Retention
    • Hydrocolloids (duoderm)
    • Films (Tegaderm)
  37. Types of Wound Care Products: Exudate Management
    • Calcium alginates (kaltostat, Seasorb/Ag)
    • Hydro fibers (Aquacel plain/Ag)
    • Foams (mepilex with/without border)
  38. Types of Wound Care Products: Odour Management
    • Charcoal (Carboflex)
    • antifungal powders (Tinactin, Flagyl)
  39. Types of Wound Care Products: Antimicrobials
    • Silvers (acticoat, actisorb, silver nitrate)
    • Cadexomer iodine (iodosorb)
    • AMG products
  40. Types of Wound Care Products: Non Adherent Layers
    • Vaseline gauze (bactigras, adaptic)
    • Telfa, restore/Ag
  41. Types of Wound Care Products: Non-Adherent Layers
    Restore/Ag, vaseline gauze, telfa
  42. Types of Wound Care Products: Other Specialty Products
    • Compression (coban, comprilan, tubigrip)
    • growth factors (promogran, prisma)
    • Grafting (oasis)
    • Hypertonic (mesalt)
    • Negative Pressure Wound Therapy (VAC)
  43. Impact Of Chronic Wounds
    • Quality of life - Often lengthy healing time!
    • Discomfort
    • Restricts normal activity 
    • Altered body image
    • Odour  
    • Cost
    • Increased cost: mean hospital costs and length of stay increase when an ulcer
    • develops
    • Estimated $9000/month to treat in the community (RNAO)
  44. Wound Measurements
    • Surface Area = Length x Width
    • Length = the longest axis of the wound
    • Width = 90 ° to the length at the next
    • longest axis
    • Depth: Use Q-tip to measure deepest area of wound to skin surface
  45. Cleaning The Wound: IRRIGATION
    Wound irrigation = using wound cleansing solution with a small amount of pressure (4-15 psi, FYI only) to decrease the amount of bacteria and to remove debris (dead tissue, dressing fibers, metabolic waste, etc.) from the wound bed.
  46. Debridement
    • Allows visualization of the wound bed, to assess depth and structures involved.
    • Five types of debridement:
    • 1.Surgical debridement
    • 2.Mechanical debridement
    • 3.Autolytic debridement
    • 4.Enzymatic debridement
    • 5.Biological debridement
  47. Debridement: Surgical
    • When the non-viable tissue is cut away by using a scalpel, scissors, or other sharp instrument
    • Quickest method of debridement
    • Indicated when large amount of non-viable tissue are present and client is septic
    • Risks:  Causes bleeding, has potential to cause injury to nervous or other viable tissue
    • Subcutaneous debridement is a controlled act that must be carried out by a physician or delegate.
  48. Debridement: Mechanical
    • Physical force to remove dead tissue.
    • Includes: wet-to-dry dressings, high pressure irrigation, and whirlpool  treatments.In wet-to-dry dressings, the nurse places a saline moistened gauze in the wound bed and allowed to dry thoroughly. When the dry dressing is removed, necrotic tissue is removed but so is viable tissue. It should never be used in a clean, granulating wound.  It is also a very painful procedure.(medicate!)
    • All types of mechanical debridement are slow, painful, and non-selective in type of tissue removed.
  49. Debridement: Autolytic
    • Uses the body's own enzymes and moisture to re-hydrate, soften and finally liquefy hard eschar and slough.
    • Advantages:
    • Very selective – only necrotic tissue is liquified. 
    • The process is safe
    • Effective,versatile and easy to perform
    • Little to no pain for the patient
    • Disadvantages:
    • Slowest method
    • Wound must be monitored closely for signs of infection. 
    • May promote anaerobic growth if an occlusive hydrocolloid is used
  50. Debridement: Enzymatic
    • Addition of chemical enzymes to the wound bed that breaks down tissue. Some enzymatic debriders are selective (i.e. removes only dead tissue), while some are not (i.e. removes dead and healthy tissue).
    • Advantages:
    • Useful on wounds with a large amount of necrotic debris that is not appropriate for
    • surgical debridement
    • Fast acting
    • Selective: Minimal or no damage to healthy tissue with proper application only to necrotic tissue.
    • Disadvantages:
    • May cause temporary increase in exudate from wound
    • žRequires a prescription.  (Expensive)
    • Inflammation or discomfort may occur
  51. Debridement: Biological
    • Maggot Debridement Therapy (MDT) is the medical use of live maggots (only greenbottle fly larvae) for treating non-healing wounds.
    • Disinfected fly larvae are applied to the wound for 2 or 3 days within special dressings to keep them from migrating. 
    • Actions on the wound:
    • 1.They clean the wounds by eating dead and infected tissue ("debridement");
    • 2.They disinfect the wound (kill bacteria);
    • 3.Thus,they speed the rate of healing.
  52. Wound Culture
    • Sterile technique is used with a culturette tube to obtain pathogens in an infected wound
    • Requires a doctor’s order –wound C&S
    • Never collect from old drainage!
    • Cleanse wound first with normal saline
    • Obtain specimen from the healthiest looking tissue.
    • Tubes: aerobic for surface wounds and anaerobic if within body cavities
  53. Wound packing
    • Definitionfilling a wound with a dressing material to promote granulation tissue by secondary intention through the elimination of “dead space”.
    • žMany materials, such as alginates, foams, hydrocolloids,  anti-microbials or gauze, can be used to pack wounds.  (P&P,Table 47-9)
    • When dead space (eg/tunnelling) is NOT filled with packing material, it allows debris to accumulate, which can lead to further abscess development
  54. Packing Wounds Procedure
    • Packing a wound is a sterile procedure!
    • Initially,same procedure as for dry dressing.  Upon removal of old packing, assess for amount and type of exudate, assess wound and periwound.
    • Perform hand hygiene, apply sterile gloves, cleanse or irrigate per order.
    • If packing with alginate, hydrocolloid or foam dressings:
    • Cover wound base and fill tunnel with dry dressing. Add additional layers for deep wound if necessary.  (Follow pkg directions)
    • Wound exodate moistens dressing to maintain moist wound  bed.
    • Will need additional moisture if wound bed dry (eg/ hydrogel)
    • žIf packing with gauze:
    • Lightly moistened gauze packing with prescribed solution, wring out excess (moist like your eyeball)
    • Unfold and place on wound bed and inside tunnels one layer at a time  (“fluffed”) until all surfaces are covered. 
    • Material is held above the wound and not
    • allowed to come into contact with skin surface prior to insertion into the wound bed.
    • Gently pack! Packing should not extend higher than wound surface.  If pressure is too firm, it will prohibit formation of new  granulation tissue
    • Do NOT cover periwound.  (causes maceration)
    • Packing material is secured with dry gauze, abd pads if drainage is moderate. Some special dressing materials require special outer covering, read directions.
    • Tape or ties, adhesive soft covering (mefix, hypofix) can be used depending on the size and location of wound.
    • Type of dressing and packing material selected will depend on stage of ulcer, wound bed, and goal of therapy.  Also, it will change as wound bed changes (heals or worsens).
  55. Types of Drains
    • Penrose drain - Passive drain with a pin or clip placed through the drain to prevent it from slipping into the wound
    • Jackson Pratt & Hemovac - Active drains that create self suction when suction device (bladder or bag) is fully compressed
  56. Drain Assessment & Care
    • Type of drain, number of drains and drain placement
    • Security of the drain and condition of the collecting apparatus
    • Type and amount of drainage
    • Empty daily and document output
    • Daily drain cleansing with dry dressing (drain sponges)
  57. Suture
    • Sutures are threads used to sew body tissues together.
    • They can be made of silk, steel, cotton, linen, wire, nylon and Dacron.
  58. Suture Types
    • Intermittent suturing - is done when each individual suture is tied.
    • Continuous suturing and blanket
    • suturing - are a series of sutures with only two knots, one at the beginning and one at the end.
    • Steel staples - are commonly used as they cause less trauma and provide extra strength.
  59. Wound repair: Partial thickness
    • Are shallow wounds involving loss of the epidermis and possible partial loss of the dermis
    • healing process: inflammatory response, epithelial proliferation(reproduction), migration and establishment of epidermal layer.
    • Inflammatory response - cause redness and swelling and moderate amount of serous membrane. Limited to first 24 hours after wounding
    • Epithelial proliferation(reproduction) and  migration - starts at both the wound edges and the epithelial cell lining  which allow quick surfacing
    • Wound left open to air can resurface = 6 to 7 days
    • Wound that is kept moist can resurface = 4 days
  60. Wound repair: Full- thickness
    • Healing process: Inflammatory, proliferation and remodeling phases are involve in the
    • Inflammatory - body's reaction to wound.
    • Beginning within minutes of injury and lasting approximately 3 days
  61. Damages tissue and mast cells secrete:
    Histamine - Result in vasodilation of surrounding capillaries and exudation of serum and white blood cells into damage tissue

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