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What are the different wound classifications (also include pressure ulcers)?
- Onset & Duration-
- Acute: wound that proceeds through an orderly & timely healing process that results in sustained healing and function
- Chronic: wound that fails to proceed through orderly & timely healing process
- Healing Process-
- Primary Intention: wound that is closed; wound edges approximated; surgical incision heals by primary intention
- Secondary Intention: wound edges not approximated; eg pressure ulcers, burns & severe lacerations
- Tertiary Intention: wound left open for several days, then wound edges are approximated; contaminated wounds require observation for signs of infection
Stages of Pressure Ulcers
- Stage I:
- -intact skin with nonblanchable redness of a localized area, usually over a bony prominence
- -Changes may include:
- Skin temperature
- Tissue Consistency
- Stage II: Partial thickness skin lossInvolves epidermis, dermis or bothUlcer is SUPERFICIALPresents clinically as an abrasion, blister or SHALLOW crater
- No slough or bruising
- Stage III: Full thickness skin loss
- Involves damage to or necrosis of subcutaneous tissueMay extend down to, but NOT through underlying fascia
- Presents clinically as a DEEP crater
- Bone or tendon not visible or directly palpable
- Stage IV: Full thickness skin loss
- involves EXTENSIVE destruction, tissue necrosis or damage to muscle, bone, or supporting structures
- UNDERMINING and sinus tracts may be presentOften includes undermining or tunneling
- Base of wound cannot be visualized
- Depth of injury unknown
- Full-thickness tissue loss but depth is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in wound bed
What are the psychological processes involved in would healing?
- 1. pain
- 2. anxiety/fear
- 3. changes in body image
What kind of assessment information do you document for wound healing?
- Focus on specific element of pts level of
- Sensation: look for decreased feeling in extremity or any region; sensitivity t heat or cold
- Movement: are there physical limitations, injury or paralysis; can pt change position easily; is movement painful
- Continence status: any involuntary loss or urine or stool; what assistance is needed in toileting; how often does pt need toilet, day and night
- Presence of wound: what caused it; when? Last tetanus; healing process; tx; any associated symptoms eg pain,tenderness, itching; goal for pt
What are the various factors that can affect wound healing?
- Tissue perfusion
- Mechanism of onset
- Time since onset
- Wound location
- Wound dimensions
- Wound hydration
- Necrotic tissue or foreign bodies
- Alcohol abuse
What are the complications of wound healing?
- -Hemorrhage and hematoma
- -Swelling and edema
- -Tissue necrosis
- -Scarring and contracture
- -Draining tracts
- -Exposed bone
- -Non-healing wounds
What are signs of wound infection?
- Pain at wound site
- Elevated WBC count
- Edges of wound appear inflamed
- Drainage is odorous and purulent (yellow, green or brown)
How do you perform a wound culture?
- Needle aspiration:
- Clean intact skin with disinfectant; let dry
- Use 10 mL disposable syringe with 22-gauge needle, pulling 0.5 mL of air into syringe
- Insert needle through intact skin next to wound; withdraw plunger and apply suction to 10 mL mark
- Move needle back and forward at different angles for two to four explorations
- Remove needle, expel excess air and cap and prepare syringe for lab
- Quantitative Swab procedure:
- Clean wound surface with nonantiseptic solution
- Use sterile swab from culturette tube
- Moisten the swab with normal saline
- Rotate swab in 1 cm2 (0.4 in2) of clean tissue in open wound
- Apply pressure to swab to elicit tissue fluidInsert tip of swab into appropriate sterile container, label and transport to lab
What is a nosocomial infection?
Health care acquired infection
What are the differences between applications of heat and cold therapy?
- Heat: therapeutic, improving blood flow to injured part. But if heat is applied for 1 hr or more body reduces blood flow by reflex vasoconstriction to control heat loss from area. Periodic removal and reapplication of local heat restores vasodilatin. Continuous exposure to heat damages epithelial cells causing redness, localize tenderness and even blisters
- Cold: initially diminishes swelling and pain. Prolonged exposure on skin results in reflex vasoilation. Inability of cells to receive adequate blood flow and nutrients results in tissue ischemia. Skin initially looks red, then bluish-purple mottling with numbness and burning pain occurs. Skin tissue freezes in extreme cold.
What safety factors must be considered and documented regarding application of heat or cold therapy?
- Do explain to patient sensations to be felt during procedure.
- Do instruct patient to report changes in sensation or discomfort immediately.
- Do provide a timer, clock, or watch so patient can help the nurse time the application.
- Do keep the call light within patients reach.
- Do refer to the policy and procedure manual of the institution for safe temperatures.
- Do not allow patient to change temperature.
- Do not allow patient to move an application or place hands on the wound site.
- Do not place patient in a position that prevents movement away from the temperature source.
- Do not leave unattended a patient who is unable to sense temperature changes or move from the temperature source.
- (Page 1211)
What factors would you consider to determine the application of moist vs. dry therapies?
- Consider the type of wound or injury, location, presence of drainage or inflammation
- Moist Advantages: reduces drying of skin and softens wound exudate, conforms well to body area being treated, penetrates deeply into tissue layers, lessens sweating and insensible fluid loss
- Moist Disadvantages: can cause maceration of the skin with prolonged exposure, cools rapidly because of moisture evaporation, creates greater risk for burns to skin because moisture conducts heat
- Dry Advantages: less likely to burn skin, does not cause skin maceration, retains temperature longer because not influenced by evaporation
- Dry Disadvantages: increases body fluid loss through sweating, does not penetrate deep into tissue, causes increased drying of skin
Heat vs. cold therapies?
- Indications for the use of heat therapy: inflammation, pain, joint stiffness, muscle spasms
- Positive effects of local heat therapy: increased blood flow, acceleration of the inflammatory process, promotion of soft tissue healing
- Indications for the use of cold therapy: traumatic injury, inflammation, muscle spasms, pain
- Positive effects of local cold therapy: vasoconstriction, helps to control bleeding, decreases swelling and inflammation, and pain after acute injury, decrease chronic pain in joints
What nursing diagnoses are used to describe skin integrity impairments?
- Risk for infection
- Imbalanced nutrition: less than body requirements
- Acute or chronic pain
- Impaired skin integrity
- Risk for impaired skin integrity
- Ineffective peripheral tissue perfusion
- Impaired tissue integrity
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