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Abnormal Reactive Hyperemia
excessive vasodilatation and induration (edema) in response to pressure. Skin appears bright pink-red. Lasts 1 hour to 2 weeks
a scraping away of the surface of the skin by friction
when skin edges are closed together in a wound
a water flow pad used for treating muscle sprains and areas of mild edema
- bandages that are made of large pieces of material to fit a specific body part
- most are made of elastic or cotton
- ex. breast binder or abdominal binder
the absence of normal red tones, to become pale
weakness and wasting of the body due to severe chronic illness
Capillary Closing Pressure
the amount of pressure it takes to close off the flow of the capillary, thus causing a lack of oxygen and blood to the area
a tough fibrous protein that forms tendons, ligaments and fascia
a pad of absorbent material pressed into part of the body to relieve inflammation or to stop bleeding
the removal of necrotic tissue so healthy tissue can regenerate
the removal of damaged tissue or foreign objects found in a wound
the partial or total separation of wound layers
the sloughing of dead skin cells
to become covered with epithelial tissue
a scab or dry crust that results from the death of skin
protrusion of visceral organs through a wound opening
the protein responsible for clotting
a cell in the CT that produces collagen and other fibers
the abnormal passage between two organs or between and organ and the outside of the body
the resistance that one surface encounters when moving over another
localized buildup of blood under tissue
connective tissue that forms during the healing process; it has more abundant blood supply than collagen
bleeding from a wound site
the bodies ability to maintain stable conditions
hardening of tissue caused by an area of localized swelling under the skin
a torn jagged wound
Normal Reactive Hyperemia
visible effect of localized vasodilatation (REDNESS) area will blanch with fingertip pressure and redness lasts less than 1 hour
bed or mattress that reduces pressure b/t the body and the support surface but not below the level of capillary closing pressure
bed or mattress that reduces the pressure b/t the body and the support surface to below 32mmHg or the capillary closing pressure
- localized area of tissue necrosis that tends to develop when soft tissue is compressed b/t a bony prominence and an external surface for a prolonged period
- specific type of skin trauma, almost exclusively those with limited mobility
- occurs as a result of mechanical trauma or tissue anoxia
a small hole in the skin cause by a sharp object
the pressure exerted against the skin in a direction parallel to the body's surface
a bath where only the pelvic area is immersed in warm fluid
the shedding of dead tissue as a result of skin ulceration
used to hold a wound closed after the sutures or staple have been removed
procedures used to eliminate any microorganisms; sterile technique
a stitch or row of stitches holding together the edges of a wound or surgical incision
a decreased supply of oxygenated blood to the tissue
an injury to living tissue caused by a cut, blow or other impact, typically one in which the skin is cut or broken
Review the anatomy and physiology of the skin.
- Epidermis: composed of several layers with the stratum corneum being the outermost layer consisting of flattened, dead, keratinized cells; it protects the underlying skin and tissue from dehydrations and some chemical agents; it allows for evaporation of water and the absorption of some topical mediations. The bottom layer is the stratum basale; this layer is where cells divide, proliferate and migrate towards the surface. The epidermis is approx 1mm thick and it lacks blood supply; it functions to resurface wounds and restore the barrier against invading organisms.
- Dermis: This is the inner layer of skin that provides strength, mechanical support and protection to underlying bone, muscle and organs. The dermis contains mostly CT, a few skin cells, collagen, blood vessels, nerves and lymph vessels. Fibroblasts are the only distinctive cell found in the dermis and its fx is to restore structural integrity and physical properties.
- Subcutaneous: This is the third layer of skin that is composed of fat, it functions to protect the tissues and for insulation.
- Skin Function: protection, homeostasis in water balance, temperature regulation, sensory organ and vitamin synthesis (absorption)
Identify common skin, nail, hair and scalp problems and discuss appropriate nursing interventions.
Skin: Dryness, Pruritus (itching), Sunburn, Uritcaria (hives), Primary Lesions (macules, papules, nodules, wheals, vesicles, pustules), Secondary Lesions (crusting, oozing), Bacterial Infections (folliculitis, furuncles, cellulitis), Viral Infections (herpes simplex 1 & 2, herpes zoster), Fungal Infections (tinea)
Differentiate bt healing by primary and secondary intention.
- Primary Intention: When wound edges approximate, such as in the case of a surgical incision, risk of infection is low and healing occurs quickly, drainage usually stops by day 3 and the wound is usually epithelialized by day 4.
- Secondary Intention: This type of healing involves the loss of tissue as in the case of an ulcer, burn or severe laceration. The wound edges do not approximate and it takes longer for a wound of this nature to heal, there is also a greater chance for infection
- *The healing process is the same for all wounds, variations depend on the location and severity of the wound and the extent of the injury. Sometimes 3rd intention wound healing is used, this type of delayed wound closure is a deliberate attempt by the surgeon to allow for effective draining and cleansing of a contaminated wound. This type of wound is not closed until all evidence of edema and wound debris has been removed.
Describe data to obtain when performing a wound assessment.
- Foreign bodies/ contaminated material
- Progress toward healing
- Appearance (open or closed edges, dehiscence or evisceration)
- Drains (condition of apparatus) and Drainage (type, color, amount, odor, increasing or decreasing)
- Wound closure (staples, sutures)
- Palpation of wound ( detects localized tenderness or drainage)
Discuss how wounds are classified.
- Status of skin integrity: open, closed, acute (surgical wound), chronic (pressure ulcer)
- Cause of the wound: intentional or unintentional
- Severity of tissue injury: superficial, penetrating, perforating (entrance/ exit wound)
- Cleanliness of wound: clean; clean-contaminated; contaminated; infected; colonized
- Descriptive qualities of the wound: laceration, abrasion, contusion
Identify and describe the character 4 types of wound drainage.
- Serous: clear, watery plasma
- Purulent: thick, yellow/green/tan/brown
- Serosanguineous: pale, red, watery
- Sanguineous: bright red, active bleeding
Describe the purpose and types of drains used in a surgical incision.
- Allow drainage such as blood and exudate to drain from the wound
- Penrose- drains into the surrounding bandages
- JP (Jackson Pratt)- has a bulb container that collects drainage, maintains a vacuum; allows for measurement of drainage
- Hemovac- vacuum, empty and measure, reapply vacuum
Describe the three phases of wound healing.
- Inflammatory phase (REACTION): occurs within minutes, lasts 3-5 days
- Proliferation phase (REGENERATION): starts on the 4th day, lasts 2-4 wks, characterized by scabbing, granulation and development of new blood vessels
- Maturation (REMODELING): 3 wks to a year, collegen collects and scar matures
Discuss the complications of wound healing.
- Infection: bacterial, ie boil or cellulitis; viral, ie herpes; fungal, ie tinea
- Hemorrhage: bleeding from a wound
- Dehiscence: when the wound fails to heal properly and the skin/tissue separate; normally occurs in people who are obese, have poor nutrition or infection
- Evisceration: protrusion of organs through a wound opening
- Fistula: an abnormal passage between 2 organs or between an organ and the outside of the body
Identify factors that delay wound healing.
- Obesity (poor vascular flow)
- Impaired Oxygenation (anything that decreases oxygen to a wound)
- Drugs (NSAIDs or steroids)
- Wound Stress
Discuss conditions that place clients at risk for impaired skin integrity.
- Sensory perception or the level of response to the environment (can they feel the pressure)
- Continence/ moisture can lead to rapid skin breakdown
- Mobility (can they change position themselves)
- Activity ( can they ambulate)
- Nutrition (normal wound healing requires proper nutrition)
- Friction and shear (this will be a problem with the pt)
Describe the differences bt nursing care of acute and chronic wounds.
- Acute wounds proceed through and orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity, they are usually easily cleaned and repaired and the edges are clean and intact.
- Chronic wounds fail to proceed through an orderly and timely process to produce anatomical and functional integrity and thus heals with granulation tissue formation, can take years for large ulcers
Define factors that influence pressure ulcer formation.
- poor nutrition
- impaired peripheral circulation
Identify common sites for pressure ulcer formation.
- *anywhere there is pressure, especially bony prominences.
- 1. Sacrum
- 2. Heels
- 3. Elbows
- 4. Greater Trochanter
- 5. Ischial Tuberosities
- 6. Back of the head
- 7. Scapula
- 8. Shoulder
Identify the four stages in the classification of pressure ulcers.
- Stage I: the skin is intact with the following indicators as compared to the adjacent skin: warmth or firmness; sensation of pain or itching; an area of persistent redness that doesn't blanch with external pressure ( in dark skin it may be purple, blue or red hue)
- Stage II: the skin is not intact, and there is partial thickness skin loss of the epidermis or dermis. the ulcer presents clinically as a superficial abrasion, blister or shallow crater
- Stage III: Full thickness skin loss involving damage or necrosis of SQ tissue that may extend down to but not through the underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue
- Stage IV: full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone or supporting structures
Discuss the role of nutrition in wound healing.
- Nutrition is fundamental to normal cellular integrity and tissue repair.
- Serum albumin should be > 3.5 mg/100ml
- Lymphocyte count should be > 1800/mm3 Hgb should be at least 12g/100ml to assure there is adequate tissue oxygenation
- Vit C promotes collagen synthesis, capillary wall integrity, fibroblast fx and immunological fx
Identify nursing interventions and evaluation criteria for pt's with impaired skin and tissue integrity.
- Prevention: do a risk assessment , reduce environmental factors (ie heat causes sweating)
- Hygiene and Skin Care: keep skin clean and dry
- Proper Positioning: reduces pressure (HOB 30* or less) and shearing forces (change positions q 1.5-2hr)
- Use of Therapeutic Beds and Mattresses: pressure relieving- reduces the pressure b/t the body and the support surface to below 32mmHg or the capillary closing pressure; pressure reducing- reduces pressure but not below the level of capillary closing pressure
- Use of pads: .
- Education: teach family to reposition pt
Identify and describe the use of cleansing solutions, topical agents, packing and dressing for wounds.
- Gauze and Nonadherent gauzes: used for covering, requires a 2nd dressing over
- Transparent Film Dressing: no absorption, provides a moist environment
- Hydrocolloids: self-adhesive, gel absorbs the drainage, allows for a moist environment
- Hydrogels: water gel, moist environment, softens the necrotic tissue
- Foams and Alginates: used for heavy drainage, very absorbable
- Wound Vacs: use negative pressure to pull out drainage and infection and promote healing
Describe the purpose and use of therapeutic beds and mattresses.
Describe nursing considerations in the application of heat and cold to an injured body part.
- Assessment for temperature tolerance
- Bodily response to heat and cold
- Local Effects of heat and cold
Describe the difference in the therapeutic effects of the application of heat and cold to an injured body part.
- HEAT:1. 105*-110*
- 2. Vasodialation- improves blood flow to the area, promotes nutrient delivery and waste removal
- 3. Reduced Blood Viscosity- improves delivery of leukocytes and antibodies
- 4. Reduced Muscle Tension- reduces pain and spasms
- 5. Increased Capillary Permeability- promotes movement of waste products and nutrients
- 6. Increased Tissue Metabolism- increased blood flow provides local warmth
- *Indicated for: inflamed body parts, new surgical wounds, infected wounds, arthritis, joint disease/pain, muscle strains, LBP.
- COLD:1. 59*
- 2. Vasoconstriction- reduces blood flow to the affected body part, prevents swelling, reduces inflammation
- 3. Local Anesthesia- reduces localized pain
- 4. Reduced Cell Metabolism- reduces oxygen need of the tissue
- 5. Increased Blood Viscosity- promotes coagulation at the injury site
- 6. Decreased Muscle Tension- relieves pain
- *Indicated for: direct trauma (sprains, strains, fx), superficial lacerations or puncture wounds, minor burns, arthritis, joint trauma.
Identify the principles of surgical asepsis.
- A sterile object remains sterile only when touched by another sterile object
- Only sterile objects may be placed on a sterile field
- A sterile object or field out of range of vision or an object held below the waist is considered contaminated
- A sterile object becomes contaminated by prolonged exposure to air
- When a sterile surface come in contact with a wet contaminated surface the sterile object or field becomes contaminated by capillary action
- Fluid flows in the direction of gravity
- The edges of a sterile field or container are considered to be contaminated
Describe the indications for using sterile technique.
- Procedures that require intentional perforation of skin
- Skin integrity broken due to trauma, surgical incision or burn
- Procedures that involve insertion of catheters or surgical instruments onto sterile body cavities (catheters vs enemas)
Those at risk for pressure ulcers include:
- impaired sensory input
- impaired motor fx
- alterations in level of consciousness
- those with orthopedic devices on
RN Dx: Actual or risk for impaired skin integrity r/t:
- pressure on bony prominences
- restricted mobility
- shearing force/ friction
Prevention of pressure ulcers by:
- establish a turning schedule
- reduce shear and friction
- provide pressure relief surfaces
- incontinence management
- adequate nutrition and hydration
- caregiver education
- increase activity
Elements that are responsible for pressure ulcer development include:
- Intensity of pressure and capillary closing pressure: pressure greater than 32mmHg
- Duration and sustenance of pressure: time/pressure relationship
- Tissue tolerance: skin is less sensitive than muscle
is the same for all wounds, variations depend on the location and severity of the wound and the extent of the injury. Sometimes 3rd intention wound healing is used, this type of delayed wound closure is a deliberate attempt by the surgeon to allow for effective draining and cleansing of a contaminated wound. This type of wound is not closed until all evidence of edema and wound debris has been removed.