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Kozier & Erb 36

Terms in this set (95)

incision
caused by a sharp instrument; open wound: deep or shallow
contusion
caused by a blow from a blunt instrument; closed wound: skin appears ecchymotic
ecchymosis
the escape of blood into the tissues from ruptured blood vessels
abrasion
surface scrape, either unintentional (e.g., scraped knee from a fall) or intentional (e.g., dermabrasion); open wound involving sking
puncture
penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional; open wound
laceration
tissues torn apart, often from accidents; open wound, edges are often jagged
penetrating wound
penetration of the skin and the underlying tissues, usually unintentional (e.g., from a bullet or metal fragments); open wound
clean wound
uninfected wounds
minimal inflamation
primarily closed wounds
clean-contaminated wound
surgical wounds
GI, respiratory, genital, or urinary tract entered
no evidence of infection
contaminated wound
open, fresh, accidental wounds, surgical wounds
major break in sterile technique or large spillage from GI tract
shows evidence of inflammation
dirty or infected wound
can contain dead tissue, or evidence of clinical infection such as purulent drainage
purulent
containing or producing pus
4 types of wounds
clean
clean-contaminated
contaminated
dirty or infected
partial thickness
confined to the skin, dermis and epidermis; heal by regeneration
full thickness
involving the dermis, epidermis, subcutaneous tissue and possibly muscle and bone; require connective tissue repair
ischemia
deficiency in the blood supply to the tissue
reactive hperemia
bright red flush to skin when pressure is released
vasodilation
increased diameter of blood vessels, allows extra blood flow
risk factors for pressure ulcers
friction & shearing
immobility
inadequate nutrition
fecal & urinary incontinence
decreased mental status
diminished sensation
excessive body heat
advanced age
chronic medical conditions
incorrect positioning
hard support surfaces
incorrect application of pressure-relieving devices
poor lifting and transferring techniques
friction
a force acting parallel to the skin surface (ex, sheets rubbing against skin)
shearing force
a combination of friction and pressure
immobility
reduction in the amount and control of movement a person has
maceration
tissue softened by prolonged wetting or soaking
excoriation
are of loss of superficial layers of the skin (denuded area)
advanced age and pressure ulcer risks
* loss of lean body mass
* generalized thinning of the epidermis
* decreased strength and elasticity of the skin due to changes in the collagen fibers of the dermis
* increased dryness due to a decrease in the amount of oil produced by the sebaceous glands
* diminished pain perception due to a reduction in the number of cutaneous end organs responsible for the sensation of pressure and light touch
* diminished venous and arterial flow due to aging vasuclar walls
Braden Scale
* 6 subscales - sensory perception, moisture, activity, mobility, nutrition, and friction/shear
* 23 possible points
* scores below 18 indicate risk for pressure ulcers
Norton's Pressure Area Risk Assessment Form Scale
* categories - general physical condition, mental state, activity, mobility, and incontinence (medication category may be added)
* 24 possible points
* scores of 15 or 16 indicate risk for pressure ulcers
stages of pressure ulcers
* Stage 1 - nonblanchable erythema signaling potential ulceration
* Stage 2 - partial thickness skin loss (abrasion, blister, or shallow crater) involving the epidermis and possibly the dermis
* Stage 3 - full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia, the ulcer presents clinically as a deep crater with or without undermining of adjacent tissue
* Stage 4 - full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures, such as a tendon, or joint capsule, undermining and sinus tracts may also be present
common pressure sites
* supine - heels, sacrum, elbows, scapulae, back of head
* prone - toes, knees, genitalia (men), breasts (women), shoulder, cheek, ear
* lateral - malleolus, knee, greater trochanter, shoulder, side of head
* Fowlers - heels, pelvis, sacrum, vetebrae, back of head
sinus tracts
a channel that connects with an abscess or suppurating area
suppurate
to form or discharge pus
primary intention healing
where tissue surfaces have been approximated and there is minimal or no tissue loss; also called primary union or first intention healing
approximated
closed
secondary intention healing
healing of a wound that is extensive and involves considerable tissue loss, and in which the edges cannot or should not be approximated
tertiary intention
wounds left open for 3 -5 days to allow edema or infection to resolve or exudate to drain and are then closed with sutures, staples, or adhesive skin closures to heal; also called delayed primary intention
exudate
material such as fluid and cells that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces
phases of wound healing
* inflammatory phase
* proliferative phase
* maturation phase
inflammatory phase
initiated immediately after injury and lasts 3 to 6 days; hemostasis and phagocytosis
hemostasis
cessation of bleeding
fibrin
connective tissue helping to form blood clots
phagocytosis
macrophages engulf microorganisms and cellular debris
proliferative phase
extends from day 3 or 4 to about day 21 postinjury; granulation tissue begins to form
collagen
a whitish protein substance that adds tensile strength to the wound
granulation tissue
formed as the capillary network develops and the tissue becomes a translucent red color; is fragile and bleeds easily
eschar
scab; composed of dried plasma proteins and dead skin cells
maturation phase
begins in about day 21 and can extend 1 - 2 years after the injury; the wound is remodeled and contracted
keloid
hypertrophic scar; scar tissue with an abnormal amount of collagen
major types of exudate
serous
purulent
sanguineous
serous exudate
consists chiefly of serum; watery and has few cells
purulent exudate
thicker than serous exudate, contains pus
sanguineous exudate
consists of large amounts of red blood cells
serosanguineous exudate
composed of serum and blood tinged drainage
complications of wound healing
* hemorrhage - massive bleeding
* infection - contamination with microorganisms
* dehiscence - partial or total rupture of a sutured wound
hematoma
a localized collection of blood underneath the skin; may appear as reddish blue swelling (bruise)
eviseration
the protrusion of the internal viscera through an incision
factors affecting wound healing
* developmental considerations
* nutrition
* lifestyle
* medications
necrotic tissue (eschar)
black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges and may be either firmer or softer than surrounding skin
slough
yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous
factors inhibiting wound healing in older adults
* vascular changes
* collagen tissue is less flexible
* scar tissue is less elastic
* changes in the immune system
* nutritional deficiencies
* diabetes or cardiovascular disease
* cell renewal is slower
untreated wounds
* control severe bleeding - apply direct pressure, elevate extremity
* prevent infection - clean or flush abrasions or lacerations with normal saline, cover the wound with a clean dressing
* control swelling and pain by applying ice over the wound and surrounding tissues
* if bleeding is severe or internal bleeding is suspected, assess client for signs of shock (rapid thready pulse, cold clammy skin, pallor, lowered blood pressure)
assessing treated wounds
inspect wound during dressing change, inspect dressing of covered wound, assess pain
observation of treated wounds
* appearance
* size
* drainage
* presence of swelling
* presence of pain
* status of drain tubes
* presence of undermining
undermining
when the wound reaches under the skin surface
observation of pressure ulcers
* location of ulcer related to a bony prominence
* size of ulcer in cm (length [head to toe] x width [side to side] x depth)
* presence of undermining or sinus tracts - location noted by position on a clock face, 12 o'clock as client's head
* stage of ulcer
* color of wound bend and location of necrosis or eschar
* condition of wound margins
* integrity of surrounding skin
* clinical signs of infection (note exudate color)
clinical signs of infection
redness, warmth, swelling, pain, odor, and exudate
important lab data for wound healing
* leukocyte count - decreased count can delay healing
* hemoglobin level - below normal indicates poor oxygen delivery to tissues
* blood coagulation studies - prolonged coagulation times can result in excessive blood loss and prolonged clot absorption
* hypercoagulability - can lead to intravascular clotting and deficient blood supply to wound area
* serum protein - protein is needed for wound healing
* albumin - below 3.5g/dL indicates poor nutrition and may increase risk of poor healing and infection
* wound cultures - confirm or rule out presence of infection
* sensitivity studies - help choose appropriate antibiotic therapy
possible NANDA diagnoses
* Risk for Impaired Skin Integrity
* Impaired Skin Integrity
* Impaired Tissue Integrity
* Risk for Infection
* Acute Pain
Supporting wound healing
* moist wound healing
* nutrition and fluids
* preventing infection
* positioning
preventing pressure ulcers
* providing nutrition
* maintaining skin hygiene
* avoiding skin trauma
* providing supportive devices
Guidelines for Preventing Infection & Transmission of Bloodborne Pathogens
* wear gloves when touching blood, body fluids, nonintact skin, or handling items soiled with blood or body fluids
* wash hands thoroughly if contaminate with blood or body fluids and after removing gloves
* wash hands before and after caring for wounds
* wear gloves, masks, and protective eyewear as appropriate if procedures commonly cause droplets or splashing of blood or body fluids (e.g., wound irrigation)
* touch an open or fresh surgical wound only when wearing sterile gloves or using sterile instruments
* remove or change dressings over closed wounds when they become wet
Treating Pressure Ulcers
* use RYB color code
* red- protect/cover
* yellow - cleanse
* black- debride
* minimize direct pressure on the ulcer
* clean the pressure ulcer with every dressing change
* clean and dress the ulcer using surgical asepsis
* if the ulcer is infected, obtain a sample of the drainage for culture and sensitivity testing
* teach the client to move frequently to remove pressure
* provide range of motion exercises and mobility as the client's condition permits
debridement
removal of necrotic material
purpose of dressing wounds
* to protect the wound from mechanical injury
* to protect the wound from microbial contamination
* to provide or maintain moist wound healing
* to provide thermal insulation
* to absorb drainage or debride a wound or both
* to prevent hemorrhage (when applied as a pressure dressing or with elastic bandages)
* to splint or immobilize the wound site and thereby facilitate healing and prevent injury
types of dressings
* transparent film
* impregnated nonadherent
* hydrocolloids
* clear absorbent acrylic
* hydrogels
* polyurethane foams
* alginates (exudate absorbers)
* collagen
transparent dressings
* act as temporary skin
* nonporous, nonabsorbent, self-adhesive dressings that do not require changing as other dressings do
* wounds can be assessed through them
* retain a small amount of serous exudate which promotes epithelial growth, hastens healing, and reduces the risk of infection
* because they are elastic, they can be placed over a joint without disrupting the client's mobility
* they adhere only to the skin area around the wound and not to the wound itself because they keep the wound moist
hydrocolloid dressing
* lasts 3-7 days
* do not need a cover dressing
* are water resistant allowing bathing or showering
* they can be molded to uneven body surfaces
* they act as temporary skin
* effective bacterial barrier
* decrease pain and need for analgesics
* absorb moderate drainage, can be used on slowly draining wounds
* they contain wound odor
Limitations of hydrocolloid dressings
* are occlusive, opaque, and obscure wound visibility
* they have a limited absorption capacity
* they can facilitate anaerobic bacterial growth
* the can soften and wrinkle at the edges with wear and movement
* they can be difficult to remove and may leave a residue on the skin
* not for infected wounds, those with deep tracts or fistulas
fistulas
abnormal passages that develop between a hollow organ and the skin or between two hollow organs
transparent film dressing
* adhesive plastic, semipermeable, nonabsorbent
* allow exchange of oxygen between atmosphere and wound bed
* impermeable to bacteria and water
* provide protection against contamination and friction
* prevents evaporation
* indications - IV dressing, central line dressing, superficial wounds, pressure ulcers (S1)
* examples - Bioclusive, Op-Site, Polyskin, Tegaderm
inpregnated nonadherent dressing
* woven or nonwoven cotton or syntheic materials impregnated with petrolatum, saline, zinc-saline, antimicrobials, or other agents
* require secondary dressings to secure in place, retain moisture, and provide wound protection
* to cover, soothe, and protect partial and full thickness wounds without exudate
* indications - postoperative dressings over staples/sutures, superficial burns
* examples - Adaptic, Aquaphor gauze, Carrasyn, Xeroform
Hydrocolloids
* waterproof adhesive wafers, pastes, or powders
* wafers designed to be worn for up to 7 days
* 2 layers - inner hydrated gel to cover wound, outer film provides an occlusive seal
* absorbs exudate, produces a moist environment that facilitates healing but does not cause maceration of surrounding skin
* protect wound from bacterial contamination, debris, urine, feces, and to prevent shearing
* indications - pressure ulcers (S2-4), autolytic debridement of eschar, partial thickness wounds
* examples - Comfeel, DuoDERM, RepliCare, Restore, Tegasorb
clear absorbent acrylic dressings
* transparent absorbent wafer designed to be worn 5-7 days
* acrylic layer absorbs exudates and evaporates the excess off the transparent membrane
* maintains a transparent membrane for easy assessment
* provides bacterial and shearing protection
* maintains moist wound healing
* can be used with alginates to provide packing to deeper wound beds
* indications - pressure ulcers, skin tears, venous stasis ulcers, surgical wounds, wounds undergoing chemical debridement agents
* examples - Tegaderm absorbent
hydrogel dressings
* glycerin or water based nonadhesive jelly-like sheets, granules, or gels are oxygen permeable unless covered by a plastic film
* requires secondary occlusive dressing
* to liquefy necrotic tissue or slough, rehydrate the wound bed, and fill dead space
* indications - pressure ulcers, skin tears, partial thickness wounds
* examples - Carrasyn, Elasto-Gel, NU-GEL, Purilon, Tegaderm, Vigilon
polyurethane foam dressings
* nonadherent hydrocolloid dressings
* need to have their edges taped down or sealed
* require secondary dressings to obtain an occlusive environment
* surrounding skin must be protected to prevent maceration
* easy to cut and fit to wound
* absorbs up to heavy amounts of exudate
* to provide and maintain moist wound healing
* to provide thermal insulation
* indications - light to highly exudating wounds, pressure ulcers, skin tears, venous stasis ulcers, surgical wounds, wounds undergoing chemical debridement agents
* examples - Allevyn, Curafoam, Flexzan, Lyofoam, VigiFOAM
alginates (exudate absorbers)
* nonadherent dressings of powder, beads, granules, ropes, sheets, or paste conform to wound surface
* absorb up to 20x their weight in exudate
* require secondary dressing
* to provide a moist wound surface by interacting with exudate to form a gelatinous mass, absorbs exudate
* eliminates dead space or pack wounds
* supports debridement
* indications - pressure ulcers, skin tears, venous stasis ulcers, surgical wounds, wounds undergoing chemical debridement agents
* examples - AlgiDerm, Curasorb, Debrisan, Kaltostat, Sorbsan
collagen dressings
* gel, past, powder, granules, sheets, sponges derived from animal sources (cow or pig)
* assists with stopping bleeding
* helps recruit cells into the wound and stimulates their proliferation to facilitate healing
* indications - clean moist wounds
* examples - Biostep, Cellerate RX, NU-GEL, Promogran
securing dressings
1. place the tape so that the dressing cannot be folded back to expose the wound, place strips at the ends of the dressing and space tapes evenly in the middle
2. ensure that the tape is long enough and wide enough to adhere to several inches of skin on each side of the dressing, but not so long or wide that the tape loosens with activity
3. place the tape in the opposite direction from the body action, for example, across a body joint or crease, not lengthwise
cleaning wounds
* follow standard precautions for personal protection
* use solutions such as isotonic saline or wound cleansers
* warm solution to body temperature before use, no not microwave
* if wound is grossly contaminated, clean the wound at every dressing change
* if a wound is clean, avoid repeated cleaning
* use gauze squares, avoid products that shed fibers into the wound
* clean superficial noninfected wounds by irrigating them with normal saline
* avoid drying a wound after cleaning it
* hold cleaning sponges with forceps or with a sterile gloved hand
* clean the wound in an outward direction to avoid transferring organisms from the surrounding skin into the wound
* consider not cleaning the wound at all if it appears to be clean
lavage
irrigation, washing or flushing out of an area
bandaging
* whenever possible, bandage the part in its normal position, with the joint slightly flexed
* pad between skin surfaces and over bony prominences
* always bandage body parts by working from the distal to the proximal end
* bandage with even pressure
* whenever possible, leave the end of the body part exposed
* cover dressing with bandages at least 5cm beyond the edges of the dressing
assessment before applying bandages or binders
* inspect and palpate the area for swelling
* inspect for the presence of and status of wounds
* not the presence of drainage
* inspect and palpate for adequacy of circulation
* ask the client to reapply the bandage or binder when needed
* assess the capabilities of the client regarding activities of daily living
local effects of heat
* causes vasodilation
* increases blood flow to the affected area
* brings oxygen, nutrients, antibodies, and leukocytes to the area
* promotes soft tissue healing
* increases suppuration
* can result in edema from the increase in capillary permeability
* often used for musculoskeletal problems, joint stiffness, contractures, and low back pain
local effects of cold
* causes vasoconstriciton
* reduces blood flow to the affected area
* reduces oxygen, nutrients, antibodies, and leukocytes to the area
* decreases the removal of wastes
* produces skin pallor and coolness
* prolonged exposure results in impaired circulation
* most often used for sports injuries to limit postinjury swelling and bleeding
* slows bacterial growth, decreases inflammation
rebound phenomenon
occurs at the time of maximum therapeutic effect and opposite effect begins
contraindications to use of heat and cold
* first 24 hours after traumatic injury - heat increases bleeding and swelling
* active hemorrhage - heat causes vasodilation and increases bleeding
* noninflammatory edema - heat increases capillary permeability and edema
* localized malignant tumor - heat accelerates cell metabolism and cell growth and increases circulation
* skin disorder - heat can burn or cause further damage
* open wounds - cold can increase tissue damage by decreasing blood flow to an open wound
* impaired circulation - cold can further impair nourishment of tissue
* allergy or hypersensitivity to cold - can cause an inflammatory response
* neurosensory impairment - unable to perceive damage to tissue
* impaired mental status - need monitoring to ensure safe therapy
* impaired circulation - (diabetes, CHF, peripheral vasuclar disease) risk for tissue damage from heat, cold is contraindicated
* open wounds - tissues around open wounds are more sensitive to heat or cold
THIS SET IS OFTEN IN FOLDERS WITH...