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| Protection, body temp regulations, sensation, excretion, maintenance of water and electrolyte balance, and vitamin d production are functions of what |
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| top layer of the skin and when the skin is injured, this functions to resurface the wound and restore the protective barrier of the skin |
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| Inner of layer of skin and contains collagen, blood vessels, and nerves |
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| reduced skin elasticity, increased dryness, wrinkling, decreased collagen, thinning of the underlying muscle and tissues puts the client at risk for |
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| decreased inflammatory response results in |
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| Increased risk of impair wound healing |
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| reduced nutritional intakes |
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| localized injury to the skin and underlying tissue usually over a bony prominence as a result from pressure or pressure combine of friction |
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| when pressure exceeds normal capillary pressure, vessels occludes and tissue ischemia develops, tissues may be damaged or tissue death may result |
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| low pressure over prolonged period of time or high pressure over a short period of time causes tissue damage |
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The ability of tissue to endure pressure depends on the integrity of the tissue and supporting structures:
Extrinsic factors: shear, friction,moisture
Condition of underlying structures: blood vessels, collagen
Systemic factors: nutrition, aging and low blood pressure |
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| majoy cause of ulcer development |
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| force exerted parallel to the skin resulting from gravity pushing down on the body and resistance (friction) between the client and a surface |
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| force of two surfaces moving across one another |
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| pressure and moisture on the skin increases the risk of ulcer formation |
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| frequence of position changes |
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| loss of 5% of usual weight, less than 90% of ideal body weight ot decrease of 10 lbs in a brief time |
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| you can't do this for skin integrity |
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| continuous exposure of urine, bile, stool, acetic fluid, anf purulent exudates, gastric |
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| has 6 subscales: sensory perception, moisture, activity, mobility, nutirtion, and friction and shear |
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| worst and best possible score on braden scale |
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| when this is noted, document the locations, size, and color and reassess the area after 1 hour |
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| Scale with 5 risk factors: physical condition, mental condition, activity, mobility, and continence |
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| Low score> risk for pressure ulcer development |
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| Total score of 5-10 on norton scale |
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| Risk of pressure ulcer development |
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| Score of 14 or less in norton scale indicates |
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| Suspected deep tissue injury |
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Definition
| Purple or marrom localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue form pressure and or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or coolor as compared to adjacent tissue |
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Definition
| intact skin with non-blanchable redness of a localized area usualy over a bony prominence |
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| partial-thickness skin loss involving epidermis and or dermis presenting as a shallow open ulcer with a red pink wound bed, wiithout slough. Abrasion blister, or shallow crater |
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| Full thickness tissue loss involving damage or necrosis of subcutaneous tissue (deep tissue).Bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the deptch of the tissue loss. May be undermining and tunneling |
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| 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 tunneling |
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| Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and or eschar (tan, brown or black in the wound bed). Until enough slough and or eschar is removed to expose the base of the wound, the true depth and therefore stage cannot be determined |
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Stable (dry, adherent, intact, without erythema or flunctuance) eschar on the here serves as the body's natural cover and should not be removed
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| reed, moist, tissue= progressing toward healing |
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| stingy tissue attached to wound bed which is tissue that must be remove before healing can proceed |
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| black or brown necrotic tissue that must be removed before healing can proceed |
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| Pressure ulcer prevention |
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Definition
| risk factors: positioning, moisture, friction and shear, nutritional deficits |
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Definition
| this is should avoided with topical skin care |
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| do not do this to bony prominences |
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Protectant (dimethicone base) cream
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| very effective as skin protectant |
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| reduces pressure and shearing: always reasses skin for hyperemia, turn pt 2 hours when supine and 1 hour when HOB is elevated, HOB should be 30 degrees or less |
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| Support surfaces (therapeautic beds and mattresses) |
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Definition
| specialized device for pressure redistribution designed for management of tissue loads, microclimate, and or therapeautic functions |
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| irrigation and use of non-cytotoxic cleanse |
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Definition
| cleanse the wound with thhese |
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| removing nonviable tissue |
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| Laceration, abrasion, puncture wound, and contusion |
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Definition
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| monitor dressing external drains and we reinforce dressing and notify MD when there's bleeding |
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Definition
| Usualy routine is for surgeon to do initial dressing and we |
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| when dressing s are ordered we must |
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| clear and water wound drainage |
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| yellow, green, tan or brown wound drainiage |
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| pale, red, water: mixture of clear and red fluid |
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| you know when the wound is swolllen, the edges or wound are deep red in color, the wound feel hot on palpation, drainage increases, theres foul odor, or would edges may be deparated with dehiscence present theres an |
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| Drains and drainage devices |
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Definition
| provides and exite for blood and lfuids that accumulate during the inflammatory response |
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| in a stab wound close to an abdominal incisions that may lie under a dressing with a pink or clip |
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| synthetic, non invasive glue for wound closure |
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| wound closure are edmatous for |
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| continued sweeling may indicate that closing is |
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| should we collect a wound culture from old drainage? |
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| clean with saline and then collect culture |
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Definition
| collecting a culture should be the first step |
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| wound has foul odor use syringe |
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| olderst and most common (4x4 or 2x2) and rolls |
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| doesnt stick but allows drainage to pass on |
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| ideal for small, superficial wound to protect and help maintain moist environment |
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| adhesive and occlusive, absords drainage, maintains moisture, liquifies necrotic debris |
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| helps care for wound without removing adhesive strips with each dressing |
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| good to use as support when someone coughs |
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| process of wound healing; the wound is made surgically with little tissue loss, minimal scarring results, and it beging during infallamtory phase of h ealing |
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| process of wound healing; healing occurs when skin edges are not close together or whe pus has formed. If purulent exudates, surgeon provides a drainage system or packs the wound, necrotized tissue decomposes and escapes, cavity begins to fill with granulation tissue, amount of granulation tissue required depends on the size of wound, scarring is greater |
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| process of wound healing; occurs with delayed suturing of a wound in which layers of granulation tissue are sutured together, occurs when a contaminated wound is left open and sutured closed after the infection is controlled or a primary wound becomes infected, opened, allowed to granulate, and then sutured |
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Term
1. inflammation phase
2.proliferation or reconstruction phase
3. maturation or remodeling phase |
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| begins immediately and last 1 to 4 days; there's swelling or edema of the injured part, erythema (redness) from increased blood supply, there's heat or increased temp, pain from pressure on nerve receptors, possible loss of function from these changes |
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| begins on the third or fourth days and lasts for 2 to 3 weeks; macrophages continue to clear the wound of debris, stimulateing fibroblasts, which synthesize collagen, new capillary networks formed to provide oxygen and nutrients to support the collagen and for further synthesis of granulation tissue, deep pink, fullthickness wound begins to close by contraction as new tissue is grown, scarring |
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| final phase begins 3 weeks after injury; may take up to 2 years, collagen is lysed (broken down) and resynthesized by macrophages, which produced a scar, scar maturation or remodeling, scar slowly thing and becomes paler |
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| can happen internally or externally |
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| localized collection of blood underneath the tissues |
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| risk of hemmorhage is the greatest during |
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| 2nd most common nosocomial infection. Surgical infection most apparent day 2-11 post op, there's purulent drainage |
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| partial or total rupturing of a sutured wound , it fails to heal properly and may separate when coughing or sitting up |
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| total separation of wound layers, visceral organs protudes, emergency, sterile saline soaked towels, have they're knees bent, NPO, and observe for shock |
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| abnormal passage between two organs or between an organ and the outside body , increase risk of infection and fluid electrolye imbalance |
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| obese 66 year old on anticoagulants with infection and low proteins whos coughing or straning |
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Definition
| risk factors for dehiscence and evisceration |
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| sudden increase in serosanguineous drainage from post op days 4-5 |
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| warning sign of wound dehiscence and evisceration |
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| Nursing action for evisceration |
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Definition
| stay with the patient, emergency, place patient at low fowler's and their knees bent, call for sterile towels/gauze and saline, moisten with sterile saline and cover the wound, notify the surgeo stat, prepare them for return to surgery (make NPO), monitor for shock |
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Definition
1 ABCs first
2 promote hemostasis
3 cleanses the wound
4 protect would from further injury
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| direct pressure with clean/sterile dressing, then use an adhesive bandage to allow closure and clot to form, more pressure and allow the puncture wound to bleed |
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| appropriate cleansing solution and mechanical means without causing injury (NS and wet to dry) |
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| apply sterile or clean dressing and immolize |
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| Assessment for temperature tolerance in heat to cold therapy |
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Definition
1. observe the skin
2. indetiny contraindication to heat or cold
3. assess clients response to stimuli
4. assess level of consciousness
5. assess condition of equipment
THE NURSE IS LEGALLY RESPONSIBLE FOR SAFE ADMINISTRATION OF HEAT AND COLD APPLICATIONS |
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| initially diminishes swelling and pain and prolonges exposure to cold results in reflex vasodilation which is red, dollowed by purplish mottling with numbness and burning type of pain |
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Definition
| effects of cold application |
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| vasoconstriction, local anesthesia, reduced cell metabolism, increase blood viscosity, decreased muscle tension, used most often for sports for sprains, strains, and fractures |
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| improves blood flow to the area and if it is applied for one hour or more it causes reflex vasoconstriction, this can damage epithelial cells, redness, and localized tenderness and blistering |
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| vasodilation, reduced blood viscosity, reduced muscle tensions, increased tissue metaolism, increased capillary permeability and is used for MS problems and low back pain |
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| contraindications to heat |
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Definition
| bleeding acte, localize inflammation, such as appendicitis, cardiovascular problems (large portions of the body) |
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| impaired circulation, neuropathy, and shivering |
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| minor temperature changes |
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| application of heat and cold therapies shoudl have ________that includes the body site, type, frequency, and duration of application |
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| moisty or dry depending on the type of injury, location, and presence of drainage or inflammation |
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Definition
| application of hot or cold therapies can be |
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Definition
With open wounds, sterile, warm, moist compresses to imporve circulation, relieve edeme and promote consolidation of pus and drainage
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| this should be 105-110 degrees F |
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| aquathermia is at_ and use _________ water |
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| cold compresses should be applied for _ minutes at ___ degrees F |
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| these are for muscle sprain, localized hemmorrhage, or hematoma, control bleeding, and anesthetize the body part |
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