Pressure Ulcers: Causes, Assessment, and Wound Healing, Exams of Nursing

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NSG 300 Topic 4 Questions With Complete Solutions pressure ulcers a localized injury to the skin and underlying tissue, usually over a bony prominence. It results from pressure in combination with shear and/or friction. what are some other names for a pressure ulcer? Pressure sore, decubitus ulcer, or bed sore what are the three major elements that cause a pressure ulcer? pressure intensity (tissue ischemia & blanching) pressure duration tissue tolerance tissue ischemia If pressure applied over a capillary exceeds normal capillary pressure and the vessel is occluded for a prolonged time blanching Blanching occurs when the normal red tones of skin are absent. pressure duration Pressure duration assesses low and extended pressures. Low pressures over a prolonged time can cause tissue damage.

Extended pressure occludes blood flow and nutrients and contributes to cell death. tissue tolerance The ability of tissue to endure pressure depends on the integrity of the tissue and supporting structures. what assessment is included for a pressure ulcer? -wound location -depth of tissue involvement (staging) -type and approximate percentage of tissue in wound bed -wound dimensions (if present include sinus tracts and tunneling) -exudate description (if present odor) -condition of surrounding skin. what are the risk factors for a pressure ulcer -Impaired sensory perception -Impaired mobility -Alteration in LOC -Shear -Friction -Moisture stage I o Intact skin with nonblanchable redness of a localized area usually over a bony prominence

-Discoloration of the skin, warmth, edema, hardness, or pain may also be present. stage II o Partial-thickness skin loss involving epidermis, dermis, or both -Presenting as a shallow open ulcer with a red pink wound bed, without slough. -May also present as an intact or open/ruptured serum-filled or serosanguineous filled blister. -Presents as a shiny or dry shallow ulcer without slough or bruising. Bruising indicates deep tissue injury. stage III o Full-thickness tissue loss with visible fat but bone, tendon, or muscle are not exposed. stage IV o Full-thickness tissue loss with exposed bone, muscle, or tendon partial thickness wound Involves the epidermis and the dermis but does not extend through the dermis to the subcutaneous layer full thickness wound the dermis, epidermis, and subcutaneous tissue are penetrated; muscle and bone may be involved

Primary intention wound healing intentional wounds with minimal tissue loss and well approximated edges. low risk for infection (ex: surgical incision) secondary intention wound healing a wound involving loss of tissue, is allowed to remain open and heal by granulation, epithelialization, and contraction - used for dirty wounds, o/w abscess can form, greater risk for infection Tertiary intention wound healing o Wound that is left open for several days, then wound edges are approximated granulation tissue the tissue that normally forms during the healing of a wound slough stringy substance attached to wound bed eschar black or brown necrotic tissue exudate fluid, such as pus, that leaks out of an infected wound black wound o black or brown necrotic tissue is eschar, which also needs to be removed before healing can proceed.

yellow wound soft yellow or white tissue is characteristic of slough (stringy substance attached to the wound bed), and it must be removed by a skilled clinician before the wound is able to heal red wound o Recall that granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates; progression toward healing wound a disruption of the integrity and function of tissues in the body. a partial thickness wound heals by regeneration a full thickness wound heals by forming new tissue (scar) what are the three components of the partial thickness healing process? inflammatory response epithelial proliferation and migration establishment of the epidermal layers inflammatory response (partial thickness)

nonspecific defense against infection, characterized by redness, heat, swelling, and pain (generally limited to the next 24 hours) epithelial proliferation and migration (partial thickness) Epithelial cells begin to migrate across wound bed soon after wound occurs. Wound left open to air: resurface 6-7 days. Moist wound: resurface 4 days. reestablishment of the epidermal layers (partial thickness) The cells slowly reestablish normal thickness and appear as dry, pink tissue. what are the four phases of the full thickness healing process? hemostasis inflammatory proliferative maturation hemostasis (full thickness) injured blood vessels constrict, and platelets gather to stop bleeding. Clots form a fibrin matrix that later provides a framework for cellular repair inflammatory (full thickness) damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and movement/migration of serum and WBCs into the damage tissues

proliferative phase (full thickness) o Begins with the appearance of new blood vessels as reconstruction progresses and lasts from 3 to 24 days. The main activities during this phase are the filling of the wound with granulation tissue, contraction of the wound, and the resurfacing of the wound by epithelialization maturation phase (full thickness) o The final stage of healing, sometimes takes place for more than a year, depending on the depth and extent of the wound. The collagen scar continues to reorganize and gain strength for several months. However, a healed wound usually does not have the tensile strength of the tissue it replaces. hemorrhage excessive/profuse Bleeding from a wound site, is normal during and immediately after initial trauma. (Hemorrhage occurs externally or internally.) hematoma A localized collection of blood underneath the tissues. It appears as a swelling, change in color, sensation, or warmth that often takes on a bluish discoloration. wound infection Infection is present when the microorganisms invade the wound tissues. (Signs of inflammation often present)

dehiscence partial or total separation of wound layers Evisceration With total separation of wound layers, evisceration or protrusion of visceral organs through a wound opening occurs evisceration is an emergency, so what needs to be done? Immediately place damp sterile gauze over site, contact the surgical team, do not allow the patient anything by mouth (NPO), observe for signs and symptoms of shock, and prepare the patient for emergency surgery. What are the s/s of a wound infection? -Contaminated or traumatic wounds: 2-3 days -Post op surgical wound: 4-5 days -Fever, tenderness and pain at wound site -Elevated WBC count -Wound edges appear inflamed -Drainage may be present: odorous and purulent (yellow, green, or brown) What is the Braden Scale used for? used to assess pressure ulcer risk braden scale

Developed based on risk factors in a nursing home population and is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. -lower total score indicates a higher risk for pressure ulcer development. what are the economic consequences of pressure ulcers Medicare and Medicaid: no additional reimbursement for care related to stage III and stage IV pressure ulcers that occur during the hospitalization what are some factors that influence pressure ulcer formation and wound healing? nutrition tissue perfusion infection age how many calories a day does a patient need for maintenance of skin and wound healing 1500kcal/day what nutritional interventions are recommended for wound healing vitamin A vitamin C

calories protein what is the effect of age on wound healing increased age affects all phases of wound healing with in _____ days a normal healing wound resurfaces with epithelial cells and edge close 7- what needs to be notes about the character of wound drainage amount color odor consistency of drainage serous clear, watery plasma sanguineous bloody drainage serosanguineous Pale, red, watery: mixture of clear and red fluid purulent producing or containing pus Hemovac and Jackson-Pratt

exert a constant low pressure as long as the suction device is fully compressed. to as self-suction. braden scale score o 9 or less = Very high risk o 10 - 12 = High risk o 13 - 14 = Moderate risk o 15 - 18 = Mild risk o 19 - 23 = Generally not at risk o Lower numerical scores on the Braden scale indicate that a patient is at high risk for skin breakdown what are the three major areas of nursing interventions for prevention of pressure ulcers · (1) skin care and management of incontinence · (2) mechanical loading and support devices, which include proper positioning and the use of therapeutic surfaces · (3) education. When should skin assessments be conducted on admission and at least every day (high risk patients need to be checked more often) what are positioning interventions for to redistribute pressure and shearing force to the skin what bed position decreases the chance of pressure ulcer development from shearing forces

30 degrees or less how often should a client be repositioned at least every 2 hours debridement · removal of nonviable, necrotic tissue. this is necessary to rid the wound of a source of infection, enable visualization wound bed, clean base necessary for healing. Autolytic debridement uses synthetic dressings wound to allow the eschar to be self- digested e action of enzymes that are present in wound fluids. Chemical debridement may use topical enzymes used to changes in the substrate resulting in the breakdown of necrotic tissue. Surgical debridement is the removal of devitalized tissue by using a scalpel, scissors, or other sharp instrument. In an emergency setting, use first aid measures for wound care, they include stabilizing cardiopulmonary function, promoting hemostasis, cleaning the wound, and protecting it from further injury. How do you control bleeding?

Control bleeding by applying direct pressure on it with a sterile or clean dressing such as a washcloth. when a patient has a puncture wound you want to... allow the puncture wound to bleed (to remove dirt and other contaminants) When a penetrating object such as a knife blade is present... do not remove the object. The presence of the object provides pressure and controls some bleeding. when cleaning a wound clean from least to most contaminated use separate swab for each stroke glean gently and often with normal saline Intermittent suturing the surgeon ties each individual suture made in the skin. Continuous suturing a series of sutures with only two knots, one at the beginning and one at the end of the suture line. retention sutures are placed more deeply than skin sutures, and nurses may or may not remove them, depending on agency policy. The manner in which the suture crosses and penetrates the skin determines the method for removal.

effects of heat application Improving blood flow to an injured part. Periodic removal and reapplication of local heat restores vasodilation. effects of cold application The application of cold initially diminishes swelling and pain. Prolonged exposure of the skin to cold results in a reflex vasodilation. Warm, moist compresses improve circulation, relieve edema, and promote consolidation of purulent drainage. what are the purposes of dressings -Protects from microorganisms -Promote homeostasis -Promotes healing by absorbing drainage or debriding a wound -Supports wound site -Promotes thermal insulation -Provides a moist environment when applying tape to a wound... ensure that it adheres to several inches of skin on both sides of the dressing and that it is placed across the middle of the dressing. When securing the dressing, press the tape gently, making sure to exert pressure away from the wound. what is the first step in packing a wound

assess its size, depth, and shape negative pressure wound therapy o NPWT is the application of subatmospheric (negative) pressure to a wound through suction to facilitate healing and collect wound fluid. o supports wound healing by edema reduction and fluid removal, macro deformation and wound contraction, and micro deformation and mechanical stretch perfusion gauze They are absorbent and are especially useful in wounds to wick away wound exudate. transparent film This type of dressing traps moisture over a wound, providing a moist environment. hydrocolloid They are adhesive and occlusive. The wound contact layer of this dressing forms a gel as wound exudate is absorbed and maintains a moist healing environment. hydrogel Hydrogel dressings are gauze or sheet dressings impregnated with water or glycerin-based amorphous gel. This type of dressing hydrates wounds and absorbs small amounts of exudate.

foam dressings are for wounds with large amounts of exudate and those that need packing. composite dressings combine two different dressing types into one dressing when should analgesic medications be administered before a dressing change 30 to 60 minutes before wound irrigation o to flush the area with a constant low-pressure flow of solution. (this will cleanse a wound of exudate and debris.) oMake sure that fluid flows directly into the wound and not over a contaminated area before entering the wound.(least to most contaminated) drainage evacuation Constant, low-pressure vacuum to remove and collect drainage bandages and binders Functions: create pressure, immobilize and/or support a wound, reduce or prevent edema, secure a splint, secure dressings lacerations a deep cut or tear in skin or flesh.

abrasions the process of scraping or wearing away. contusions A region of injured tissue or skin in which blood capillaries have been ruptured; a bruise penetrating wounds Trauma is usually by a sharp and pointed instruments like needles, sticks, pencils, knives, arrows, pens, glass and any object with sharp edges