NURSE-3101 Lecture Notes - Lecture 11: Air Mattress, Safety Pin, Debridement

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20 Oct 2016
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Chapter 31 Skin Integrity and Wound Care
Wound Classification
Intentional
o Planned invasive therapy (e.g., surgery).
Clean
Bleeding controlled.
Unintentional
o Unexpected trauma (e.g., accident).
Contaminated
Uncontrolled bleeding.
Open
o Skin surface broken
o Bleeding
o Tissue trauma.
Closed
o From blow or trauma such as fall or assault
o Skin intact but soft tissue damage, internal injury and bleeding.
Wound Healing
Primary intention
o Skin edges approximated, risk of infection low, heals quickly
Surgical incision
Secondary intention
o Loss of tissue, open and fills with scar tissue, takes longer to heal
Burn or pressure ulcer
Tertiary intention
o Left open after potential contamination during surgery, closed later
Bowel surgery where stool has entered the peritoneum
Wound Healing
Hemostasis
o Formation of exudate.
Inflammatory Phase
o Pain, heat, redness, swelling, mildly elevated temperature, elevated WBC count,
malaise.
Proliferation Phase
o New tissue built to fill wound space.
o New tissue called granulation tissue
Highly vascular, red, bleeds easily
Maturation
o Weeks after injury
o Scar formation.
Factors Affecting Wound Healing
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Pressure
o Interferes with blood flow.
Desiccation
o Drying
Best wound healing if wound is moist, not wet.
Maceration
o Skin softening/break down from prolonged exposure to moisture
Incontinence
Necrosis
o Dead tissue.
o Slough
Moist, yellow, stringy tissue.
o Eschar
Dry, black, leathery tissue.
Wound Complications: Infection
Symptoms 2-7 days
o Contaminated/traumatic wounds 2-3 days after injury
o Surgical wound infection 4-5 days post-op.
Purulent drainage
o Increased drainage; pain; redness; swelling; fever; elevated WBC count.
Risk
o Sepsis; presence of pathogenic organisms in blood or tissues.
Wound Complications: Hemorrhage
Slipped suture, dislodged clot, infection, blood vessel erosion.
External bleeding
o Increasing bloody drainage from the wound, soaking the dressing or pooling
beneath the pt.
o Risk greatest 1st 24-48 hrs.
o Check dressings frequently first 48 hrs.
Excessive bleeding
o May require pressure dressings, additional packing, or surgery.
Internal bleeding
o Hematoma formation
o Large accumulation of blood can put pressure on surrounding blood vessels and
cause tissue ischemia.
Wound Complications: Dehiscence
Partial or total separation of wound layers as result of excessive stress on wounds that are
not healed.
Increased fluid from wound on post-op days 4-5 indicate impending dehiscence.
Feels like “something has suddenly given way.”
Cover wound with sterile towels moistened with sterile NS
o Treat as open wound
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o Low Fowler’s position.
Wound Complications: Evisceration
Most serious complication of dehiscence
o Wound completely separates with protrusion of viscera through incisional area.
Risk factors
o Obesity; excessive coughing, straining, vomiting.
Dehiscence and evisceration of abdominal wound = surgical emergency.
Cover with sterile towels moistened with sterile NS.
Wound Complications: Fistula
Abnormal passage from internal organ/vessel to outside of body or from 1 internal
organ/vessel to another.
Usually start with abscess
o Collection of infected fluid which has not been drained.
Accumulated fluid applies pressure to surrounding tissues leading to fistula formation.
Fistula
o Delayed healing, infection, fluid/electrolyte imbalance, skin breakdown.
Pressure Ulcers
Wound with a localized area of injury to the skin and/or underlying tissue.
Pathologic changes from blood vessel collapse caused by pressure, usually from body
weight.
Necrosis eventually occurs.
Factors in Pressure Ulcer Development
EXTERNAL PRESSURE.
o Over bony prominences (sacrum, coccyx, trochanter, heel).
o Pressure
Occluded capillaries and poor tissue circulation.
o Ischemia
Deficiency of blood.
o Hypoxia
Inadequate cell oxygen.
o Leads to necrosis and ulcer formation.
FRICTION AND SHEAR.
o Friction
Two surfaces rub against each other.
Causes an abrasion which damages superficial blood vessels.
Patient pulled/slid over sheets while being moved.
o Shear
Layer of tissue slides over another layer.
Small blood vessels/capillaries tear.
Patient pulled, not lifted
Slides down in bed or chair.
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