Understanding Wound Healing and Complications: A Comprehensive Guide, Exams of Nursing

Download Understanding Wound Healing and Complications: A Comprehensive Guide and more Exams Nursing in PDF only on Docsity! 1 Fundamentals of Nursing:Exam 2 Review 05/22/2018 Phases of Wound Healing 1. Hemostasis: immediately after the initial injury. • Warm, red, swollen o Involved blood vessels constrict & blood clotting begins through platelet activation & clustering o Exudate – liquid consisting of plasma & blood components which leaks out to the injured area. o Increased perfusion results in heat and redness 2. Inflammatory Phase: follows hemostasis, lasts 4-6 days • Pain, redness, swelling, fever, malaise o WBC (leukocytes & macrophages) move to wound ▪ Leukocytes: ingest bacteria & cellular debris ▪ Macrophages: (24 hrs after injury) ingest debris & release growth factors necessary for the growth of epithelial cells & new blood vessels. ▪ Pt. has generalized body response 3. Proliferation Phase: lasts several weeks, new tissue is built • Fibroblasts – connective tissue cells that synthesize & secrete collagen & produce specialized growth factors • Granulation tissue – forms the foundation for scar tissue & is then converted by skin cells that grown over it; highly vascular, red, & bleeds easily. • Capillaries grow across the wound • A thin layer of epithelial cells forms across the wound 4. Maturation Phase: final stage, 3 weeks after injury (months-yrs) • collagen that was haphazardly deposited in the wound is remodeled, making the healed wound stronger & more like adjacent tissue. • Scar becomes a flat, thin, white line 2 Factors Affecting Wound Healing 1. Local • Pressure – disrupts blood supply to the wound • Desiccation – process of drying up which forms a crust, delaying healing (dehydration) • Maceration – softening & breakdown of skin resulting from prolonged exposure to moisture (overhydration) • Trauma • Edema – interferes w/blood supply & nutrient delivery to wound • Infection – increases stress on the body, requiring increased energy to deal w/the invaders • Excessive bleeding • Necrosis – dead tissue delays wound healing o Healing of he wound will not take place w/necrotic tissue in the wound. Dead tissue must be removed to heal. ▪ slough-moist, yellow, stringy tissue ▪ eschar-dry, black, leathery tissue • biofilm – creates a barrier that decreases effectiveness of antibiotics & the normal immune response 2. Systemic • age • circulation/oxygen • nutritional status-wound healing requires adequate proteins, carbs, fats, vit., & minerals o protein-necessary to rebuild cells & tissues o vitamins A & C-epithelialization & collagen synthesis 5 Wound Healing 1. Regenerative – epithelial wound, superficial, no scar 2. Primary intention –well approximated 6 • Clean surgical incision/edges approximated o ex: intentional wounds w/minimal tissue loss such as those made by a surgical incision 3. Secondary Intention – edges that are not well approximated o a process during which the wound edges do not come together; instead the wound heals by the formation of granulation tissue, wound contraction, and epithelialization. o Wound edges not approximated o Tissue loss o Heals from inner layer to surface ex: large, open wounds, such as from burns or major trauma, which require more tissue replacement & are often contaminated 4. Tertiary Intention – wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed • Granulating tissue brought together • Delayed closure of wound edges Intrinsic factors that affect wound healing – age, chronic illness, compromised immune systems Extrinsic factors that affect wound healing - Medications can affect wound healing, especially those that inhibit platelet action, such as aspirin, and those that suppress the immune system, such as corticosteroids; Cancer treatments; stress Acute Wound – surgical incisions that usually heal w/in days to weeks • Edges are well approximated (edges meet close to skin surface) • Risk for infection in lessened • Move through healing process w/out difficulty 7 Chronic Wounds –the healing process is impeded; wound remains in inflammatory phase of healing • wound edges are often not approximated • risk for infection is increased • healing time is delayed Wound Assessment 1. visual assessment – • location • shape, size • colors • exudate, bleeding • redness • swelling 2. Temperature changes - range from very warm (typical with infection) to very cold (vascular compromise). 3. Textural changes - include roughened or raised wounds or deep wounds that interrupt the natural contour of the skin. 4. Odor - a very important component of wound assessment, can help you detect specific infectious organisms or suggest the cause of the wound. 5. condition of the skin- should also be part of your assessment. In addition, the psychosocial impact of a patient’s wound should be regularly evaluated. 6. Psychosocial impact – Purpose of wound dressing 1. Provide physical, psych, and aesthetic comfort 10 Nursing Intervention: Pressure Ulcers 1. Prevention 2. Meticulous skin care and moisture control 3. Adequate nutrition 4. Frequent repositioning 5. Therapeutic mattresses 6. Client/family teaching Measurement of pressure ulcer 1. Size of wound 2. Depth of wound 3. Presence of undermining, tunneling, or sinus tract Wound Cleansing 1. Passive irrigation - a method that involves a solution and gravity. The solution is introduced in a top-to-bottom fashion to allow it to flow by gravity along the full length of the wound to the absorbent pad beneath the patient 2. Mechanical cleansing - involves the use of gauze and a cleansing solution to clean contaminated wound areas. Excessive scrubbing of a wound can be painful, however, and can also cause further injury.. 3. Pressurized Solution - Some wounds require pressurized solutions for adequate cleansing coverage. Wound Cleaning Guidelines • Approximated edges 11 • clean downward, • from top to bottom • outward from the incision in lines parallel to it • wipe form clean area to less clean area • Unapproximated edges o clean in full or half circles beginning at the center and working outward o clean at least 1 inch beyond the end of the new dressing (if no new dressing, clean 2 inches beyond the wound margins) Wound Debridement 1. Autolytic debridement - uses the wound’s own fluids to self-digest nonviable tissue through the use of dressings that facilitate this 2. Mechanical debridement - can be achieved with wound irrigation or wet-to- dry gauze dressings; when the dressings are removed, the tissue adhered to the gauze is also removed. • Wet-to-dry dressings are nonselective, possibly removing both nonviable as well as healthy tissue 3. Surgical debridement - involves the use of a scalpel, scissors, or other instruments to remove devitalized tissue. Dressing/Bandages 1. Dry Dressings - generally work well for wounds with small amounts of exudate, but they can stick to the wound bed of heavily exudative wounds or expose the wound to the outside environment. • When removing dry dressings that appear stuck to the wound bed, it is helpful to pour some normal saline over the area to moisten the dressing for easier removal 2. Wet to Dry - place a saline-soaked gauze within a wound after wringing out excess and unfolding. • As the dressing dries, it pulls exudate out of the wound. • The disadvantages of wet-to-dry dressings are that they are nonselective with debridement; therefore, they take healthy as well as necrotic tissue with them. 3. Chemical-impregnated dressings - Many manufacturers provide dressings that are impregnated with chemicals or agents intended to speed up the healing process. 12 • Ex:povidone-iodine, silver, petroleum, collagen, and antibiotics 4. Foam dressings - absorbant and provide a moist healing environment while protecting wounds. • Because of the padding that foam dressings offer, they can be beneficial when used over a bony prominence to provide additional protection. 5. Alginate dressings - are manufactured from seaweedprovide a moist environment for healing and good absorption of exudate, establish hemostasis, and do not adhere to the wound when used appropriately. • They are helpful in treating wounds with large amounts of exudate and can be used as packing for deeper wounds. • Alginates should not be used in dry wounds. 6. Hydrofiber dressings - are similar to alginate dressings in their absorbant properties. do not affect hemostasiscomposed of the polymer carboxymethylcellulose, a substance that can absorb exudate vertically. manufactured in sheets to place in wounds that have considerable exudate. • The sheet materials swell on contact with exudate, thus absorbing the unwanted material. • Cut these dressings to a size just larger than the wound cavity and use a secondary dressing over them. 7. Wound fillers - are manufactured as pastes, powders, gels, and beads for providing a moist healing environment beneath dressings 8. Transparent film dressings - a thin layer of plastic that covers the wound area, provides no absorption but does create a barrier to the environment allow some oxygen exchange and a moist environment to promote healing and autolytic debridement commonly used for wounds with necrotic tissue or for superficial skin tears. • Removal of transparent dressings can cause damage to underlying skin, and the uniform application can cause maceration of wound edges. 9. Hydrogel dressings - used for autolytic debridement, or promoting the body’s own natural functions of removing necrotic tissue. work by maintaining a moist wound environment. • This dressing type is used for wounds with necrosis, infection, and a need for a moist healing environment. • Do not use hydrogel dressings to treat dry gangrene or dry ischemic wounds. • A disadvantage is that hydrogel dressings are costly Negative pressure wound therapy (NPWT) - used to assist in wound contraction and provide debridement and removal of exudate. • This therapy applies suction to a wound area. 15 Drainage – amount, color, odor, consistency 1. Serous – clear, watery 2. Sanguineous – bright red (indicative of fresh bleeding) or darker (older bleeding) 3. Serousanguineous – light pink to blood tinged; mix of serum & red blood 4. Purulent – dark yellow to green, thick, smelly Braden Scale – predicts risk for pressure sore • 19-23=not at risk • 15-18=low risk • 13-14=moderate risk • 10-12=high risk • <9=very high risk skin diagnosing • disturbed body image • deficient knowledge related to wound care • impaired tissue integrity • risk for impaired skin integrity • risk for infection outcome identification/planning – skin diagnosis 16 • maintain skin integrity • demonstrate self-care measures to prevent pressure ulcer development • demonstrate self-care measures to promote wound healing • demonstrate evidence of wound healing • remain free from infection • experience no new areas of skin breakdown • be discharged to home within the established parameters • demonstrate appropriate wound care measures before discharge Wound Drainage 1. Open • Penrose – soft, flexible drain w/out a collection device that promotes passive drainage from greater to less pressure 2. Closed – consist of a drainage tube that may be connected to an electrical suction device or have a portable built-in reservoir to maintain constant low suction a. Jackson Pratt b. Hemovacs Ulcers 1. Venous: injury & poor venous return, resulting form underlying conditions, such as incompetent valves or obstruction 2. Arterial: injury & underlying ischemia, resulting form underlying ocnditions, such as atherosclerosis or thrombosis 3. Diabetic: injury & underlying diabetic neuropathy, peripheral arterial diseas, diabetic foot structure 17 Nursing Process: Skin Integrity 1. Assessment – PUSH Tool used a. Risk b. Mobility c. Appearance i. Location ii. Stage identification iii. Size, length, width, depth iv. Color and type v. Necrotic tissue/slough visable? vi. Exudate/drainage present? vii. Odor viii. Presence/absence of granulation tissue ix. Epithelialization visable? x. Periwound skin condition d. Pain 2. Diagnosis- identifies patient problem & suggests expected outcome a. Disturbed body image b. Deficient knowledge related to wound care c. Impaired tissue integrity d. Impaired skin integrity 20 1. Hemorrhage – occurs from a slipped suture, a dislodged clot at the wound site, infection, or the erosion of a blood vessel by a foreign body, such as a drain 2. Dehiscence – the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed 3. Evisceration – the most serious complication of dehiscence; the wound completely separates, with protrusion of viscera through the incisional area 4. Infection – microorganisms invade the wound a. Purulent drainage b. Increased drainage c. Pain d. Redness e. Swelling f. Increased body temp g. Increased white blood cell count 5. Fistula – an abnormal passage from an internal organ or vessel to the outside of the body or from on internal organ or vessel to another Nursing diagnosis Assessing – collecting, validating, and communicating patient data Diagnosing – analyzing patient data to identify patient strengths and problems Planning – specifying patient outcomes and related nursing interventions Implementing – carrying out the plan of care Evaluating – measuring extent to which patient achieved outcomes NANDA- Oxygenation 21 Ineffective airway clearance – gunk in lungs • Not getting enough air • Thick, yellow secretions • Pale skin with cyanosis • R:40, shallow, crackles • Ineffective cough Impaired gas exchange – low sats, high Co2 • Cyanosis • Pursed-lip breathing • Sitting hunched forward with overbed table • Altered blood gases show respiratory acidosis • SOB, nausea, and ankle edema for 1 week Ineffective breathing pattern • Hyperventilating, tachypneic • Tingling in fingers • Can’t catch breath Decreased cardiac output – weak L. ventricle Activity intolerance – SOB, DOE, dyspnea Anxiety – early sign of hypoxia Fatigue related to impaired oxygen transport system – later sign of hypoxia Imbalanced nutrition: Less than body requirements – use extra calories to breath 22 Disturbed sleep pattern – cough, orthopnea Cough – cleansing mechanism of the body to help keep the airway clear of secretions (more effective when combined with deep breathing) Deep breathing – encourages expansion of alveoli, increases relaxation, reduces anxiety Pursed-lip breathing – exhaling through pursed lips creates a smaller opening for air movement, effectively slowing and prolonging expiration • Results in decreased airway narrowing during expiration and prevents the collapse of small airways • Improves air exchange and decreases dyspnea • Helps patient control the rate and depth of respiration, helping to reduce dyspnea • Encourages relaxation Lung sounds 1. Crackles – soft, bubbling, popping, high-pitched discontinuous (intermittent) sounds a. Air passing through fluid in the airways b. Due to inflammation or congestion and are associated with pneumonia, heart failure, bronchitis, and COPD 2. Wheezes – continuous musical, high pitched sounds produced during as air passes though airways constricted by swelling, narrowing, secretions, or tumors a. Heard in pt with asthma, tumors, or a buildup of secretions b. Air passing through narrowed airways 3. Rhonchi – course, snore like, low-pitched, continuous sounds a. Coughing may clear the sound 25 ▪ hypoventilation Drugs that can cause respiratory depression 1. Opiates 2. Benzodiazepines 3. Barbiturates Infectious Agents • Pathogens • Normal flora that become pathogenic Stages of Infection 1. Incubation period – period b/t pathogen’s invasion of the body and the appearance of symptoms of infection a. Organisms are growing and multiplying b. Lasts 1-2 days 2. Prodromal stage – most infectious stage; early signs and symptoms of disease present, but often vague ranging from fatigue to malaise. a. Lasts several hours to days. b. Patient is often unaware resulting in the spread of infection. 3. Full stage – specific s/s of disease 4. Convalescent – recovery period 26 Factors that increase infection risk • Developmental stage • Breaks in the skin • Illness/injury, chronic disease • Smoking, substance abuse • Multiple sex partners • Medications • Medical procedures Infectious agents 1. Bacteria – most significant and most prevalent in hospital settings 2. Virus – smallest of all microorganisms 3. Fungus – plant-like organisms present in air, soil, and water Signs of infection 1. Redness 2. Heat 3. Swelling 4. Pain 5. Loss of function Lab data indicating infection 1. Elevated WBC count – normal is 5,000 to 10,000 2. Increase in specific types of WBC 3. Presence of pathogen in urine, blood, sputum, or draining cultures Jaundice – yellow hue due to high blood levels of bilirubin, a breakdown product of hemoglobin that is potentially toxic Erythema – redness of skin cause by dilation of superficial blood vessels • Sunburn, fever, trauma, inflammation, allergic reaction Chronic infection – the body is never completely rid of the pathogen, but symptoms may disappear temporarily between flare ups due to physical/emotional stress or weakening due to another illness 27