1. How does the RN Assess the Appearance of the Wound?
1.1. Look for signs of infection
1.2. Location of Wound and what type of wound is it?
1.3. Measure the length, width, and depth of the wound using a disposable ruler and sterile cotton swab if tunneling is present.
1.4. Take note of the color of the wound bed and the surrounding skin's color and firmness.
1.5. Note the characteristics of the wound edges.
1.6. Look for any exudate or drainage and note its characteristics.
1.6.1. How to Document Drainage from a Wound
1.6.1.1. Record the amount of drainage, what type it is (serous - clear liquid, serosanguinous - clear with some blood, purulent - thick and white) and the color of the drainage is applicable.
1.7. Notice if there are any foul smells coming from the wound.
1.8. 5. Look at the texture, specifically for granulation, eschar and slough.
1.9. 6. If skin is intact, with gloved hands gently place dorsal side of hand against wound to feel for warmth.
1.10. 7. Blanching can be assessed in in tact wounds as well.
1.11. Wound Dressings
1.11.1. Vacuum Assisted Closure Systems
1.11.1.1. An automatic suctioning device that is fixed to the wound's dressing. They assist in wound contraction and provide debridement and removal of exudate. Must be applied by a trained wound specialist. It can be used in hospital, office, long term and even home settings.
1.11.1.1.1. Why are they Beneficial?
1.11.2. Wound dressings can be used to maintain moisture, absorb moisture or add moisture to a wound. There are a growing number of options to choose from.
1.11.2.1. Transparent Film
1.11.2.1.1. Helps keep moisture out
1.11.2.1.2. Good for pressure ulcers with skin intact
1.11.2.1.3. Provides barrier from friction against sheets
1.11.2.2. Wet to Dry
1.11.2.2.1. Used for mechanical debridement of wound
1.11.2.2.2. No longer considered good practice
1.11.2.3. Hydrocolloid
1.11.2.4. Dry Dressings
1.11.2.5. Chemical-impregnated Dressings
1.11.2.6. Foam Dressings
1.11.2.7. Alginate Dressings
1.11.2.8. Hydrogel Dressings
1.11.2.9. Wound Fillers
2. Wound Dehiscence v. Wound Evisceration > Dehiscence is when a sutured wound ruptures/opens after surgery. > Evisceration is a more serious form of dehiscence where the underlying organs protrude through the ruptured sutures/incision.
2.1. Pressure Injury Stages
2.1.1. Suspected Deep Tissue Injury: Discolored and intact skin. If the underlying tissue feels spongy, you can assume damaged tissue is present.
2.1.2. Stage 1: Skin intact, red, may be swollen, blanching does not occur when palpated.
2.1.3. Stage 2: Partial thickness skin loss. Wound may be open or have a fluid filled blister.
2.1.4. 3. Full thickness tissue loss without exposed muscle or bone. Possibility of tunneling present.
2.1.5. 4. Full thickness tissue loss with exposed muscle and/or bone. Possibility of tunneling and eschar are present.
2.1.6. Unstageable Wounds: are not classifiable due to being covered by eschar or slough. Eschar is surgically removed before staging of wound and care plan can be determined.
2.1.6.1. Eschar: necrotic tissue that appears black and scab like. Can cover a wound and make it impossible to see what is beneath.
2.1.6.2. Slough: yellowish-white, stringy tissue found in the wound bed. It is made of dead skin cells and wound exudate.
2.2. Risk Factors Associated with Increased Pressure Injuries
2.2.1. Reduced mobility/activity
2.2.1.1. Ex: prolonged periods of sitting in the same position causes pressure on bony prominences and can also increase moisture, which in turn increase risk of PI.
2.2.2. Perfusion alterations
2.2.2.1. Ex: diabetes, cardiovascular disease, high blood pressure, poor circulation, and a history of smoking all increase risk of pressure injury development.
2.2.2.1.1. Gohil (2021) expands upon the increased risk of pressure injuries and slow healing wounds for diabetic patients and provides solutions for healthcare workers assessing and monitoring this population.
2.2.3. Skin Status and Pressure Injury History
2.2.3.1. Ex: thin skin that has edema is at an increased risk; history of pressure injuries increases risk.
2.3. Explain how RN would treat deep tissue injuries stages 1-4
2.3.1. Stage 1: RN will need to keep pressure off of the wound as much as possible be regular repositioning of the patient. The wound can also be covered with a transparent film bandage or barrier cream to ensure no further friction and skin breakdown occurs. Monitor the wound regularly.
2.3.2. Stage 2: RN needs to remove pressure from wound, keep wound clean and dry with a mild saline solution. Dry gently with gauze and bandage accordingly.
2.3.3. Stages 3 & 4: Requires immediate medical intervention of antibiotic therapy to reduce risk of spreading infection. RN will need to irrigate and debride the wound as needed to promote healing and prevent infection.
2.3.4. Unstageable: Patient would have eschar surgically removed. RN will stage wound pot-operatively and continue care from there.
2.4. Complications Associated with Pressure Injuries
2.4.1. Gangrene - Bacterial infection of necrotic tissue that is difficult to treat and can lead to amputation of affected limb.
2.4.2. Necrosis - Tissue death
2.4.3. Sepsis - Blood Infection
2.4.4. Cellulitis - Infection of Connective Tissue and Skin
2.4.5. Bone and Joint Infections
3. List and Describe The Stages of Wound Healing
3.1. Physiology of Healing Process
3.1.1. Hemostasis Phase
3.1.1.1. > The body attempts to stop blood flow to an injury by clotting. > Lasts seconds to minutes after an injury.
3.1.1.1.1. Clotting: Blood vessels constrict near the site then platelets stick together forming a dam.
3.1.2. Inflammatory Phase
3.1.2.1. A complex immune response process to acute injury that also triggers the complement system.
3.1.2.1.1. Signs and Symptoms: change in skin color, heat, swelling, pain, and possible loss of function
3.1.2.1.2. Purpose: Protects body from further injury and expedites healing.
3.1.3. Proliferative Phase
3.1.3.1. Wound is filled with new tissue and angiogenesis occurs.
3.1.3.1.1. Angiogenesis is the formation of new blood vessels.
3.1.3.1.2. Signs and Symptoms: mild swelling, granulation tissue, epithelization/new scar formation.
3.1.3.1.3. Purpose: Restore skin integrity.
3.1.4. Maturation and Remodeling Phase
3.1.4.1. Final step in wound healing overlaps with the proliferation phase and can last over 1 year.
3.1.4.1.1. Signs and Symptoms: changes in scar coloration, reduced vascularization, and scar may thin overtime.
3.1.4.1.2. Purpose: Remodeling reorganizes collagen within a scar to increase skin integrity in an attempt to regain as much of the original skin’s strength as possible.
3.2. Primary Healing Process
3.2.1. When a wound is closed using staples, stitches, glues, or other forms of wound-closing measures.
3.3. Secondary Healing Process
3.3.1. Secondary wound healing is when a wound that can't be stitched together causes a large amount of tissue loss.
3.4. Tertiary Healing Process
3.4.1. When a wound is left open after a procedure when there is a need to delay the wound-closing process. Usually there is a risk for certain infection if wound is closed prematurely.
3.5. Factors that Affect Wound Healing
3.5.1. Intrinsic Factors
3.5.1.1. Age
3.5.1.1.1. Epidermis is more prone to injury as it thins with age Cell functions for wound healing diminish overtime
3.5.1.2. Chronic Illness
3.5.1.2.1. Suppressed immune systems. Chronic respiratory disorders can be inhibitive since wound healing requires an oxygen-rich environment.
3.5.1.3. Reduced Skin Sensation
3.5.1.3.1. At risk for repeat trauma and less awareness of injury since patients are unable to recognize pain.
3.5.2. Extrinsic Factors
3.5.2.1. Medications
3.5.2.1.1. Corticosteroids suppress the immune system and Meds that inhibit platelet action.
3.5.2.2. Cancer Treatments
3.5.2.2.1. Radiation and Chemotherapy suppress the immune system through cell destruction
3.5.2.3. Inadequate Nutrition
3.5.2.3.1. Not getting enough vitamins or protein can slow healing
3.5.2.4. Stress
3.5.2.4.1. Neurochemicals released during periods of stress can alter body’s response to injury
3.5.2.5. Infection
3.5.2.5.1. Localized infection and systemic infections can divide macrophage and leukocyte’s attention from wounds.
3.5.2.6. Repeat trauma or damage to underlying tissue