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Largest organ of the body15% of body weightPurpose:ProtectionAbsorptionExcretion & secretionImmune functione. Temperature regulationf Sensationg. IdentificationInflammatory phase: Initiated immediately after injury; lasts 3 to 6 days. 1. Hemostasis: cessation of bleeding results from a. VASOCONSTRICTION of the larger vessels in the affected area b. Retraction (drawing back) of injured blood vessels c. Deposition of fibrin (connective tissue) d. Formation of CLOTSe. The inflammatory phase also involves vascular and cellular response intended to remove any foreign substances. The blood supply to the wound increases, bringing with it oxygen and nutrients needed in the healing process. 2. Phagocytosis: removal of foreing substances. B. Proliferation phase: 1. Angiogenesis: 30 year old has not had time to make new blood vessels. 2. Re-epithelization: C. Maturation phase: begins about day 21 and can extend 1 or 2 years after injury. Collagen start to migrate in orderly fashion. Hypertrophic: increased amount collagenKeloid: scare does not stop growing. Wound Healing.Regeneration or renewal of tissue. There are two types of healing, influenced by the amount tissue loss. Primary intention healing: occurs where the tissues surfaces have been approximated (closed) and there is minimal or no tissue loss; it is characterized by the formation of minimal granulation tissue and scaring. Examples include: A closed surgical incision Used of tissue adhesive, a liquid glue that can be used to seal clean lacerations or incisions and can result in less noticeable scars. Secondary intention healing: healing of a wound that is extensive and involves considerable loss, and in which the edges cannot or should not be approximated. Pressure ulcer. Secondary intention healing differs from primary intention healing in three ways. The repair time is longerScaring in greaterSusceptibility to infection is greater. Types of Wound ExudateExudate is material such as fluid and cells, that escape from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces. There are three types of exudate:Serous exudate Consists chiefly of serum derived from blood and serous membrane of the body. Purulent exudate Thicker than serous exudate because of presence of pus. Pus consists of leukocytes, liquefied dead tissue debris, and dead and living bacteria. Suppuration: process of puss formation; color depends on causative organism. Sanguineous exudate consists of large amounts of red blood cells. Indication of damage to capillaries. Serosanguineous: consists of clear and blood tinged drainage. Commonly seen in surgical incisions. Purosanguineous exudate: consists of pus and blood. Often seen in a new wound that is infected. What are the main complications and factors that affect wound healing? Hemorrhage: Massive bleeding caused by dislodged clot, a slipped stitch, or erosion of a blood vessel may cause severe bleeding. Internal hemorrhage may be detected by swelling or distention in the area of wound and, possibly by sanguineous drainage from a surgical drain. 2. Some clients may have hematoma, localized collection of blood underneath the skin, appearing reddish blue swelling. 3. Large hematomas are danger; they place pressure on blood vessels and can thus obstruct blood flow. 4. Hemorrhage is an emergency, Nurse should apply pressure dressing to the area and monitor vital signs. Infection: Because the colonizing organism compete with new cells for oxygen and nutrition, and because their by-products can interfere with healthy surface conditions, the presence of contamination can impair wound healing and lead to infection.Infection suggest by a change in wound color, pain, odor, or drainage is confirmed by performing a culture of the wound.Severe infections causes fever and elevated white blood cell count. A wound can be infected with microorganisms at time of injury, during surgery, or postoperatively. Surgery involving intestines can result in infection as result of microorganisms inside intestine.Surgical infection is most likely to become apparent 2 to 11 days post-operatively. Dehiscence with Possible Evisceration: Dehiscence: partial or total rupturing of a sutured wound. Dehiscence usually involves an abdominal wound in which layers below the skin separate. Evisceration: protrusion of the internal viscera through an incision. Obesity, poor nutrition, multiple trauma, failure of suturing, excessive coughing, vomiting, and dehydration, heighten a client’s risk to dehiscence.When dehiscence or evisceration occur, the wound should be quickly supported by a large sterile dressings soaked in sterile normal saline. Place the client in bed with knees bent to decrease pull on the incision. What are the main factors that affect wound healing? Developmental considerations (Age): Healthy children and adult often heal more quickly than older adults, who are more likely to have chronic disease that hinder healing. (From box 2 page 831)Vascular changes associated with aging, such as atherosclerosis and atrophy of capillaries of the skin, can impair blood flow to the wound. Collagen tissue is less flexible, which can increase the risk of damage from pressure, friction, and shearing.Scar tissue is less elasticChanges in the immune system may reduce the formation of the antibodies and monocytes necessary for wound healing. Nutritional deficiencies may reduce number of red and white blood cells, thus impeding delivery of oxygen and the inflammatory response. Oxygen is need for the synthesis of collagen and the formation of new epithelial cells. Having cardiovascular disease and or diabetes increases risk for delayed healing due to impaired oxygen delivery to these tissues. Cell renewal is slower, leading to delayed healing. Nutrition: Wound healing places additional demands on the body. Clients require a diet rich in: Proteins, carbohydrates, lipids.Vitamin A and CIron, Zinc, and Copper Lifestyle: People who exercise tend to have good circulation. Blood brings oxygen and nourishment to wound, they are more like to heal quickly. Smoking reduces the amount of functional hemoglobin in the blood and constricts arterioles. Medications: 1. Anti-inflammatory drugs (steroids and aspirin)2. Antineoplastic agents interfere with healing. 3. Prolonged use of antibiotics may make a person susceptible to wound infection by resistant organism. Nursing Management Assessment Skin IntegrityNurse conducts examination of the integument as part of routine assessment and during regular care. Remove barriers such as anti-embolic stockings, braces, or devices. Nursing history and Physical assessment. Principles of Care & Assessment of Untreated Wounds: ----------------------------------------------->1. Control severe bleeding by: Apply pressure over the woundElevate the involved extremity2. Prevent infectiona. Clean or flush abrasion or laceration with normal salineb. Cover the wound with clean dressing. (Sterile dressing preferred)When applying dressing, wrap the wound tightly enough to apply pressure and approximate wound edges. If first layer becomes saturated with blood, apply a second layer without removing the first layer of dressing to avoid disturbing blood clots, thus preventing more bleeding. 3. Control swelling and pain by applying ice over the wound and surrounding tissues. 4. If bleeding is severe or if internal bleeding is suspected, and if emergency equipment is available, assess the client for signs of shock: a. Rapid thread pulseb. Cold clammy skinc. Pallor d. Lowered blood pressure. C. Treated Wounds: are usually assessed to determine the progress of healing. 1. May be inspected during change of dressing. 2. If wound cannot be inspected directly, the dressing is inspected and pain. 3. Assessment of treated wounds involves observation of its:a. appearance b. sizec. drainaged. swelling- if presente. painf. statues of drains and tubes.4. Estimate amount of drainagea. Minimal drainage: only stain the dressing.b. Moderate: saturates the dressing without leakage prior to dressing change.c. Heavy: overflows the drainage. D. Pressure Ulcers: 1. When pressure ulcers are present, nurse notes the following. a. Location of ulcer, related to bony prominence. b. Size of ulcer in centimeters (cm) i. L,W,& depth: length= head to toe, width= side to side. (Fig 5, 832) ii. Presence of undermining and sinus tract. iii. Stage of Ulcer (fig. 1) iv. Color of wound bed and location of necrosis or eschar. v. Conditions of wound margin.vi. Conditions of surrounding skin.vii. Clinical signs of infection: color of exudate, warmth, redness, swelling, pain, and odor.2. Document status and wound on standard agency form. 3. Laboratory date: can support assessment of wound’s progress in healing. a. Leukocyte count (low) can delay healing and increase risk for infection. b. Hemoglobin below normal range= poor oxygen delivery to tissue. c. Coagulation (prolonged)= excessive blood loss; prolonged clot absorption. d. Hypercoagulability: can lead to in intravascular clotting, resulting in deficient blood supply to the wound. e. Serum Protein analysis: provides indication of body’s nutritional reserves for rebuilding cells. i. Albumin: < 3.5 g/dL= poor nutrition= healing and high risk for infection. 4. Skill 1: guidelines to obtain specimen of wound drainage. I. DiagnosingA. The NANDA that relate to clients who have skin wounds are or who are at risk for skin breakdown are as follows: 1. Risk for impaired skin integrity: at risk for being adversely altered.a. Applies to pressure ulcers b. To wounds extending through the epidermis but not through the dermis. 2. Impaired skin integrity: altered epidermis and / or dermis. 3. Impaired Tissue Integrity: damage to mucous membrane, corneal, integumentary, or subcutaneous tissue. a. Applies to pressure ulcers and wounds extending into subcutaneous tissue, muscle, or bone. 4. Risk for infection: if skin impairment is severe, immunosuppressed client, or wound caused by trauma. 5. Acute pain: r/t nerve involvement within the tissue impairment or as a consequence of procedure used to treat wound. II. PlanningA. For clients at risk for Risk for Impaired skin integrity, major goal is to maintain skin integrity and avoid potential associated risks. B. Clients in Impaired skin integrity, goal is to demonstrate progressive skin healing and restore skin intact within specific time frame. III. ImplementingA. Supporting wound healing. Four major areas in which a nurse can help a client develop optimal wound healing conditions. 1. Moist wood healing: a. dressing and frequency of change should support moist wound conditions. b. wound beds that are too dry or disturbed fail to heal. 2. Nutrition and Fluids: a. Assist client to intake at least 2500 mL of fluids, unless contraindicated. b. Adequate amount vitamins and minerals. Excessive amount not necessary. c. Ensure client receives C,A,B1, B5 and Zinc. d. Registered Dietitian consultation helpful to ensure correct supplementation met. 3. Prevent infection: there are two ways. a. prevent microorganisms from entering the wound. b. prevent transmission of bloodborne to or from client or other. (Table 3, p. 838)4. Positioning: to promote healing, client must be positioned to keep pressure off wound(off-laoding).a. Assist client to be mobile to enhance circulation. b. Range-of-motion exercise and turning schedule if client not independent.B. Preventing Pressure Ulcer: Nurse instruct clients, support people, and caregivers on how to prevent pressure ulcer.Risk assessment tool: Norton and Branden scale.1. Institute for Healthcare Improvement’s (5 million Lives Campain) delineates two major steps:a. Identify clients at risk.b. Implement strategies for all clients.2. Nurse conducts pressure ulcer assessment on admission. 3. For clients at risk, nurse optimizes nutrition and hydration, keep client dry, inspect skin, and minimize pressure. 4. Provide Nutriton: monitor weight, and assess nutritional status.5. Monitor lymphocyte count, protein (albumin), and hemoglobin. 6. Maintain skin hygiene7. Avoid skin traumaa. avoid shearing forces by not elevating > 30 degrees unless contraindicated.b. Never use cornstarch or baby powder. c. reposition every 2 hours. 8. Provide supportive devicesa. Overlay mattress on top of standard mattres, replacement of standard matress with mattress made of gel and foam, and specialty beds. b. Use pressure reducing devices: foam, gel, air pillows. c. Doughnut-type devices are NEVER used. C. Treating pressure Ulcers. Nurse should follow agency protocol. 1. RYB color Code: To guide wound care. a. Red: protect (cover) red. i. gently cleaning, fill dead space with hydrogel or alginate, cover with appropriate dressing. b. Yellow: clean (yellow) characterized by liquid to semiliquid (slough)c. Black: wound are covered with thick necrotic tissue. Nurse must debride (black): i. sharp: scalpel or scissorsii. mechanical: scrubbing force or damp-to-damp dressing. iii. chemical: collagenase enzymes such as papin-urea recommended. Debridement TypeProcedureTimeWound TypeSharp (conservative or surgical)ScalpelQuickestRemove necrotic tissue and thick escharStage IV ulcersMechanicalWet to dry dressingsWound irrigationsHydrotherapyChange every 4 to 6 hrsRemove stringy exudatesSmall to moderate woundsChemicalTopical enzymatic agentApply as directedDevitalized tissueAutolyticMoisture retentive dressing + enzymesApply as directedLiquefy selective dead tissueD. Dressing wounds: applied for the following purposes. 1. protect from mechanical injury2. protect from microbial contamination3. provide thermal insulation4. Absorb drainage or debride a wound or both. 5. prevent hemorrhage.6. splint or immobilize wound. Table 5: selected type of Wound dressing. Page 842Hydrocolloids: frequently used for pressure ulcers.a. last 3 to 7 days.b. do not need cover. Client can shower c. they are molded to uneven body surfaces.d. effective bacterial barriere. decrease painf. absorb moderate drainageg. contain wound odor.Cleaning Wounds: Venous UlcerRuddy color base (we can get blood there, but we can’t remove it)Shallow woundIrregular marginsModerate to heavy exudateWarm skin temperature Minimal to severe painPedal pulses present Medial VSArterial: Pale base color when elevated (pale due to poor circulation to it)Shiny, taut skinPunched out appearance Minimal exudate Cool skin temperature Pain with rest & exercisePedal pulses diminished or absentLateral HeatColdVasodilationvasoconstrictionIncreases capillaries Decreases capillariesPermeability permeabilityIncrease cellular decrease cellular metabolismMetabolismIncreases inflammation slowDecreases inflammation,slows bacterial growthSedative effectLocal anesthetic effect. Variables Affecting Physiological Tolerance to heat and Cold.a. Body: back of hand and foot are very sensitiveb. size of Exposed body part: the larger the body part, the lower the tolerance. c. Individual tolerance: very young and very old have low tolerance. D. Length of exposure: after a period of time, tolerance increases. e. Intactness of skin: Injured skin areas are more sensitive to temperature variations. Rebound Phenomenon: example: Heat; vasodilation for 20 to 30 mins; after, vasoconstriction occurs.Cold: vasoconstriction occurs when skin reache 15.Table 8 Page 853A. Muscle spasms Heat: relaxes muscles and increases contractility.Cold: relaxes muscle, but decreases contractilityB. Inflammation: Heat: increase blood flow, soften exudatesCold: vasoconstriction decreases capillary permeability, decreases blood flow, slows cellular metabolism. C. Pain: Heat: relieves pain. Possibly by promoting muscle relaxation, increases circulation, acts as counterirritant. Cold: decreases pian by slow nerve conduction, blocks nerve impulses, increases pain threshold. D. Contracture: Heat: reduces contracture and increase join ROME. Join stiffness: reduces join stiffness by decreasing viscosity of synovial fluid and increase tissue distentibility. F. Traumatic Injury: Heat: no effectCold: decreases bleeding by constricting blood vesselsDecreases edema by reducing capillary permeability. ................
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