Class 7 - Nursing Interventions Chronic Illness and Chronic Wound Management Flashcards
factors that can predispose the older adult to skin breakdown are
- age
- nutrition (fluid and food intake)
- genetics
- immobility
- chronic illnesses
- polypharmacy
- cognitive impairment
what is a primary intention wound
- Wound surfaces are approximated (to bring
together the cut edges) closed and no or
minimal tissue loss (i.e. surgical wound) - heals from the top down
- Healing occurs within the connective tissue
what is a secondary intention wound
- Wound is open, involves considerable tissue
loss – edges can not be approximated
- heals from the bottom up
- Healing occurs through granulation
pressure ulcerwhat is a tertiary intention wound
- Wound is left open initially (3-5 days), then
edges are approximated - reasons for delay due to, edema or infection
to resolve or exudate to drain - closed with staples, sutures, or adhesive skin
- healing occurs both from the bottom and the
top
partial vs full thickness wound repair
partial:
- shallow, involves loss of epidermis and partial
dermis
- heals by regeneration (ex: surgical wounds)
full
- extend beyond the dermis
- heals by scar formation - deeper structures do
not regenerate (ex: pressure ulcers)
what are the stages of wound healing
- inflammatory phase
- immediate repsonse occurs (redness,
swelling, throbbing, heat and pain)
- lasts 3-6 days - proliferation phase
- lasts 3-24 days
- this is the rebuilding stage of the wound with
granulation tissue - maturation phase
- begins about day 21 can take up to 2 yrs
- remodelling occurs
what are some types of chronic wounds
- pressure ulcers
- venous and arterial wounds
- diabetic ulcers
- fungating wounds (cancer wounds)
what is a skin tear
a wound that is caused by shear, friction and or blunt force resulting in the separation of skin layers
what are some causes of skin tears
- blunt trauma
- shearing or friction
- removing tape
- removing stockings
- banging into furniture
who is at risk for skin tears
- older adults over the age of 85
- females
- immobilized persons
- polypharmacy
- dehydration
- poor nutrition
- cognitive impairments
what can be done to prevent skin tears
- skin hygiene
- hydration
- proper transferring
- avoid using adhesive products on frail skin
- avoid antiseptics, chemicals and heavy soaps
- proper clothing (long sleeves, long pants)
what are the three things to do for a skin tear to treat it
- control bleeding
- approximate edges
- dressing
what are venous wounds
- caused by poor blood return
- result of weak veins, decreased ability of the
calf muscle to pump blood back up to the
heart (d/t limited ROM)
what are the signs and symptoms of venous wounds
- edema
- pain (constant or intermittent)
- discoloration of the skin
- hardening of the skin around the ulcer
- itching, heaviness and aching
what causes venous wounds
- obesity
- blood clots
- varicose veins
- immobility
- diabetes
how can you treat a venous wound
- absorbent dressings
- compression bandages or stockings to
support the valves in the veins to improve
blood flow
what are arterial wounds
- these are ischemic ulcers (arterial
insuficiency). Build up of fatty substances in
the wall of the artery
- they are commonly caused by peripheral artery disease (PAD).
what causes arterial wounds
- poor blood supply
- vasculitis
- diabetes
- renal failure
- high blood pressure
- trauma
what are the signs and symptoms of arterial wounds
- painful
- pale or necrotic wound bed
- they often appear on the distal lateral
extremity - the effected extremity is usually cool, absent
of hair growth, has diminished pulses and
thickened toenails
what can you do to treat arterial wounds
- urgent treatment
- DO NOT use compression bandages (this can
reduce blood supply further) - surgery may be indicated to clear the blocked
artery
