January 14 Management of Skin & Wounds Flashcards
Wounds in Canada Facts
70% of these wounds considered preventable
The prevalence of pressure Injury across all health-care settings estimated to be 26%
Stage 2 pressure injury can cost up to $44,000 per patient; up to $90,000 per patient for Stage 4.
15 per cent of Canadians (345,000 people) living with diabetes will develop a diabetic foot wound in their lifetime
Complications from diabetic foot wounds led to more than 2,000 amputations across Canada in 2011–2012, which cost 10 to 40 times more than initiatives to prevent amputation
Ostomy and would care
And services 5
Consultation-based practice
Speciality Mattress
- Acute care
- Triage-base
- Nurse initiates consult
Ostomy
- Pre/post op
- Outpt follow up
- Nurse initiates consult
Complex wounds
- Acute care
- Stage 3, 4 + pressure injury, NPWT, complex surgical wounds, fistulas, etc.
- Most responsible physician (MRP) initiates consult
Negative pressure wound therapy
- Acute care and community
- Specialist initiates consult (i.e. Plastics, General Surgery Vascular)
Phone Consult
- Acute Care, Rural, LTC, etc.
- Limited in scope
- Patient, nurse or MRP initiates consult
Skin
- Largest what
- how much does it weigh and how thick
- Ph of skin?
- Two primary layers?
Largest organ in the body
6 to 8 lbs
0.5 to 6 mm thick
Acidic pH (4.5-6.5)
‘Acid mantle’ protects skin
Two primary layers:
Dermis
Epidermis
Function of skin 7
Thermoregulation Regulation of cutaneous blood flow Insulation Immunity Sensory perception Barrier function / protection Synthesis of Vitamin D
6 Risk factors of Skin
Understand loosly? Mostly the headings
Age
-old/young
Comorbidities: Liver disease Renal diseases Autoimmune disease DM (glycemic control) Spinal cord injury
Psychosocial: Poverty Chronic pain Stress Smoking, ETOH
Treatments: Chemo/RT Immunosuppression Anticoagulants Steroids
Nutrition:
Malnutrition
Calorie, protein and nutrient deficiency
Circulation: Immobility COPD CAD, LEAD PVD Vascular/thrombotic disorders
Risk Factors age:
6
Decreased elasticity
Decreased adipose layer
Decreased padding, feel cold
Decreased sweat
-Dry, flaky skin
Decreased tensile strength
-Risk for friction, shear, skin tears
Decreased inflammatory response
Increased risks r/t decreased nutrition, hydration, mobility, ability to conduct ADLs (i.e. hygiene)
Risk Factors Nutrition5
Recent unintentional weight loss
Obesity
Lack of key vitamins and minerals
Low serum albumin
Nutrients that help heal
Protein
Vitamins A, C, and B-complex
Iron, Copper, Zinc
Braden scale for predicting pressure injury risk
Key benefits: 4
Score 4 15to18 12to14 10to12 9orless
Identification of at-risk patients using consistent tool
Quantifies severity of risk
Informs Nursing Care Plan
Provides Nursing interventions based on level of risk in six specific risk areas.
At risk Moderate Risk High Risk Very High Risk The smaller it is the worse it is
Wound Classification
2
and describe
Partial thickness
-Loss of epidermis and possibly part of dermis
Full Thickness
-Damage through epidermis, dermis and into subcutaneous layer, possibly to muscle and bone
Wound Healing
4 steps
Hemostasis
- starts in minutes, last 5-10
- initiates healing/growth factor
- Vasoconstriction, platelets clump/clot
Inflammation
- Injury triggers increased blood flow = warmth redness edema exudate pain
- Neutrophils & macrophages digest bacteria, debris to clean wound bed
- Growth factors stimulate granulation tissue
- Lasts 3-7 days (depending on patient factors)
Proliferation
- Granulation tissue, new blood vessels, contraction of wound margin, epithelial cells migrate across surface of granulated tissue
- Most surface (rich blood supply
- 4 to 24 days
Maturation
- Remodeling after closure
- Scar tissue = strength = collagen
- 80% of old strength and limited elasticity
- 2 years plus
Builds bottom to top
What is granulation?
What is it made up of
What does it look like
How does it bleed
Growth of small blood vessels and connective tissue in a full thickness wound
Collagen + Capillaries + Cells
Red, bumpy with “meaty” appearance
Does not bleed easily
What is epithelialization?
Where does it come from
Needs what kind of wounds
Delayed until?
Regeneration of epidermis across a wound surface
Migrates from surrounding skin
Needs open wound edges, not rolled
Delayed until granulation forms, as needs a moist, vascular wound bed.
Skin Assessment
- Head to toe
- Check hidden area
What do you use document
Head to toe: Turgor (dehydration?) Moisture (dry, itchy, wet, weeping?) Colour (redness, white, bruises?) Temperature Swelling / firmness (induration?) Irritation (breakdown, rash, blisters?) Healed ulcers/scars
Check “hidden” areas:
Creases / skin folds (breasts, pannus, groin, armpits)
Perineal / perianal
Joints, boney prominences
Braces, casts, orthotic and prosthetic devices
If you find a dressing lift and look
NISS Wound Record
Name some causes you can eliminate
Name some causes you can decrease
Pressure, friction, shear
Moisture
Infection
Recurring trauma
Poor mobility Poor nutrition Poor circulation Smoking Blood sugars Disease process Neuropathy/ paralysis
What to do if you find a wound 6
wounds affect pt as a whole
Assess wound Identify cause Record Provide wound care (cleaning or dressing) Wound management into care plan Alert most responsible practitioner
MRP directs wound management and provides orders
MRP might initiate consult to Ostomy and Wound Care for assessment of complex wound
or
MRP may initiate consult to specialist (Plastics, Vascular, Dermatology) for assessment of complex wound
