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Term Test 2 Study Guide
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Lecture notes of 56 pages for the course PNUR 124 at (Test 2 Study Guide)
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PNUR 124Test 2 Study Guide
Week 5: Wound Care
Types of Wound Healing
Primary intention
o Primary intention healing happens when the wound edges are approximated e.g. by sutures,
staples or glue.
Secondary intention
o Healing by second intention or Secondary intention healing takes place when the wound edges
cannot be approximated and the wound needs to heal from the bottom.
Phases of Healing
1. Inflammatory phase – This phase begins at the time of injury and lasts up to four days. ...
2. Proliferative phase – This phase begins about three days after injury and overlaps with the
inflammatory phase. ...
3. Remodeling phase – This phase can continue for six months to one year after injury.
Types of Drainage
Serous
Sanguineous
Serosanguinous
Purulent
Wound Complications
Infection/sepsis
Gangrene
Nerve or organ damage
Amputation
Skin Ulcers
Skin ulcers are a common issue in geriatric and nursing home care.
The impact of skin ulcers can be significant with increased length of hospital stays, higher rates of
nursing home placement, and decreased quality of life. The management of a large ulcer can be
daunting but a sound basic approach can have a significant impact on the majority of ulcers.
The purpose of this presentation is to provide an approach to ulcer management, with emphasis on
assessment, optimization of the healing environment and choice of dressings
Prevention of ulcers is important in frail older patients.
Clarifying the cause and contributing factors is the first step in management.
Pressure and venous ulcers are the most common cause in the elderly. Poor nutrition, edema, arterial
insufficiency, and anemia commonly impair wound healing. Adequate debridement is important to
decrease infection risk and to promote healing. Guidelines exist for the cleaning of ulcers.
The choice of dressings depends on the needs of the individual wound but should emphasize the
provision of a moist wound environment.
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When you assess a wound, you need to know if the intention is to heal the wound, prevent further
injury (maintain) or treat as palliative
Need to know “heal-ability” of wound and this is dependent on the following:
o Oxygenation
o Infection
o Foreign body
o Venous sufficiency
Risk Factors for Pressure Ulcer Development
Poor mobility/immobility: Patients who are unable to independently change position are at increased
risk of developing a pressure ulcer, due to pressure exerted over bony prominences which results in
reduced blood flow to the tissues and subsequent hypoxia.
Poor nutritional status: Although there are few studies to support this idea, it is widely accepted
(based on anecdotal evidence) that patients who are compromised nutritionally are at higher risk for
the development of pressure ulcers; for this reason, patients with poor nutritional status may benefit
from a dietary consult.
Compromised blood flow: Whenever there is compromised blood flow to the tissues, there is
increased risk of pressure ulcer development. What are some common reasons that blood flow might
be compromised? Peripheral arterial disease (PAD), venous insufficiency and shock are common
culprits.
Neuropathy/compromised sensation: Obviously, if you cannot feel pain or pressure, you are at higher
risk of developing a pressure ulcer. Patients who fit into this category include patients with spinal cord
damage, stroke, MS, neuropathy and other conditions that compromise one’s ability to perceive pain
and/or pressure.
Skin color/changes: Patients with darker skin pigmentation may be at risk for pressure ulcers simply
because health care professionals fail to recognize the early signs of pressure damage (i.e. blanching
erythema). In addition, patients with conditions that change the normal appearance of the skin are at
high risk (e.g. patients with bruising, dermatitis, eczema and other skin diseases).
Support surfaces: The surface upon with the patient lies or sits can profoundly influence pressure over
bony prominences, as can lying or sitting in the same position for long periods of time. Support
surfaces should be assessed frequently and adjusted accordingly.
Pain: Pain may prevent patients from moving, even when they are feeling the unpleasant effects of
pressure. Too much pain medication may sedate patients to the point where they don’t change
position as often as they should. Patients should be assessed for their ability to move while still
maintaining an acceptable level of comfort.
Age: At the extremes of age, patients may be at higher risk for the development of pressure ulcers due
to inability to move/change position independently. Very young infants are unable to change position
by themselves; the elderly may be similarly unable to change position due to other health problems
limiting movement.
Mental status: Patients suffering from dementia or other cognitive disorders may be unable to
comprehend instruction given that could help prevent pressure injuries, or may fail to recognize
discomfort as a signal to change position.
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Incontinence: Incontinence may cause skin damage that can increase the risk of developing pressure
ulcers. This skin damage may make it more difficult for health care professionals to recognize the early
warning signs of pressure ulcers (i.e. reddened areas of skin that blanch when light pressure is applied).
Braden Assessment Scale
Used for predicting pressure ulcer risk as a risk assessment tool in nursing practice
The Braden Scale is a scale made up of six subscales, which measure elements of risk that contribute to
either higher intensity and duration of pressure, or lower tissue tolerance for pressure.
These are: sensory perception, moisture, activity, mobility, friction, and shear
Pressure Injury Nursing Process
Assessment
Patients should be assessed for pressure injury risk initially on
admission to the hospital and at periodic intervals thereafter
on the basis of the patient’s condition and the care setting.
The nurse should conduct a thorough head-to-toe skin
assessment on admission to identify and document pressure
injuries.
The skin and wounds should be reassessed on an ongoing
basis and the treatment plan modified accordingly
SAFETY ALERT
o In acute care, the patient should be reassessed every
24 hours.
o In long-term care, a resident should be reassessed
weekly for the first 4 weeks after admission and at
least monthly or every 3 months thereafter.
o In home care, the patient should be reassessed at each nurse visit.
Risk assessment should be performed with a validated assessment tool such as the Braden scale
To obtain a patient’s pressure injury risk assessment score on the Braden scale, the nurse adds the
numerical scores for the factors in each of the six subscales (sensory perception, moisture, activity,
mobility, nutrition, and friction and shear). Scores can range from 6 to 23. The lower the numerical
score on the Braden scale, the higher is the patient’s predicted risk of developing a pressure injury.
Incremental changes in the score indicate the level of risk: no risk (19 to 23), at risk (15 to 18), at
moderate risk (13 to 14), at high risk (10 to 12), and at very high risk (≤9).
Knowing the level of risk can help the health care provider determine how aggressive the preventive
measures should be.
The Braden scale has also been modified (Braden Q scale) for use with the pediatric population
Identification of stage 1 pressure injuries may be difficult in patients with dark skin
Subjective and objective data that should be obtained from a person with a pressure injury are
presented in
Objective and Subjective:
History of wound healing
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Braden / Norton skin guide (see Potter & Perry; Lewis text p. 242, Table 14-14) – also see if your
clinical agency uses a Braden or Norton scale (some agencies will use this tool as part of the initial
admission assessment).
Any factors
Any pain
Physical:
Where is the wound (location?)
Odour – note the wound bed odour (not just the old dressing)
Ulcer category (staging)
Necrotic tissue
Drainage (colour, consistency, amount)
Pain (don’t forget a comprehensive pain assessment!)
Induration (hard or soft surrounding tissue - edema)
Colour of wound bed (red, yellow, black or combination)
Tunnelling (length and direction)
Undermining (length and direction – use clock references to describe)
Redness or other discolouration in surrounding skin (peri-wound)
Edge of skin (peri-wound – assess for maceration)
Size/Shape (length, width, depth)
Systemic
temperature
malaise
diaphoresis
Nursing Diagnosis
Impaired skin integrity/Impaired Tissue Integrity (depending on depth of wound)
Risk for infection
But will also include: pain, body image changes, anxiety, may be even knowledge deficit
Planning
Goal – to restore skin integrity & prevent infection
Nursing Interventions
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