lOMoAR cPSD| 67756003
Exam 3:
Skin Integrity & Wound Care:
Dressings:
Gauze – (bring GAUZE when you CAMP) Gels - (ANNA likes GEL nails)
C – Cover dressing A – Adds moisture
A – Absorb heavy drainage N – No-minimal drainage
M – Moistened N – Nonabsorbent
P – Packing wounds A – Autolytic debridement
Transparent film – IV SITE – (PAWN) Hydrocolloids (PAPAS OG)
P – Prevents bacteria & fluid from entering P – Pressure Ulcers
A – Autolytic debridement. A – Avoid if infected
W – Wounds with minimal to no drainage. P – Provide moistened environment
N – Not absorbent A – Autolytic debridement
S – Small – moderate drainage
O – Occlusive dressing (3-7 days)
G – Gelling agent
Foams Alginates - (BASH)
Moderate to heavy B – Bleeding wound
drainage/enzymatic A – Avoid in dry wound
debridement S – Seaweed fiber
H – Highly absorbent
• Negative pressure wound therapy wound vac
• Infection, exposed arteries, fistulas, necrotic tissue, anticoagulants no wound vac
• Approximated = together
• Granulation tissue – beefy red, bleeds easy, bumpy, new tissue
Phases of Wound Healing –
1. Inflammatory (3 days initial phase):
a. Coagulation cascade: clotting of blood to prevent blood
loss/stop bleeding
b. Increase in pain, redness, warmth, and swelling 2.
Proliferative (last several weeks, repair phase):
a. Granulation tissue fills the bed *beefy red*
b. Wound edges begin to contract
3. Maturation (last up to a year):
a. Scar tissue is formed
b. 80% of tensile strength comes back
, lOMoAR cPSD| 67756003
Healing Process:
- Acute – rapid healing, uncomplicated
- Chronic – fails healing in timely manner… often remains open
- Primary – Surgical wounds, heals quickly, minimal scarring
- Secondary – new tissue, not approximated, must form to fill from bottom to sides
until bed is filled
- Tertiary – wound, surgical incision that got infected, had to open back up, delay
occurs between injury & closure
Types of wound drainage:
• Serous – clear, watery
• Purulent – pus: thick, yellow, green, or tan
• Serosanguineous: pink clear and red mixture
• Sanguineous – red: active bleeding
Debridement: removal of necrotic tissue
• Sharp: use of sharp instruments to remove necrotic tissue, needs to be premedicated –
fastest method
• Mechanical: removes necrotic tissues & viable tissues, wet/damp to dry-moist & are
removed when dry, whirlpool, GAUZE
• Enzymatic: use topical agents that remove fibrin, collagen, & elastin in devitalized
tissue
• Occlusive: require moist environment autolytic slowest & most comfy
• Biologic: maggots remove necrotic tissue
Wound Classifications:
- Open: Break in skin (surgical, abrasion, puncture wound)
- Closed: Bruising, skin still intact Wound Depth:
- Superficial: Epidermis ONLY
- Partial thickness: Epidermis, dermis, NOT to the subcutaneous, heal quickly, no scar
- Full thickness: Dermis-subcutaneous, can extent to muscle, bone & underlying
structures
- Clean wound: infection FREE, no risk for developing infection
- Clean contaminated: Surgery involves organ system that contains bacteria, great risk
for infection
- Contaminated: Break in sterile (colon, bowel, appendix)
- Infected: Clinical signs of infection (redness, warmth, increased drainage)
- Colonized: One or more organisms present on surface
Interventions for Pressure Injuries:
• Padding on bony prominences
, lOMoAR cPSD| 67756003
• Move every 2 hours
• Keep skin clean & moisturized
• Good nutrition Malnutrition:
• Vitamin A, C, & E
• Copper & zinc
Contraindications:
• Dementia patients
• Paralysis
Stages:
Stage 1:
o Non blanchable erythema
intact skin o Epidermis
only
Stage 2:
o Partial thickness skin loss
o Exposed dermis o
Intact/blister
Stage 3:
o Full thickness skin loss o
Subcutaneous tissue o Not
to muscle/bone
Stage 4:
o Full thickness skin & tissue
o Bone & tissue exposure
o Risk for bone infection
Unstageable:
o Necrotic tissue (eschar) o
Needs debridement to
stage
Heat Application:
• Vasodilation – widening of blood vessels
• Improves blood flow
• Decreases edema
• Promotes relaxation
• Debride wounds (soothing for pt)
• Brings oxygen
Exam 3:
Skin Integrity & Wound Care:
Dressings:
Gauze – (bring GAUZE when you CAMP) Gels - (ANNA likes GEL nails)
C – Cover dressing A – Adds moisture
A – Absorb heavy drainage N – No-minimal drainage
M – Moistened N – Nonabsorbent
P – Packing wounds A – Autolytic debridement
Transparent film – IV SITE – (PAWN) Hydrocolloids (PAPAS OG)
P – Prevents bacteria & fluid from entering P – Pressure Ulcers
A – Autolytic debridement. A – Avoid if infected
W – Wounds with minimal to no drainage. P – Provide moistened environment
N – Not absorbent A – Autolytic debridement
S – Small – moderate drainage
O – Occlusive dressing (3-7 days)
G – Gelling agent
Foams Alginates - (BASH)
Moderate to heavy B – Bleeding wound
drainage/enzymatic A – Avoid in dry wound
debridement S – Seaweed fiber
H – Highly absorbent
• Negative pressure wound therapy wound vac
• Infection, exposed arteries, fistulas, necrotic tissue, anticoagulants no wound vac
• Approximated = together
• Granulation tissue – beefy red, bleeds easy, bumpy, new tissue
Phases of Wound Healing –
1. Inflammatory (3 days initial phase):
a. Coagulation cascade: clotting of blood to prevent blood
loss/stop bleeding
b. Increase in pain, redness, warmth, and swelling 2.
Proliferative (last several weeks, repair phase):
a. Granulation tissue fills the bed *beefy red*
b. Wound edges begin to contract
3. Maturation (last up to a year):
a. Scar tissue is formed
b. 80% of tensile strength comes back
, lOMoAR cPSD| 67756003
Healing Process:
- Acute – rapid healing, uncomplicated
- Chronic – fails healing in timely manner… often remains open
- Primary – Surgical wounds, heals quickly, minimal scarring
- Secondary – new tissue, not approximated, must form to fill from bottom to sides
until bed is filled
- Tertiary – wound, surgical incision that got infected, had to open back up, delay
occurs between injury & closure
Types of wound drainage:
• Serous – clear, watery
• Purulent – pus: thick, yellow, green, or tan
• Serosanguineous: pink clear and red mixture
• Sanguineous – red: active bleeding
Debridement: removal of necrotic tissue
• Sharp: use of sharp instruments to remove necrotic tissue, needs to be premedicated –
fastest method
• Mechanical: removes necrotic tissues & viable tissues, wet/damp to dry-moist & are
removed when dry, whirlpool, GAUZE
• Enzymatic: use topical agents that remove fibrin, collagen, & elastin in devitalized
tissue
• Occlusive: require moist environment autolytic slowest & most comfy
• Biologic: maggots remove necrotic tissue
Wound Classifications:
- Open: Break in skin (surgical, abrasion, puncture wound)
- Closed: Bruising, skin still intact Wound Depth:
- Superficial: Epidermis ONLY
- Partial thickness: Epidermis, dermis, NOT to the subcutaneous, heal quickly, no scar
- Full thickness: Dermis-subcutaneous, can extent to muscle, bone & underlying
structures
- Clean wound: infection FREE, no risk for developing infection
- Clean contaminated: Surgery involves organ system that contains bacteria, great risk
for infection
- Contaminated: Break in sterile (colon, bowel, appendix)
- Infected: Clinical signs of infection (redness, warmth, increased drainage)
- Colonized: One or more organisms present on surface
Interventions for Pressure Injuries:
• Padding on bony prominences
, lOMoAR cPSD| 67756003
• Move every 2 hours
• Keep skin clean & moisturized
• Good nutrition Malnutrition:
• Vitamin A, C, & E
• Copper & zinc
Contraindications:
• Dementia patients
• Paralysis
Stages:
Stage 1:
o Non blanchable erythema
intact skin o Epidermis
only
Stage 2:
o Partial thickness skin loss
o Exposed dermis o
Intact/blister
Stage 3:
o Full thickness skin loss o
Subcutaneous tissue o Not
to muscle/bone
Stage 4:
o Full thickness skin & tissue
o Bone & tissue exposure
o Risk for bone infection
Unstageable:
o Necrotic tissue (eschar) o
Needs debridement to
stage
Heat Application:
• Vasodilation – widening of blood vessels
• Improves blood flow
• Decreases edema
• Promotes relaxation
• Debride wounds (soothing for pt)
• Brings oxygen
