NR 324 MODULE 6 ADULT HEALTH ROK WITH ANSWERS 3

NR 324 MODULE 6 ADULT HEALTH ROK WITH ANSWERS 3 1. Explain the process of wound healing by primary, secondary, and tertiary intention. Primary Intention. Primary intention healing takes place when wound margins are neatly approximated, as in a surgical incision or a paper cut. A continuum of processes is associated with primary healing. These processes include three phases. A. Initial Phase. In the initial (inflammatory) phase, the edges of the incision are first aligned and sutured (or stapled) in place. The incision area fills with blood from the cut blood vessels, blood clots form, and platelets release growth factors to begin the healing process. This forms a matrix for WBC migration. An acute inflammatory reaction occurs. B. Granulation Phase. The granulation phase is the second step. The components of granulation tissue include proliferating fibroblasts; proliferating capillary sprouts (angioblasts); various types of WBCs; exudate; and loose, semifluid, ground substance. C. Maturation Phase and Scar Contraction. The maturation phase, during which scar contraction occurs, overlaps with the granulation phase. It may begin 7 days after the injury and continue for several months or years. This is the reason abdominal surgery discharge instructions limit lifting for up to 6 weeks. Collagen fibers are further organized, and the remodeling process occurs. Fibroblasts disappear as the wound becomes stronger. Secondary Intention. Wounds that occur from trauma, ulceration, and infection have large amounts of exudate and wide, irregular wound margins with extensive tissue loss. These wounds may have edges that cannot be approximated (brought together). The inflammatory reaction may be greater than in primary healing. This results in more debris, cells, and exudate. The debris may have to be cleaned away (debrided) before healing can take place. The process of healing by secondary intention is essentially the same as healing by primary intention. The major differences are the greater defect and the gaping wound edges. Healing and granulation take place from the edges inward and from the bottom of the wound upward until the defect is filled. There is more granulation tissue, and the result is a much larger scar. Tertiary Intention. Tertiary intention (delayed primary intention) healing occurs with delayed suturing of a wound in which two layers of granulation tissue are sutured together. This occurs when a contaminated wound is left open and sutured closed after the infection is controlled. It also occurs when a primary wound becomes infected, is opened, is allowed to granulate, and is then sutured. Tertiary intention usually results in a larger and deeper scar than primary or secondary intention. 2. Explain the red-yellow-black wound concept (description, characteristics, give examples) Red Wound Yellow Wound Black Wound Can be a superficial or deep wound if it is clean and pink in appearance, possible presence of serosanguineous drainage, pink to bright or dark red healing, or chronic wound with granulating tissue. Presence of slough or soft necrotic tissue. Liquid to semiliquid slough with exudate ranging from creamy ivory to yellow-green. Black, gray, or brown adherent necrotic tissue called eschar. Possible presence of purulent drainage. Risk of wound infection increases in proportion to amount of necrotic tissue present. Protection and gentle atraumatic cleansing. Wound cleansing to remove nonviable tissue and absorb excess drainage. Debridement of eschar and nonviable tissue. Skin tears, pressure ulcers (stage II), partial-thickness or second-degree burns, and wounds created by trauma or surgery that are allowed to heal by secondary intention. Wounds with nonviable necrotic tissue, which creates an ideal situation for bacterial growth and therefore must be removed. Full-thickness or third-degree burns, pressure ulcers (stages III and IV), and gangrenous ulcers. 3. Explain surgical, mechanical, autolytic, and enzymatic debridement. Surgical debridement • Quick method of debridement to prevent, control, or remove infection. • Used when large amounts of nonviable tissue are present. • Prepares wound bed for healing, skin grafting, or flaps. Mechanical debridement • Wet-to-dry dressings in which open-mesh gauze is moistened with normal saline, packed on or into wound surface, and allowed to dry. Wound debris adheres to dressing and then dressing is removed. • Wound irrigation. Make certain bacteria are not accidentally driven into wound with high irrigation pressure. • Whirlpool. Should not be used in a clean granulating wound. Used when minimal debris is present. Nonselective and will also debride some healthy tissue. Autolytic debridement • Semiocclusive or occlusive dressings used to soften dry eschar by autolysis. • Assess area around wound for maceration when using these dressings. • Malodorous. Enzymatic debridement • Drugs applied topically to dissolve necrotic tissue and then covered with moist dressing (e.g., saline-moistened gauze). • Examples of these drugs include collagenase and papain and urea (e.g., Panafil, Gladase). • Process can be slow, and thick eschar may need to be scored with scalpel. 4. Describe the risk factors for pressure ulcers. • Identify patients at risk through frequent assessment using a pressure ulcer assessments tool. Maintain adequate nutrition. • Decrease shearing by using lift sheets when moving patients in bed. • Reposition frequently (at least every 2 hours). • If incontinence occurs, cleanse promptly. • Decrease pressure (padding, appropriate cushions, and mattresses). • Inspect skin daily, at a minimum, and more frequently with patients who are at higher risk for pressure ulcer formation. • Document any skin changes, enact the standard pressure ulcer protocol for the healthcare setting, and notify the healthcare provider. 5. Differentiate the characteristics of a stage I, II, III, IV, deep tissue injury, and an unstageable ulcers. (See table 12-13). Stage 1 Pressure Ulcer Intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Stage 1I Pressure Ulcer Partial thickness loss of dermis, shallow open ulcer with a red pink wound bed without slough. Stage 1II Pressure Ulcer Full thickness tissue loss Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. Stage 1V Pressure Ulcer Full thickness tissue loss with exposed bone, tendon, or muscle Slough or eschar may be present. Exposed bone or muscle is visible or directly palpable. Unstageable Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. NOTE: A pressure ulcer may also be unstageable because the ulcer is covered by eschar (dry, dead skin). The eschar must be removed for the wound to be correctly staged (Lewis, 2014a). The stage of a healing or healed pressure ulcer does not reverse the staging of the wound. A pressure ulcer that was once identified a Stage 4 will always be referred to as healing Stage 4 or healed Stage 4 pressure ulcer. 6. Provide at least 5 different patient/caregiver teaching concepts regarding pressure ulcers. 1. Change positions frequently (at least every two hours) Reposition patients frequently to prevent pressure ulcers (usually every 2 hours). Use devices to reduce pressure and shearing force (e.g., low-air-loss mattresses, foam mattresses, wheelchair cushions, padded commode