Revised focus on inflammation

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  • Chemotaxis figure (eFig. 13-1) is available on Evolve website.
  • Types of wound healing. A, Primary intention. B, Secondary intention. C, Tertiary intention.
  • The area of injury is composed of fibrin clots, erythrocytes, neutrophils (both dead and dying), and other debris. Macrophages ingest and digest cellular debris, fibrin fragments, and RBCs. Extracellular enzymes derived from macrophages and neutrophils help digest fibrin. As the wound debris is removed, the fibrin clot serves as a meshwork for future capillary growth and migration of epithelial cells.
  • {See next slide of figure}Although wound is pink and vascular, the wound is friable, at risk for dehiscence, and resistant to infection.In a superficial wound, re-epithelialization may take 3 to 5 days.
  • A, Wound clean but not granulating (note lack of red cobblestone appearance), suggesting heavy bacterial contamination or other impediments to wound healing. B, Same wound granulating after 1 week of topical antibiotic use (note healthy red cobblestone appearance).
  • This is the reason abdominal surgery discharge instructions limit lifting for up to 6 weeks. Active movement of the myofibroblasts causes contraction of the healing area, helping to close the defect and bring the skin edges closer together.The scar may be more painful at this phase than in the granulation phase.
  • 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.
  • 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 results from primary or secondary intention.
  • A superficial wound involves only the epidermis. Partial-thickness wounds extend into the dermis. Full-thickness wounds have the deepest layer of tissue destruction because they involve the subcutaneous tissue and sometimes even extend into the fascia and underlying structures such as the muscle, tendon, or bone.
  • The red-yellow-black classification can be applied to any wound allowed to heal by secondary intention, including surgically induced wounds left to heal without skin closure because of a risk for infection. A wound may have two or three colors at the same time. In this situation, the wound is classified according to the least-desirable color present.
  • {See Table 13-8} Nutritional deficiencies may include vitamin C, protein, and zinc.
  • {See Table 13-8}
  • {See Table 13-9}
  • {See Table 13-9}
  • Record the consistency, color, and odor of any drainage, and report if abnormal for the situation. Staphylococcus and Pseudomonas species are common organisms that cause purulent, draining wounds.{See next slide for wound measurement figure}If a wound fails to heal in a timely manner, assess and identify factors that may delay healing. The patient should be referred to a health care provider who specializes in wound management.
  • Wound measurements are made in centimeters. The first measurement is oriented from head to toe, the second is from side to side, and the third is the depth (if any). If any tunneling (when cotton-tipped applicator is placed in wound, there is movement) or undermining (when cotton-tipped applicator is placed in wound, there is a “lip”) is noted around the wound, this is charted with respect to a clock, with 12 o’clock being toward the patient’s head. This wound would be charted as a full-thickness, red wound, 7 cm x 5 cm x 3 cm, with a 3-cm tunnel at 7 o’clock and a 2-cm undermining from 3 o’clock to 5 o’clock.
  • Wound measurements are made in centimeters. The first measurement is oriented from head to toe, the second is from side to side, and the third is the depth (if any). If any tunneling (when cotton-tipped applicator is placed in wound, there is movement) or undermining (when cotton-tipped applicator is placed in wound, there is a “lip”) is noted around the wound, this is charted with respect to a clock, with 12 o’clock being toward the patient’s head. This wound would be charted as a full-thickness, red wound, 7 cm x 5 cm x 3 cm, with a 3-cm tunnel at 7 o’clock and a 2-cm undermining from 3 o’clock to 5 o’clock.
  • Superficial skin injuries may only need cleansing. Adhesive strips or tissue adhesives may be used instead of sutures. The treatment plan can include covering these wounds with a film dressing to provide a moist healing environment and wound protection from trauma. Deeper skin wounds can be closed by suturing the edges together. If the wound is contaminated, it must be converted into a clean wound before healing can occur normally. Debridement of a wound that has multiple fragments or devitalized tissue may be necessary.
  • Most commonly, sutures are used to close wounds because suture material provides the mechanical support necessary to sustain closure. In contrast, fibrin sealant is a biologic tissue adhesive that can function as a useful adjunct to sutures. Example of drain: The Jackson-Pratt drainage device is a suction drainage device consisting of a flexible plastic bulb connected to an internal plastic drainage tube (see next slide for figure).
  • The red-yellow-black concept of wound care presented in Table 13-7 provides a method of dressing selection based on the wound tissue color. Examples of types of wound dressings are presented in Table 13-10.
  • A dressing material that keeps the wound surface clean and slightly moist is optimal to promote epithelialization. Transparent film or adhesive semipermeable dressings (e.g., OpSite, Tegaderm) are occlusive dressings that are permeable to oxygen. The wound then is usually covered with a sterile dressing.
  • Yellow Wounds After these preparations are saturated with exudate, they should be removed by washing with sterile saline or water. The quantities of wound secretions determine the number of dressing changes. Hydrocolloid dressings (i.e., DuoDerm) are designed to be left in place for up to 7 days, or until leakage occurs around the dressing.
  • Wound types suitable for this therapy include acute or traumatic wounds, surgical wounds that have dehisced, pressure ulcers, and chronic ulcers.
  • It can be given systemically with the patient placed in an enclosed chamber (or the injured limb), where 100% O2 is administered at 1.5 to 3 times the normal atmospheric pressure. Elevated O2 levels stimulate angiogenesis, kill anaerobic bacteria, and increase the killing power of WBCs and certain antibiotics (e.g., fluoroquinolones, aminoglycosides). Hyperbaric O2 therapy accelerates granulation tissue formation and wound healing.
  • Becaplermin should be used only when the wound is free of devitalized tissue and infection. It should not be used if cancer is suspected in the wound. Individuals at risk for wound-healing problems are those with malabsorption problems (e.g., Crohn’s disease, GI surgery, liver disease), deficient intake or high energy demands (e.g., malignancy, major trauma or surgery, sepsis, fever), and diabetes.Vitamins needed include C, B-complex, and A.
  • The culture should be taken before the first dose of antibiotic is given. Cultures can be obtained by needle aspiration, tissue culture, or swab technique. The Z-technique involves rotating a culture swab over the cleansed wound bed surface in a 10-point Z-track fashion. Levine’s technique involves rotating a culture swab over a cleansed 1-cm2 area near the center of the wound, using sufficient pressure to extract wound fluid from deep tissue layers.
  • When you are changing a dressing, inappropriate facial expressions can alert the patient to problems with the wound or your ability to care for it. Wrinkling your nose may convey disgust to the patient. You should also be careful not to focus on the wound to the extent that the patient is not treated as a total person.
  • Because patients are being discharged earlier after surgery and many have surgery as outpatients, it is important that the patient, the family, or both know how to care for the wound and perform dressing changes. Wound healing may not be complete for 4 to 6 weeks or longer. Drug-specific side effects and adverse effects, as well as methods to prevent side effects, should be reviewed with the patient.Awareness of the necessity to continue the drugs (i.e., antibiotics) for the specified time is an important point to teach the patient.
  • Pressure ulcers generally fall under the category of healing by secondary intention.
  • The incidence of pressure ulcers is estimated to be about 23% among residents of long-term care facilities. The prevalence is between 5% and 10% of hospitalized patients and about 15% of residents of long-term care facilities.
  • Care of a patient with a pressure ulcer requires local care of the wound and support measures for the whole person such as adequate nutrition, pain management, control of other medical conditions, and pressure relief. Assessment: For example, in acute care, a patient should be reassessed every 24 hours; in long-term care, a resident should be reassessed weekly for the first 4 weeks after admission and then minimally monthly or quarterly; in home care, a person should be reassessed every nurse visit.

Transcript

  • 1. Focus on Inflammation (Relates to Chapter 13,“Inflammation and Wound Healing,” in the textbook) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 2. Inflammatory Response• Sequential response to cell injury – Neutralizes and dilutes inflammatory agent – Removes necrotic materials – Establishes an environment suitable for healing and repair Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 2
  • 3. Inflammatory Response• Mechanism of inflammation basically the same regardless of injuring agent• Intensity of the response depends on – Extent and severity of injury – Reactive capacity of injured person Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 3
  • 4. Inflammatory Response• Inflammatory response can be divided into: – Vascular response – Cellular response – Formation of exudate – Healing Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 4
  • 5. 5
  • 6. Inflammatory Response Vascular Response• After cell injury, arterioles in area briefly undergo transient vasoconstriction.• After release of histamine and other chemicals by the injured cells, vessels dilate, resulting in hyperemia. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 6
  • 7. Inflammatory Response Vascular & Chemical Response• Vasodilation chemical mediators – Endothelial cell retraction – Increased capillary permeability – Movement of fluid from capillaries into tissue spaces Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 7
  • 8. Inflammatory Response Vascular Response• Fluid in tissue spaces – Initially composed of serous fluid – Later contains plasma proteins, primarily albumin • Proteins exert oncotic pressure that further draws fluid from blood vessels. • Tissue becomes edematous. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 8
  • 9. Inflammatory Response Vascular Response• As plasma protein fibrinogen leaves blood, it is activated to fibrin by products of the injured cells.• Fibrin strengthens a blood clot formed by platelets.• In tissue, clots trap bacteria to prevent spread. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 9
  • 10. Inflammatory Response Cellular Response• Blood flow through capillaries in the area of inflammation slows as fluid is lost and viscosity increases.• Neutrophils and monocytes move to the inner surface of the capillaries and then migrate through the capillary wall to the site of the injury. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 10
  • 11. Inflammatory Response Cellular Response• Chemotaxis – Directional migration of WBCs along concentration gradient of chemotactic factors – Mechanism for accumulating neutrophils and monocytes at site of injury Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 11
  • 12. Inflammatory Response Cellular Response• Neutrophils – First leukocytes to arrive at site of injury (6 to 12 hours) – Phagocytize bacteria, other foreign material, and damaged cells – Short life span (24 to 48 hours) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 12
  • 13. Inflammatory Response Cellular Response• Neutrophils – Pus is composed of • Dead neutrophils accumulated at the site of injury • Digested bacteria • Other cell debris Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 13
  • 14. Inflammatory Response Cellular Response• Neutrophils – Bone marrow releases more neutrophils in response to infection, resulting in elevated WBC. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 14
  • 15. Inflammatory Response Cellular Response• Monocytes – Second type of phagocytic cells to migrate to site of injury from circulating blood – Attracted to the site by chemotactic factors – Arrive within 3 to 7 days after the onset of inflammation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 15
  • 16. Inflammatory Response Cellular Response• Monocytes – On entering tissue spaces, monocytes transform into macrophages. – Assist in phagocytosis of inflammatory debris – Macrophages have a long life span and can multiply. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 16
  • 17. Inflammatory Response Cellular Response• Macrophage – Important in cleaning the area before healing can occur – May stay in damaged tissues for weeks – Cells may fuse to form a multinucleated giant cell. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 17
  • 18. Inflammatory Response Cellular Response• Lymphocytes – Arrive later at the site of injury – Primary roles of lymphocytes involve • Cell-mediated immunity • Humoral immunity Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 18
  • 19. Inflammatory Response Cellular Response• Exudate – Consists of fluid and leukocytes that move from the circulation to the site of injury – Nature and quantity depend on the type and severity of the injury and the tissues involved. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 19
  • 20. Inflammatory Response Clinical Manifestations• Local response to inflammation – Redness – Heat – Pain – Swelling – Loss of function Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 20
  • 21. Inflammatory Response Clinical Manifestations• Systemic response to inflammation – Increased WBC count with a shift to the left – Malaise – Nausea and anorexia – Increased pulse and respiratory rate – Fever Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 21
  • 22. Inflammatory Response Clinical Manifestations• Systemic response to inflammation – The causes of the systemic response are poorly understood, but it is probably due to complement activation and the release of cytokines. – Some of the cytokines are IL-1, IL-6, and tumor necrosis factor. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 22
  • 23. Inflammatory Response Clinical Manifestations• Systemic response to inflammation – Fever • Onset is triggered by release of cytokines. • Cytokines cause fever by initiating metabolic changes in the temperature-regulating center. • Epinephrine released from the adrenal medulla increases metabolic rate. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 23
  • 24. Fig. 13-3. Production of fever. When monocytes-macrophages are activated, they secrete cytokinessuch as interleukin-1 (IL-1), interleukin-6 (IL-6), andtumor necrosis factor (TNF), which reach thehypothalamic temperature-regulating center. Thesecytokines promote the synthesis and secretion ofprostaglandin E2 (PGE2) in the anterior hypothalamus.PGE2 increases the thermostatic set point, and theautonomic nervous system is stimulated,resulting in shivering, muscle contraction, andperipheral vasoconstriction. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 24
  • 25. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 25
  • 26. Inflammatory Response Clinical Manifestations• Systemic response to inflammation – Fever • Patient then experiences chills and shivering. • Body is hot, yet person seeks warmth until the circulating temperature reaches core body temperature. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 26
  • 27. Inflammatory Response Clinical Manifestations• Systemic response to inflammation – Fever • Beneficial aspects of fever include increased killing of microorganisms, increased phagocytosis, and increased proliferation of T lymphocytes. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 27
  • 28. Inflammatory Response Types of Inflammation• Acute – Healing occurs in 2 to 3 weeks, usually leaving no residual damage. – Neutrophils are the predominant cell type at the site of inflammation. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 28
  • 29. Inflammatory Response Types of Inflammation• Subacute – Has same features as acute inflammation but persists longer Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 29
  • 30. Inflammatory Response Types of Inflammation• Chronic – May last for years – Injurious agent persists or repeats injury to site. – Predominant cell types involved are lymphocytes and macrophages. – May result from changes in immune system (e.g., autoimmune disease) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 30
  • 31. Wound Healing• The final phase of the inflammatory response – Healing • Two major components--regeneration and repair.• Regeneration – Replacement of lost cells and tissues with cells of the same type – Ability to regenerate depends on cell type. – Constantly dividing cells that rapidly regenerate • Skin, bone marrow, lymphoid organs, as well as mucous membrane cells of the urinary, reproductive, and GI tracts Copyright © 2011, 2007 by Mosby, Inc., an affiliate 31 of Elsevier Inc.
  • 32. Wound Healing• Regeneration – Replacement of lost cells and tissues with cells of the same type • Stable cells such as liver, bone, kidney, and pancreas regenerate in response to injury. • Permanent cells such as neurons and skeletal and cardiac muscle do not divide. – Neurons are replaced by glial cells or stem cells. – Skeletal and cardiac muscle will be repaired with scar tissue. Copyright © 2011, 2007 by Mosby, Inc., an affiliate 32 of Elsevier Inc.
  • 33. Wound Healing• Repair – Healing as a result of lost cells being replaced with connective tissue – More common than regeneration – More complex than regeneration – Occurs by primary, secondary, or tertiary intention Copyright © 2011, 2007 by Mosby, Inc., an affiliate 33 of Elsevier Inc.
  • 34. 34Fig. 13-4. Types of wound healing. A, Primary intention. B, Secondary intention. C, Tertiary intention.
  • 35. Wound Healing• Repair – Primary intention • Includes three phases – Initial phase – Granulation phase – Maturation phase and scar contraction Copyright © 2011, 2007 by Mosby, Inc., an affiliate 35 of Elsevier Inc.
  • 36. Wound Healing• Repair – Initial phase • Lasts 3 to 5 days • Edges of incision are aligned. • Blood fills the incision area, which forms matrix for WBC formation. • Acute inflammatory reaction occurs. Copyright © 2011, 2007 by Mosby, Inc., an affiliate 36 of Elsevier Inc.
  • 37. Wound Healing• Repair – Granulation phase • Lasts 5 days to 3 weeks • Fibroblasts migrate to site. • Wound is pink and vascular. • Surface epithelium begins to regenerate. Copyright © 2011, 2007 by Mosby, Inc., an affiliate 37 of Elsevier Inc.
  • 38. Before and After Granulating Fig. 13-5. A, Wound clean but not granulating (note lack of red cobblestone appearance), suggesting heavy bacterial contamination or other impediments to wound healing. B, Same wound granulating after 1 week of topical antibiotic use (note healthy red cobblestone appearance). Copyright © 2011, 2007 by Mosby, Inc., an affiliate 38 of Elsevier Inc.
  • 39. Wound Healing• Repair  Maturation phase and scar contraction • Begins 7 days after injury and continues for several months/years • Fibroblasts disappear as wound becomes stronger. • Mature scar forms. Copyright © 2011, 2007 by Mosby, Inc., an affiliate 39 of Elsevier Inc.
  • 40. Wound Healing• Repair  Secondary intention • Wounds that occur from trauma, ulceration, and infection have large amounts of exudate and wide, irregular wound margins with extensive tissue loss. • Edges cannot be approximated. • Results in more debris, cells, and exudate Copyright © 2011, 2007 by Mosby, Inc., an affiliate 40 of Elsevier Inc.
  • 41. Wound Healing• Repair  Tertiary intention • Delayed primary intention due to delayed suturing of the wound • Occurs when a contaminated wound is left open and sutured closed after the infection is controlled Copyright © 2011, 2007 by Mosby, Inc., an affiliate 41 of Elsevier Inc.
  • 42. Wound Classification• Classified by  Cause • Surgical or nonsurgical • Acute or chronic  Depth of tissue affected • Superficial, partial thickness, full thickness Copyright © 2011, 2007 by Mosby, Inc., an affiliate 42 of Elsevier Inc.
  • 43. Wound Classification• Classified by – Color • Red • Yellow • Black • May have two or more colors Copyright © 2011, 2007 by Mosby, Inc., an affiliate 43 of Elsevier Inc.
  • 44. Delay of Healing• Nutritional deficiencies• Inadequate blood supply• Corticosteroid drugs• Infection• Smoking Copyright © 2011, 2007 by Mosby, Inc., an affiliate 44 of Elsevier Inc.
  • 45. Delay of Healing• Mechanical friction on wound• Advanced age• Obesity• Diabetes mellitus• Poor general health• Anemia Copyright © 2011, 2007 by Mosby, Inc., an affiliate 45 of Elsevier Inc.
  • 46. Complications of Healing• Adhesions• Contractures• Dehiscence• Evisceration• Excess granulation tissue• Fistula formation Copyright © 2011, 2007 by Mosby, Inc., an affiliate 46 of Elsevier Inc.
  • 47. Complications of Healing• Infection• Hemorrhage• Hypertrophic scars• Keloid formation Copyright © 2011, 2007 by Mosby, Inc., an affiliate 47 of Elsevier Inc.
  • 48. Nursing Assessment• Assess on admission and on a regular basis.• Identify factors that may delay healing. Copyright © 2011, 2007 by Mosby, Inc., an affiliate 48 of Elsevier Inc.
  • 49. Fig. 13-9. Wound measurements are made in centimeters. Thefirst measurement is oriented from head to toe, the second isfrom side to side, and the third is the depth (if any). If there isany tunneling (when cotton-tipped applicator is placed in wound,there is movement) or undermining (when cotton-tippedapplicator is placed in wound, there is a “lip” around the wound)this is charted in respect to a clock with 12 o’clock being towardthe patient’s head. This wound would be charted as a full-thickness, red wound, 7 cm × 5 cm × 3-cm, with a 3-cm tunnel at7 o’clock and 2 cm undermining from 3 o’clock to 5 o’clock. 49
  • 50. 50
  • 51. Nursing Diagnoses• Impaired skin integrity• Impaired tissue integrity• Risk for infection Copyright © 2011, 2007 by Mosby, Inc., an affiliate 51 of Elsevier Inc.
  • 52. Nursing Implementation• Care varies depending on – Causative agent – Degree of injury – Patient’s condition Copyright © 2011, 2007 by Mosby, Inc., an affiliate 52 of Elsevier Inc.
  • 53. Nursing Implementation• Purposes of wound management – Cleaning a wound – Treating infection – Protecting clean wound from trauma Copyright © 2011, 2007 by Mosby, Inc., an affiliate 53 of Elsevier Inc.
  • 54. Nursing Implementation• Sutures/fibrin sealant help closure.• Primary intention wounds may be covered with dry dressing.• Drains may be inserted.• Topical antimicrobials/antibacterials should be used with caution. Copyright © 2011, 2007 by Mosby, Inc., an affiliate 54 of Elsevier Inc.
  • 55. Nursing Implementation• Secondary intention wound care depends on etiology and type of tissue in the wound. Copyright © 2011, 2007 by Mosby, Inc., an affiliate 55 of Elsevier Inc.
  • 56. Nursing Implementation• Red Wounds  Protect the wound  Gentle cleaning, if needed Copyright © 2011, 2007 by Mosby, Inc., an affiliate 56 of Elsevier Inc.
  • 57. Nursing Implementation• Yellow wounds – Dressing that absorbs exudate and cleanses the wound surface – Hydrocolloid dressings• Black Wounds – Debridement of nonviable, eschar tissue Copyright © 2011, 2007 by Mosby, Inc., an affiliate 57 of Elsevier Inc.
  • 58. Nursing Implementation• Negative-pressure wound therapy – Suction removes drainage and speeds healing. – Monitor serum protein levels, F&E balance, and coagulation studies. Copyright © 2011, 2007 by Mosby, Inc., an affiliate 58 of Elsevier Inc.
  • 59. Nursing Implementation• Hyperbaric O2 – Delivery of O2 at increased atmospheric pressure – Allows O2 to diffuse into serum – Last 90 to 120 minutes, with 10 to 60 treatments Copyright © 2011, 2007 by Mosby, Inc., an affiliate 59 of Elsevier Inc.
  • 60. Nursing Implementation• Drug therapy  Becaplermin (Regranex)• Nutritional therapy  Diet high in protein, carbohydrates, and vitamins with moderate fat Copyright © 2011, 2007 by Mosby, Inc., an affiliate 60 of Elsevier Inc.
  • 61. Nursing Implementation• Infection prevention  Do not touch recently injured area.  Keep environment free from possibly contaminated items.  Antibiotics may be given prophylactically. Copyright © 2011, 2007 by Mosby, Inc., an affiliate 61 of Elsevier Inc.
  • 62. Nursing Implementation• Infection control  Should cultures be done?  Are they reliable?  When would wound cultures be reliable?  When would they be unreliable? Copyright © 2011, 2007 by Mosby, Inc., an affiliate 62 of Elsevier Inc.
  • 63. Nursing Implementation• Psychologic implications – Fear of scar or disfigurement – Drainage or odor concerns – Be aware of your facial expressions while changing dressing. Copyright © 2011, 2007 by Mosby, Inc., an affiliate 63 of Elsevier Inc.
  • 64. Patient Teaching• Teach signs and symptoms of infection.• Note changes in wound color or amount of drainage.• Provide medication teaching. Copyright © 2011, 2007 by Mosby, Inc., an affiliate 64 of Elsevier Inc.
  • 65. Focus on Pressure Ulcers (Relates to Chapter 13,“Inflammation and Wound Healing,” in the textbook) Copyright © 2011,© 2011, 2007 by Mosby, affiliate affiliate Copyright 2007 by Mosby, Inc., an Inc., an of Elsevier Inc. of Elsevier Inc.
  • 66. Pressure Ulcer• A localized injury to the skin and/or underlying tissue due to pressure with or without shear/friction Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 66
  • 67. Incidence• Most common sites  Sacrum  Heels Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 67
  • 68. Influencing Factors• Amount of pressure (intensity)• Length of time pressure is exerted (duration)• Ability of tissue to tolerate externally applied pressure Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 68
  • 69. Contributing Factors• Shearing force—Pressure exerted on the skin when it adheres to the bed and the skin layers slide in the direction of body movement• Friction—Two surfaces rubbing against each other• Excessive moisture Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 69
  • 70. Risk Factors• Advanced age• Anemia• Contractures• Diabetes mellitus• Elevated body temperature Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 70
  • 71. Risk Factors• Immobility• Impaired circulation• Incontinence• Low diastolic blood pressure (<60 mm Hg)• Mental deterioration Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 71
  • 72. Risk Factors• Neurologic disorders• Obesity• Pain• Prolonged surgery• Vascular disease Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 72
  • 73. Clinical Manifestations• Ulcers are graded or staged according to deepest level of tissue damage: – Stage I (minor) to stage IV (severe) – Slough or eschar may have to be removed for accurate staging of some ulcers. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 73
  • 74. Clinical Manifestations Stage I• Intact skin with non-blanchable redness• Possible indicators—Skin temperature, tissue consistency, pain Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 74
  • 75. Clinical Manifestations Stage I• May appear with red, blue, or purple hues in darker skin tones Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 75
  • 76. Clinical Manifestations Stage II• Partial-thickness loss of dermis• Shallow open ulcer with red pink wound bed• Presents as an intact or ruptured serum- filled blister Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 76
  • 77. Clinical Manifestations Stage III• Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 77
  • 78. Clinical Manifestations Stage III• Presents as a deep crater with possible undermining of adjacent tissue• Depth of ulcer varies by anatomic location. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 78
  • 79. Clinical Manifestations Stage IV• Full-thickness loss can extend to muscle, bone, or supporting structures. – Bone, tendon, or muscle may be visible or palpable. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 79
  • 80. Clinical Manifestations Stage IV• Undermining and tunneling may also occur. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 80
  • 81. Clinical Manifestations Infection• Signs – Leukocytosis – Fever – Increased ulcer size, odor, or drainage – Necrotic tissue – Pain Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 81
  • 82. Clinical Manifestations Complications• Most common—Recurrence• Cellulitis• Chronic infection• Osteomyelitis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 82
  • 83. Assessment• Assess pressure ulcer risk on admission and at periodic intervals based on care setting and patient’s condition. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 83
  • 84. Assessment Tools• Use risk assessment tools such as the Braden scale for systematic skin inspection. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 84
  • 85. Assessment of Patients With Dark Skin• Look for areas of skin darker (purplish, brownish, bluish) than surrounding skin.• Use natural or halogen light for accurate assessment (fluorescent light casts a blue color that can skew results). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 85
  • 86. Assessment of Patients With Dark Skin• Assess skin temperature using your hand.  An ulceration may feel warm initially, then become cooler. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 86
  • 87. Assessment of Patients With Dark Skin• Touch the skin to feel its consistency.  Boggy or edematous tissue may indicate a stage I pressure ulcer.• Ask about pain or an itchy sensation. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 87
  • 88. Planning• Overall goals  No deterioration  Reduce contributing factors  Not develop an infection  Have healing  Have no recurrence Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 88
  • 89. Prevention – Education• Prevention is the best treatment.• Identify risk factors and implement prevention strategies. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 89
  • 90. PreventionCopyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 90
  • 91. Prevention – Skin Care• Remove excessive moisture.• Avoid massage over bony prominences.• Turn every 1 or 2 hours (with care to avoid shearing).• Use lift sheets. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 91
  • 92. Prevention – Skin Care• Position with pillows or elbow and heel protectors.• Use specialty beds.• Cleanse skin if incontinence occurs.  Use pads or briefs that are absorbent. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 92
  • 93. Prevention – Nutrition• Caloric intake elevated to 30 to 35 cal/kg/day or 1.25 to 1.50 g protein/kg/day – Supplements, enteral, or parenteral feedings may be necessary. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 93
  • 94. Treatment – Ulcer Care• Document and describe size, stage, location, exudate, infection, pain, and tissue appearance.• Keep ulcer bed moist.• Cleanse with nontoxic solutions.• Debride. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 94
  • 95. Treatment – Ulcer Care• Use adhesive membrane, ointment, or wound dressing.• Verify good nutrition.• Teach self-care and signs of breakdown.• Initiate specialty services. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 95
  • 96. Operative Repair• Skin grafts• Skin flaps• Musculocutaneous flaps• Free flaps Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 96