Nursing: Pressure Injuries and Wound Healing

Non-blanchable redness.
· Intact skin with non-blanchable redness, usually over bony prominence.
· Discoloration of skin warmth, edema, hardness, or pain may be present

Partial thickness.
· Partial thickness loss of dermis presenting as shallow upen ulcer with red/pink wound bed, no slough
· May present as intact or openuptured serum-filled or serosanguineous filled blister

· Full-thickness
· Full-thickness skin loss
· Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed.
· Slough may be present but doesn't obscure depth of tissue loss
· May include undermining and tunneling

· Full-thickness tissue and skin loss
· Full-thickness tissue and skin loss with exposed bone, tendon, or muscle.
· Subcutaneous fat may be visible
· Slough or eschar may be present
· Often includes undermining and tunneling

· Persistent non-blanchable deep red, maroon, or purple in color

base of ulcer covered by slough and/or eschar in the wound bed.

§ Odor
§ Discharge of yellow, green, or brown
§ Redness
§ Swelling or inflammation
§ Fever

· Oldest and most common dressing
· They're absorbent and useful in wounds to wick away wound exudate

· Wounds with large amounts of exudate
· Wounds that need packing
· Used around drainage tubes to absorb drainage

· Self-adhesive, transparent film
· Traps moisture over a wound, providing moist environment

· Complex formulations of colloids and adhesive components
· Adhesive and occlusive
· Wound contact layer of dressing forms a gel as wound exudate is absorbed and maintains moist healing environment
· Hydrocolloids support healing in clean granulating wounds and autolytically debride necrotic wounds

· Can be gauze or sheet dressings impregnated with water or glycerin-based amorphous gel
· Hydrates wounds
· For partial-thickness and full-thickness wounds, deep wounds with some exudate, necrotic wounds, burns, and radiation-damaged skin

§ Heals by sutures, can be easily pulled together

§ Heals from bottom up
§ Requires more cells to the site

§ Separation of the edges of a wound, revealing underlying tissues
§ May feel like something popped
§ Wound or sutures opened

§ Protrusion of visceral organs through a surgical wound
§ Prevent by using a binder, holding a pillow over to protect, bracing during coughing, and moving slowly

§ Nutrition
§ Tissue perfusion
§ Infection
§ Age
§ Pressure intensity
§ Tissue ischemia
§ Blanching
§ Pressure duration
§ Tissue tolerance - immobility
§ Impaired sensory perception
§ Impaired mobility
§ Level of consciousness
§ Shear - sliding movement of skin and subcutaneous tissue while underlying muscle and bone are stationary
§ Friction - force of two surfaces moving across one another. Similar to shear but friction affects the epidermis. AKA sheet burn
§ Moisture

§ Wound that proceeds through healing process that results in sustained restoration of anatomical and functional integrity
§ Caused by trauma and surgical incision
§ Implications for healing
· Wound edges are clean and intact

§ Wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity
§ Caused by vascular compromise, chronic inflammation, or repetitive tissue injury
§ Implications for healing
Continued exposure to insult impedes wound healing

§ Wound that is closed
§ Causes
· Surgical incision
· Wound that is sutured or stapled
§ Implications for healing
· Healing occurs by epithelialization
· Heals quickly with minimal scar formation

§ Wound edges not approximated
§ Causes
· Surgical wounds that have tissue loss or contamination
§ Implications for healing
· Wound heals by granulation tissue formation, wound contraction, and epithelialization

§ Wound that is left open for several days, then wound edges are approximated
§ Causes
· Wounds that are contaminated and require observation for signs of inflammation
§ Implications for healing
· Closure of wound is delayed until risk of infection is resolved

§ Inflammatory response
· Tissue trauma that causes redness and swelling
· Generally limited to first 24hrs after wounding
§ Epithelial proliferation and migration
· Starts at both the wound edges and epidermal cells lining epidermal appendages, allowing for quick resurfacing
§ Reestablishment of epidermal layers

§ Hemostasis
· Blood vessels constrict and platelets gather to stop bleeding
§ Inflammatory phase
· Damaged tissue and mast cells secrete histamine resulting is vasodilation of capillaries and movement of serum and WBC's
· Leukocytes reach wound within a few hours
o Neutrophil is primary acting
o Monocytes transform into macrophages and they clean the wound of bacteria, dead cells, and debris
§ Proliferative phase
· Appearance of new blood vessels as reconstruction progresses
· Lasts 3-24 days
· Main activitys are filling of wound with granulation tissue, wound contraction, and wound resurfacing by "epithelialization"
§ Maturation
· Final stage of healing
· Can take longer than a year, depending on the wound

§ Clear, watery plasma

§ Pale, pink, watery
§ Mixture of clear and red fluid

§ Bright red
§ Indicates active bleeding

o Vegetarian
o Vegan
- No animal or animal made products
o Zen-macrobiotic
- Brown rice and teas
o Fruitarian
- Fruits, nuts, honey

No pork alcohol or caffienee

§ Some baptists don't drink alcohol
§ Meatless days during the year

§ No meat
§ No fish or shellfish
§ No alcohol

§ No pork
§ No predatory fowl
§ Only eat fish with scales
§ No rare meat
§ No blood sausage
§ No mixing of milk or dairy products with meat dishes

§ No alcohol
§ No tobacco
§ No caffeine

§ No pork
§ No shellfish
§ No fish
§ No alcohol
§ No caffeine
§ Vegetarian diet is encouraged

Low iron

a diet that consists of foods that are liquid at room temperature.
§ Clear fat-free broth
§ Bouillon
§ Coffee
§ Tea
§ Carbonated beverages
§ Clear fruit juices
§ Gelatin
§ Fruit ice
§ Popsicles

Anything that melts at room temp
§ Smooth textured dairy products
· Ice cream
§ Strained or blended cream soups
§ Custard
§ Refined cooked cereal
§ Vegetable juice
§ Pureed vegetables
§ All fruit juices
§ Sherbet
§ Pudding
§ Frozen yogurt

-shake consistency
§ Clear liquids
§ Full liquids
§ Scrambled eggs
§ Pureed meat
§ Vegetables
§ Fruit
§ Mashed potatoes and gravy

clear and full liquids + diced or ground foods
§ Clear liquids
§ Full liquids
§ Pureed
§ All cream soups
§ Ground or finely diced meat
§ Flaked fish
§ Cottage cheese
§ Cheese
§ Rice
§ Potatoes
§ Pancakes
§ Light breads
§ Cooked veggies
§ Cooked or canned fruit
§ Bananas
§ Soup

o Thin liquids - low viscosity
o Nectar-thick liquids - medium viscosity
o Honey-thick liquids - viscosity of honey
o Spoon-thick liquids - viscosity of pudding

o Coughing while eating
o Change in voice tone or quality after swallowing
o Abnormal movements of the mouth, tongue, or lips
o Slow, weak, imprecise, or uncoordinated speech
o Pocketing
o Pooling
o Regurgitation

§ Uncooked fruit
§ Steamed vegetables
§ Bran
§ Oatmeal
§ Dried fruit

§ 4g NAS
§ 2g
§ 1g
§ 500mg
daily

300mg/day

§ Focus on total energy
§ Nutrient and food distribution
§ Balanced intake of carbohydrates, fats, and proteins

§ No wheat, oat, rye, barley, or their derivatives

§ Type 1 is insulin dependent
§ Type 2 treated with diet and oral medication
§ Low carbs, less that 7% of calories from saturated fats, cholesterol less that 200mg/day

§ High in fruits, veggies, whole grains
§ Fish 2x weekly
§ Limit sugar and salt
§ Less than 7% saturated, less than 1% trans-fat
§ Less than 300mg/day cholesterol

§ Chilled foods
§ Spicy foods
§ Small frequent meals and snacks that are easy to digest
§ High protein/low fat

§ Small, frequent, nutrient dense meals
§ Limit fatty and overly sweet foods
§ Cold, drier, and saltier with fluid in-between

o Dry, flaky, rough skin
o Hair is stringy, dull, and brittle
o Eyes are pale and dry
o Easily fatigued
o Flaccid muscles, poor tone
o Poor posture
o Confusion
o GI function
o Cardiovascular function
o Dry lips
o Abnormal gums, tongue, teeth
o Spoon-shaped nails

o 3.4-5.4
Shows nutrition over long period of time (6mo)

o 16-40
§ Shows nutritional status over shorter period

o Absorption
§ Citrus fruits
§ Orange juice
o Administered
§ IM - Z-track to avoid staining the skin
§ Oral tablet - teach about darker stools and constipation
§ Liquid - stains the teeth, take through a straw

o Healthy - 19-24.9
o Overweight - 25-29.9
o Obese - 30+

o 5-12 servings of whole grains
o 1-3 servings of legumes and soy
o 3-4 servings of fruit
o 6-9 servings of veggies
o 1-2 servings nuts and seeds
o 0-2 servings vegetable oils
o 0-2 servings dairy
o 0-1 servings eggs
o 0 sweets

o Teaching
o Achieve higher levels of health
o Maintenance and promotion of health
o Restoration of health
o Coping with impaired functioning

o 1. ID a need for information
o 2. Establish learning objectives
o 3. RN (sender) conveys information
o 4. Patient (receiver) learns the information
o 5. Provide feedback
o 6. Evaluate success of teaching plan

o Speak up if you have questions or concerns. If you still don't understand, ask again. It's your body, and you have a right to know.
o Pay attention to the care you get. Always make sure you're getting the right treatments and medicines by the right health care professionals. Don't assume anything.
o Educate yourself about your illness. Learn about the medical tests that are prescribed and your treatment plan.
o Ask a trusted family member or friend to be your advocate
o Know which medicines you take and why. Medication errors are the most common health care mistakes.
o Use a hospital, clinic, surgery center, or other type of health care organization that you have researched or checked carefully.
o Participate in all decisions about your treatment. You're the center of the health care team.

o Occurs when person gains information to further develop intellectual abilities, mental capacities, understanding, and thinking process.

o Deals with expression of feelings and emotions and development of values, attitudes, and beliefs

o development of manual or physical skills, learning how to walk or how to type on a computer

•An array of health care approaches with a history of use or origins outside of mainstream medicine. Complementary therapies used in addition to conventional treatment

•Based on different philosophies and life systems
•Chinese Medicine (Ying yang cultural spritual related

§Relaxation
-Focuses on abdominal breathing and redirecting thoughts
§Music
-Utilizes soft music or music the patient enjoys to calm and relax
§Meditation
-Requires the patient to be in a quite environment, where they clear their mind and breathe slowly
-Decrease Anxiety
§Imagery
-Imagery may be self-directed, in which individuals create their mental images, or guided, during which a practitioner leads an individual through a particular scenario
-Difficult to use with a confused client
§Acupuncture
-Regulates or realigns vital energy (qi), which flows through channels in the form of a system of pathways called meridians
§Therapeutic Touch
-Therapeutic touch is a natural human potential that consists of placing the practitioner's hands on or close to the body of a person, redirecting energy balance into the person
-Newborns
§Herbs: (See table 32-3 Unsafe Herbs in P&P)

Sexual development: sexuality changes with each stage of development:
•Infancy and early childhood (Development of gender identity gender roll copying)
•School-age years (more physical emotional question asking curiosity)
•Puberty/adolescence (Most emotional hormonal changes drama constant thoughts is this normal? experimentation HIGHEST RISK STAGE FOR STI OR PREGNANCY)
•Young adulthood (continue explore and more mature relationships long term family planing)
•Middle adulthood (Infertility can rear its head at this point same types of continuation as young adulthood)
•Older adulthood (can have higher risk for STI over looked many older people still having intercourse)

How does a person think about their self in sexuality

1. Nonprescription contraceptive methods:
Abstinence, barrier methods (condom), spermicide, rhythm (religious usage calculation in menstrual cycle to avoid ovulation time frame) OLDEST METHOD
2. Methods that require a health care provider's intervention:
Hormonal contraception, intrauterine device (IUD), diaphragm, cervical cap, sterilization (tubal ligation or vasectomy)
Nothing is 100% effective other then abstinence (cultural beliefs can come into effect here about waiting till marriage)

•Anyone who partakes in sexual acts (15-24 highest risk ages)
•What is curable?
•Syphilis gonorrhea, chlamydia, trigger
•Which one's are viral?
•HPV(silent STD, HIV, hepatitis B, herpes
•How can the spread be prevented?
• uses of contraceptives EDUCATION SAFETY while having sex
•What treatments are available?
ANTIBIOTICS
Ati viral medication doesn't cure them (lessens symptoms and spread)

Infertility:
•Inability to conceive after 1 year of unprotected intercourse (very straining on relationships)
-surrogate pregnancy and egg donations
Sexual abuse:
•Must be reported!
-S/S know signs
Sexual dysfunction:
•Absence of complete sexual functioning
•Affected by illnesses and medications
ED in men

1. Factors Affecting Sexuality:
-Physical, functional, relationship, lifestyle, developmental, and self-esteem

2. PLISSIT Assessment of Sexuality:
-Permission to discuss sexuality issues
-Limited Information related to sexual health problems being experienced
-Specific Suggestions—only when the nurse is clear about the problem
-Intensive Therapy—referral to professional with advanced training if necessary
3.Sexual Dysfunction:
-Many illnesses, injuries, medications, and aging changes have a negative effect on sexual health. What information can the nurse provide regarding this?
4.Physical Assessment:
-Teach patient about breast and testicular self-examination
-High rate of testicular cancer in young men (20-30yr). Be concerned with testicular lumps reported by a young college student