RN CONSIDERATIONS
what is the difference between acute and chronic skin injuries. give examples.
Acute- example- dog bites, stabs, steps on a nail. Heals in days or weeks depending.
Chronic- takes months or more to heal depending on PTS health. Bed sores. Diabetic sores.
When do you do wound cultures
after cleaning but before antibiotic administraton
Closed drainage system, commonly used in abdominal surgeries. Sutured into the body.
Looks like a small grenade
Jackson Pratt drain
what two age groups are most at risk for developing skin alterations
Why?
what causes bed sores?
External pressure compressing blood vessel for a prolonged period.
People with this condition are high risk for sores, skin deuteration and skin breakdown (including necrosis) without even realizing it due to neuropathy.
Diabetics
what asepsis technique is for acute wounds?
surgical (sterile)
name the types of fluid you may see in a drain, describe them.
serosanguinous- slightly pink tinged. mix of plasma and blood.
serous - clear fluid. no blood or puss
sanguinous- bright red blood
purulent- thick yellow/green. puss
complication with Aqua therapy- water therapy. Why you need to make sure you are always drying in-between toes?
Maceration
what and where are boney prominences?
shoulders, scrum, back, elbow, thigh, buttocks, ankle, knees, rib cage.
Where bones tend to stick out.
What are the stages of wound healing?
Hemostasis- Initially after the injury- blood clots, scab forms.
Inflammatory- swelling, lasts a few days
Proliferation- new tissue forms.
Maturation- end of healing process, new skin has matured
what asepsis technique is for chronic wounds?
medical (clean)
COCA
what is it and what does it mean?
COCA- color, order, consistency, amount
color of drainage, amount in mL, consistency (think watery or thick) and how does it smell.
What type of wound is this?
surgical wound, sterile procedure, bleeding controlled. SMALL RISK OF INFECTION
Intentional
partial thickness injury, break in the skin. Wound bed is visible (pink, red, moist) blisters. Not very deep. Resembles abrasion.
Stage 2 bed sore
- wound splits apart. Caused by Straining to have a bowel movement, sneezing, coughing, vomiting, bending down
What is this?
Dehiscence
DAILY DOUBLE
what are the CLASSIC signs of infection
What are advanced stages?
classic- hot to touch, redness, tenderness, pain
Advanced- puss, fever, change in mental status,
open drainage system held together with a safety pin.
Penrose
difference between closed and open wounds. Give examples of each.
closed -unintentional or intentional. Brusing, swelling.
Open wounds- portal of entry. Cuts, burns, surgical cuts, dog bites.
full thickness injury- loss of skin and adipose tissue (fat) tunneling may happen. Eschar (blackening) no muscle or bone showing
stage 3 bed sore
- What’s supposed to be inside comes out (bowel) EMERGENCY. Immediately (STAT) lower the bed (head down), cover with STERILE NORMAL SALINE GAUZE. Do NOT leave the Pt alone.
What is this?
Evisceration
What are the stages of wound closure?
PRIMARY- early wound closure, no visible granulation. Would is approximated
SECONDARY- the wound opening is NOT approximated, packed with gauze as granulation fills the wound.
TIERTARY- Packed with gauze, closed later once granulation has begun
what is a wound vac and how is it put on?
closed drainage system, gel foam and tegriderm cover the wound and the vacuum sucks all air out leaving an airtight seal. The vacuum then drains the wound.
what is your skin responsible for?
LARGEST organ
Protection from the sun
Body temp regulation
Psychosocial- wounds affect mental health!
Sensation -touch, pain, pleasant sensations
Vitamin D production!
Immunology- protects us from bacteria. Its why wounds have high infection risks. Any break in the skin is a risk.
Absorption
Elimination- sweating
DAILY DOUBLE
what stages are these bed sores
1. FULL thickness! Muscle and bone shown, tunneling.
2. can’t tell how deep it is. Eschar is blocking the view. Down to muscle and bone.
stage4 and unstageable