Module 8 - wound healing

Module 8 - wound healing - 1. Examine factors in risk...

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1. Examine factors in risk assessment for skin breakdown. Health History – Every hospitalized or long-term care patient should be assessed for impaired skin integrity and risk for impaired skin integrity. The health history should identify factors that make the client at risk for injury, for delayed wound healing or for pressure ulcers. Physical Examination – A thorough skin assessment is an important part of the physical examination. If the client cannot move in bed, assessment for pressure ulcers is imperative. Document a clear description of any lesions on the skin and factors associated with the lesion. Diagnostic Tests – Diagnostic studies can help identify skin or wound infection, poor oxygenation and general nutrition status – factors that can affect skin integrity and wound healing. Lab tests to assess client’s hydration status, identify possible infections and help formulate nursing diagnoses and develop a plan of nursing care: White blood cell count – Will not be elevated due to wound infection as most are local infections. Elevated count may suggest a systemic infection. Prealbumin and albumin levels – Abnormally low levels indicate poor nutritional status, which slows wound healing. Radiological studies – If a patient has a suspected infection in a wound over a bony prominence, the physician may order radiological studies to rule out osteomyelitis (infection of the bone). 2. Use the Braden skin assessment to identify patients at risk for skin breakdown. See additional PDF file titled “Braden Chart” 3. Discuss the phases of wound healing. Hemostasis – control of bleeding. The process by which injured blood vessels constrict and platelets accumulate. Inflammatory Phase – Begins at the time of tissue injury and lasts for 3 to 4 days. The cardinal signs of inflammation are heat, erythema, edema and pain at the wound site. Histamine is secreted by mast cells and damaged tissues, leading to capillary dilation, which increases the supply of blood and nutrients to the wound and allows migration of cells, compliment and antibodies. Proliferative (Reconstructive) Phase – Lasts 4 to 21 days. During this phase, collagen fills the wound bed, new blood vessels develop and granulation tissue is formed by fibroblasts. Giving the wound a bright red granular appearance.
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Maturation (Remodeling) Phase – Although much maturation occurs by 3 to 4 weeks, the scar may not achieve maximum strength for up to 2 years. Although the wound is considered fully healed, it will always be at risk for breakdown as the tensile strength will never exceed 80% of its original strength. 4. Identify types of wound healing: primary, secondary, tertiary. Primary Intension Healing
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This note was uploaded on 09/13/2011 for the course RNSG 1105 taught by Professor Cooper during the Spring '11 term at Austin Community College.

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Module 8 - wound healing - 1. Examine factors in risk...

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