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ETIOLOGY OF SKIN WOUNDS AND ULCERS
Wound Care
Noah Carpenter, MD Dr. Noah Carpenter is a Thoracic and Peripheral Vascular Surgeon practicing in Brandon, Manitoba. He is known for the development of surgical techniques. He attended the University of Manitoba where he graduated with the B.Sc. in chemistry, completed medical school and did his surgical residency and fellowship at the University and Affiliated Hospitals in Edmonton, Alberta. Dr. Carpenter did an additional fellowship at the University of Edinburgh,
Scotland in Adult Cardiovascular and Thoracic Surgery, and has specialized in microsurgical techniques, vascular endoscopy, laser and laparoscopic surgery in Vancouver, British Columbia, Canada and Colorado, Texas, Vancouver, and Los Angeles. He has an Honorary Doctorate of Law from the University of Calgary, and was appointed a Citizen Ambassador to China, and has served as a member of the Native Physicians Association of Canada, the Canadian College of Health Service Executives, the Science Institute of the Northwest Territories, the Canada Science Council, and the International Society of Endovascular Surgeons, among others. He has been an inspiration to youth, motivating them to understand the importance of achieving higher education.
Abstract
Although many types of wounds are easily treated, some require specialized
care in order to resolve or treat the primary cause and to avoid
complications. Health clinicians specializing in wound prevention and
treatment focus on patients with an acute or chronic skin injury, related
disease, and medical treatment. Increasingly, wound care specialists are
adopting a holistic approach to treatment, coordinating efforts between
interdisciplinary team members to ensure that all aspects of a patient's
physical and mental health are met during the acute and long-term phases
of the treatment plan.
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Policy Statement
This activity has been planned and implemented in accordance with the
policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses. It is the policy of NurseCe4Less.com to
ensure objectivity, transparency, and best practice in clinical education for
all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 2.5 hours. Nurses may only claim
credit commensurate with the credit awarded for completion of this course
activity.
Statement of Learning Need
Wound care involves an interdisciplinary health team approach to provide
holistic care for patients with acute or chronic wounds that includes
psychosocial, health prevention and medical interventions. Complete
coordination by collaborating health team members improves wound care
management beginning in acute care and throughout the entire continuum
of care. Current evidence and wound care guidelines emphasize the
importance of adhering to evidence-based wound care protocol and of
actively including the patient in ongoing education to support wound healing.
A neglected focus of clinical education pertains to end-of-life care involving
skin and other organ system failure and the challenges most clinicians face
related to prevention of ulcer formation and skin breakdown.
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Course Purpose
To provide health clinicians a basic understanding of the different phases of
healing in acute and chronic wounds, of the risk factors affecting wound
development and healing, and of the prevention and treatment of wounds.
Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures Noah Carpenter, MD, William S. Cook, PhD, Douglas Lawrence, MA,
Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.
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1. Tertiary intention involves the process of
a. wound closure done by applying physical measures to close a wound.
b. initially leaving the wound open to partial healing. c. leaving a wound open to heal through production of new
granulation tissue to fill in the wound base. d. None of the above
2. When a clinician administers medications intravenously, he or she
should be aware that
a. vesicants are safe because these medications do not cause tissue damage to the skin.
b. it is preferable to administer medications intravenously so they may infiltrate the skin tissues.
c. some medications, when administered intravenously, can cause significant wounds if they accidentally infiltrate the skin and tissues.
d. extravasation does not develop if medications are administered intravenously.
3. The National Pressure Ulcer Advisory Panel (NPUAP) has defined
several classifications of pressure ulcers according to the
a. length of tissue involvement and presence of exudate. b. depth of tissue involvement and the extent of damage. c. circumference of tissue involvement and level of pain. d. world health criteria.
4. The dermis is thicker than the epidermis and
a. it is involved in the wound healing process but not scar formation. b. it is the upper levels that contain collagen fibers. c. is not as tough as the epidermis because of its many structures. d. mostly consists of connective tissue.
5. A patient in an intensive care unit may be at higher risk of
pressure ulcers and this is more likely due to
a. a chronic disability. b. a patient’s advanced age. c. language barriers. d. an illness that has caused the patient to be immobile.
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Introduction
Wounds can develop through a number of causes, such as chronic disease,
trauma, cancer, or through surgical procedures. Clinical specialists who care
for patients with skin injuries and varied types of acute or chronic wounds
require thorough knowledge of the skin and its potential for breakdown and
ulceration. When treating a wound, health clinicians manage multiple factors
influencing skin care outcomes, including an underlying disease condition,
medication administration, rehabilitation therapy, and patient education to
promote wound healing and skin health.
Etiology of Wound Development
Multiple causes of skin wounds exist. Known as the largest body organ, skin
provides a significant amount of protection from damaging pathogens and
environmental factors that can cause internal organ injuries. When the skin
breaks down, its damaged areas are unable to function normally. Skin
wounds require time and extra care for healing, particularly when the wound
is deep or extensive.
Skin Injuries
Injuries to the skin surface may result in various types of wounds, from
small and minor tears in the skin to large openings that expose underlying
tissue and organs. The mechanism of injury determines the extent of the
wound, and could include incisions, lacerations, abrasions, bites, penetrating
wounds, and burns.1,8
Wound care can occur at different stages of healing. Initial management of
wounds involves assessment of the injured area (size and depth) and
understanding the mechanism of injury. The health clinician would want to
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ensure no other factors exist that could complicate the wound, such as the
presence of foreign objects or other injuries around the wound. An important
aspect of wound care involves managing the patient’s pain, and preventing
other complications associated with the wound, such as bleeding or
infection.1,8,9
Chronic Disease
Chronic disease can impair skin and tissue integrity, causing wounds that
may be slow to heal. Certain diseases impact the circulatory system, which
causes skin breakdown when the peripheral tissues do not receive enough
oxygen. Examples of diseases that can cause wounds include venous
insufficiency and diabetes.
Skin breakdown after exposure to substances or environmental stimuli can
cause wounds and can impact a person’s mobility and activity levels. There
is also a risk of skin breakdown from pressure sores and poor circulation.
Some diseases can cause an internal growth within the body that may
develop into an external wound. An example would be a cancerous tumor
underneath the skin that grows and results in a skin surface wound, known
as a fungating wound.68,69 When treating a wound caused by a disease
process, a significant part of treatment includes management of the
underlying disease. This may involve administering medications, therapy,
and educating patients about treatment of their health condition.
When a wound has developed as a result of a disease, clinicians need to
assist patients to control symptoms and to prevent recurrence of the wound
in the future.1,8,9
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Medical and Surgical Treatment
Surgical incisions are one of the most common types of wounds that occur,
although other procedures, such as radiation therapy or the administration
of certain kinds of medications, can also cause sores or burns on the skin
that must be monitored and treated.1,9 The process of wound healing may
vary depending on the method of intention used to close the wound. There
are three different stages of intention for wound healing based on the type
of wound, the amount of debris present, whether the wound is
contaminated, and the mechanisms that caused the wound.1,3
Primary Intention
Primary intention is a method of wound closure that is done by applying
physical measures to close a wound. A wound may be closed by primary
intention by applying sutures, staples, or medical-grade glue to approximate
the wound edges and bring them together for healing. Primary intention is
most often used with linear wounds, such as when closing a surgical incision.
As the wound edges grow together to form a scar, the resulting tissue is
typically as strong as the surrounding, undamaged tissue.
Secondary Intention
Secondary intention involves leaving a wound open to heal through the
development of new granulation tissue to fill in the wound base. Eventually,
the wound edges will heal and result in a scar, although this process
typically takes months longer than a wound healed by primary intention.
When the wound has completely healed, the scar tissue covering the wound
is not as strong as the surrounding tissue, and reaches approximately 80
percent of its previous strength as the surrounding, undamaged tissue once
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the wound has healed by secondary intention.3 Examples of wounds that
may heal by secondary intention include wounds that develop from pressure
ulcers, venous ulcers, and diabetic ulcers.
Tertiary Intention
Tertiary intention involves the process of initially leaving the wound open to
partial healing. The application of sutures, staples, or glue, brings the wound
edges together and closes the wound over time. These types of wounds
initially develop some scar tissue as they heal. After the wound edges are
brought together, the scar may become stronger than when the wound was
healing through secondary intention. Tertiary intention may be performed in
a case of an extensive wound that is contaminated and needs to be cleaned
and debrided for a period before surgically closing the wound.3
As a wound heals, it goes through a series of stages in which the tissue that
was broken down comes back together to form a scar. A wound that is small
may heal relatively quickly and without complications. Alternatively, a very
deep wound, one that is contaminated, or a wound in a patient who has an
underlying chronic disease that is poorly controlled, may take much longer
to heal. The phases of wound healing are further explained next.3
Inflammatory Phase
Bleeding that initially occurs will stop when the blood starts to clot. As the
blood clots dry, they form a scab, which is a combination of old blood and
wound exudate. The body’s immune system responds to the wound by
causing inflammation. In the first hours or days after the wound has
developed, it may become red, swollen, and tender to the touch.
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White blood cells are sent to the wound site and there is increased blood
flow to provide oxygen. There may be exudate production at this stage.1,3
Proliferative Phase
Granulation tissue begins to form in the wound bed and angiogenesis, the
process of creating new blood vessels, takes place under the skin. The
wound edges begin to come together as the cells migrate during
epithelialization. This stage lasts anywhere from a few days to several weeks
after the wound has developed.1,3
Remodeling Phase
Collagen formation builds strength in the wound bed; the wound fills in with
epithelial tissue, although it is not as strong as the surrounding tissue. The
remodeling phase may occur for months or years after a wound has
developed.1,3
Wound Types
Wounds are typically classified as being either chronic or acute wounds,
depending on how the wound has formed and the mechanism of injury
causing the wound. Chronic wounds are those that develop after tissue
damage has been ongoing. Examples of chronic wounds include wounds that
develop due to arterial insufficiency, diabetic ulcers, pressure sores, and
wounds that occur from venous insufficiency. The period of time that it takes
to develop a chronic wound may be weeks to months, but the point that
differentiates chronic wounds from acute wounds is that chronic wounds
develop over some period of time.1,3,9
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Alternatively, acute wounds are those that occur after injury to the skin
leads to damage and bleeding. Examples of types of acute wounds include
wounds from burns or trauma, and surgical wounds in which an incision is
made and the surgeon closes the wound with sutures or staples. The type of
wound that occurs, whether it is acute or chronic, typically affects one or
more layers of the skin, and may extend enough to impact the subcutaneous
fat, underlying tendons and ligaments, or may even affect the bones and
organs under the skin.1,3,9,60
The outermost layer of skin, the epidermis, consists of layers of cells that
are continuously pushed upward toward the skin surface where they are
eventually sloughed from the body. The lowest layer of the epidermis is a
row of cells known as germinative cells; these cells divide continuously to
form keratinocytes, which are the cells that make up a majority of the
epidermis. Keratinocytes form from the germinative layer of cells and then
slowly proceed toward the outside edge of the epidermis. As they move,
they become filled with keratin, which is a fibrous protein that provides
structure. Once the keratinocytes reach the outermost layer of the
epidermis, they die. They are not removed immediately, but instead remain
as the surface of the skin where they provide protection against
environmental components that could otherwise invade the body.1,3,9,60
When a wound occurs, part of the healing process involves producing new
skin cells from the germinative cells of the epidermis that are near the
wound edges. The epidermis is a very thin outer layer and covers the lower
dermal layer. Because it is so thin, the epidermis does not contain hair
follicles, blood vessels, or sweat glands, although hairs will protrude from
where they are formed in the dermis and extend through the epidermis to
the skin surface. When a wound occurs that is very superficial and only
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affects the epidermis, the wound typically heals quickly and with little
scarring, as the body is able to produce new skin cells from nearby
germinative cells.
Deeper wounds may affect the dermis, the skin layer that lies below the
epidermis. The dermis is thicker than the epidermis and it mostly consists of
connective tissue. The dermal layer contains many structures, including
blood vessels, hair follicles and nerve endings, as well as other cells that
take part in inflammatory processes when a wound occurs. The dermis is
much tougher than the epidermis because of its composition. The lower
levels of this layer contain collagen fibers that provide strength for the skin
and that take part in wound healing and scar formation.1,3,9,60
Below the dermis is the subcutaneous tissue, which consists of fat and other
components, including blood vessels, nerves, and lymph channels. The
subcutaneous tissue is covered by fascia, a membrane of connective tissue
that provides protection. The subcutaneous tissue covers underlying
structures such as bone and muscle, however, the thickness of
subcutaneous tissue layers varies between locations. Some areas, such as
those of the abdomen or upper thigh, naturally contain more fat tissue when
compared to other areas. The organs and muscles underneath the
subcutaneous tissue also have their own protective membranes. Depending
on the wound and the mechanism of injury, the wound can extend down into
the subcutaneous tissue and can expose underlying muscles or bone.1,3,9,60
There are many different mechanisms that can produce wounds, whether by
disease processes, through acute injury to the tissue, or through ongoing
factors that contribute to skin breakdown over time.
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Pressure Ulcers
A pressure ulcer develops in an area that becomes ischemic because
increased pressure on the skin and underlying tissue prevents adequate
blood flow to the area. Pressure ulcers can develop almost anywhere on the
body where excessive pressure impairs blood flow, but they are most
common on areas that cover bony prominences. The most likely areas where
pressure ulcers develop include the sacrum, the heels, the ear, and the
coccyx.3 Pressure ulcers were once referred to as decubitus ulcers or
bedsores; however, these terms do not necessarily reflect a comprehensive
mechanism of injury. For instance, a person who is not confined to bed may
still develop a pressure ulcer. The term pressure ulcer is more consistent in
defining the means of injury that occurs with this type of wound.9,25
Increased pressure over an area of skin causes compression of the blood
vessels that normally supply oxygenated blood to the skin, subcutaneous
tissue, and underlying fascia. When the blood vessels are constricted in this
manner, blood flow to these areas will slow and the distal areas will not
receive adequate oxygen or nutrients required to maintain healthy skin.9,25
Further, venous return is also slowed, and blood is unable to adequately flow
away from these areas and back toward the heart because of vessel
compression. As a result, metabolic wastes, which are normally carried away
from the area as part of venous return, instead accumulate in the affected
area. This causes a negative cycle as the increased buildup of metabolic
wastes causes vasodilation of surrounding blood vessels, followed by edema,
and further compression of the blood vessels supplying the area.
After a period of time in which blood flow is restricted, tissue ischemia
develops whereby the tissues fed by the compressed blood vessels no longer
have enough oxygen to survive and cell death occurs.9 This cell death then
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contributes to skin breakdown and the affected person develops a pressure
ulcer.
Regular wound assessment is required to determine the depth and extent of
the wound, as well as whether treatment measures are being effective in
healing the wound. The clinician should note the location, size, and
appearance of the wound to better determine the degree of damage. The
National Pressure Ulcer Advisory Panel (NPUAP) has defined several
classifications of pressure ulcers according to the depth of tissue
involvement and the extent of damage.78 By understanding the stages of
pressure ulcers, the clinician can assess a wound and better understand how
it is staged. By staging the wound, the clinician then has a guide for the best
form of wound management.1,3,8,78
Stage I
In stage I the skin is still intact but does not blanch when pressed. The skin
appears red, which does not resolve with time or position changes. It may
more likely appear over a bony prominence. In a person with dark skin, the
area may not be red or even noticeable except that the affected skin
appears as a different color when compared to the surrounding skin.
Normally, an area of skin may turn red after a short period of pressure; this
situation is known as reactive hyperemia. The process occurs when the body
increases blood flow to the compressed area to make up for temporary
oxygen deprivation. With reactive hyperemia, the skin becomes red and
appears flushed; however, this typically resolves quickly with position
changes and as blood flow resumes to its normal pattern.
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An area of redness can be considered a stage I ulcer if the redness does not
resolve and the area does not blanch.
Stage II
The skin is broken in Stage II but the wound is typically confined to the
epidermis. The skin appears red and blisters, filled with serous fluid. Blisters
may have broken, resulting in shallow wounds that ooze. The base of the
wound may appear pink or red and slough may or may not be present.
Stage III
In stage III the wound is deep enough that it extends through the epidermis
and into the dermis. A stage III pressure wound is considered a full-
thickness wound; however, this stage of wound does not affect the
underlying muscle, tendons, or bone. The subcutaneous fat under the dermis
may be seen in some areas where there are greater amounts of fat. Slough
may or may not be present at the base of the wound, which may make it
difficult to determine depth. Stage III wounds can have tunneling, in which a
hole or tunnel progresses deeper into surrounding tissue. If a second wound
is nearby, tunneling may connect the two wounds.
Undermining may also be present at stage III, which occurs when the edges
of the wound at the surface cover more of the wound than is present at the
base. When undermining is present, the wound is actually larger than it
appears at the surface.
Stage IV
Stage IV pressure ulcer is a full-thickness wound that extends from the
epidermis into the dermis and subcutaneous tissue and exposes underlying
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bones, muscles, or tendons. In areas where there is less subcutaneous fat
and cartilage is present instead, such as on the nose or the ear, the
exposure of underlying cartilage classifies the wound as a stage IV pressure
ulcer. Tunneling and undermining may also be present with this stage of
wound.
In addition to the standard categories of wounds based on the depth of the
affected tissue and the exposure of underlying structures, there are other
classifications of pressure wounds that account for injuries with
measurements or depth that are not obvious and apparent.1-4,9,78
Unstageable Wound
The unstageable type of wound is not obvious as far as its depth is
concerned. The clinician may not be able to classify the wound based on its
appearance and further measurements are often required. The base of the
wound is usually covered with slough or eschar, which makes the depth of
the wound difficult to determine.
Several other terms that describe wound tissue may be identified as
characteristics of wounds; these elements may be present in pressure ulcers
or in wounds that have developed as a result of other reasons. Eschar is
used to describe necrotic tissue that has developed within a wound. Eschar
is dead skin that is often tough and thick; it may have a similar appearance
to a scab but it is not the same. Eschar is what must be removed with
debridement. Without removal of eschar, would healing can be significantly
delayed.
Slough is another component of the wound that may develop alongside
eschar, but it has an appearance that is different. Slough is also a collection
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of necrotic tissue, but unlike eschar, it is typically moist, crusty, or crumbly.
It is typically white, yellow, or cream colored and it is thought to contain
dead leukocytes, bacteria, dead skin, fibrin, and wound exudate. Slough
must be removed during debridement in order to promote wound healing, as
the body typically cannot get rid of slough on its own and it may accumulate,
harboring bacteria and preventing growth of normal, new skin tissue.
Deep Tissue Injury
In a deep tissue injury (DTI) the skin may or may not be broken but there is
significant bruising that appears as blue or purplish skin with bruising that
extends down into lower layers of skin. The appearance of the wound may
also look like that of a blood-filled blister. The texture of the skin with a DTI
can vary; some patients have skin that feels warmer than surrounding
tissue, while others have cooler skin. The skin texture may feel firm or it
may be mushy. Some patients have intense pain while others do not.
Deep tissue injury occurs in an area that has been injured by shear forces. It
can be difficult to determine how deep the injury is and if it extends down
past the dermal layer. A DTI can be difficult to assess in a patient with dark
skin. As the injury heals, it may become an ulcer with open skin on the
surface or it may resolve under the skin.
Kennedy Terminal Ulcer
The Kennedy Terminal Ulcer is a specific type of skin breakdown that may
occur hours, weeks, or months before death in a terminal patient. This type
of terminal ulcer typically develops among patients who are nearing death
and placed in a long-term care setting. The skin takes on a purple, red, or
yellow appearance and the wound may be shaped like a pear or a butterfly.
The most common location where the ulcer develops is on the sacrum,
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although it can show up on any part of the skin. This type of ulcer may be
more commonly seen by clinicians caring for patients in a long-term care
facility or among those who work in Critical Care Units (CCUs) that may
receive patient transfers from long-term care facilities.
A Kennedy terminal ulcer may develop rapidly through the process of skin
breakdown as the patient nears death. As a person nears death, organ
failure is often a cause of death. The skin, the largest organ of the body,
may also fail, leading to skin breakdown associated with a Kennedy terminal
ulcer.
Factors Contributing to Pressure Ulcers
Other factors may contribute to the development of pressure ulcers, placing
certain patients at higher risk. Immobility is a primary cause of pressure
ulcer development, as the inability to move or change positions to relieve
pressure on an affected area results in compressed blood vessels over time.
Patients who have excess skin moisture due to sweating or poor hygiene are
at increased risk, particularly when the skin becomes ischemic from too
much pressure. The excess moisture on the skin causes the surface skin to
become softer and more prone to breakdown.5,9
Older adults are a population at high risk, not only because of their
increased instances of immobility, but also because of body changes
associated with aging. Many older adults have less subcutaneous fat under
the surface of the skin, which results in less protection from epidermal
injury.9,25 Older adults also have thinner skin as a result of aging, which
often becomes dry and less elastic due to decreased action of collagen and
elastin within the skin’s structure. These effects of aging cause the skin to
heal much more slowly when a wound occurs. Further, some older adults
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suffer from sensory changes that result in diminished sensation in the
extremities and distal tissues. These older adults may be less likely to
perceive when tissue damage is happening because they cannot feel it
immediately.
Obese patients are also at higher risk of skin breakdown due to pressure
ulcers and tissue ischemia. Patients who are obese have more weight
applied to certain areas when lying in different positions. A person who is
obese may have extra skin folds that can retain moisture and can be difficult
to clean. The skin in these folds may break down more easily when moisture
remains between the folds or when skin folds rub on bed sheets or linens,
causing small abrasions on the surface of the skin.
Various intrinsic and extrinsic factors can impact the risk of developing
pressure ulcers.78 Intrinsic factors that affect wound development include
age, circulation status, personal habits that affect skin integrity (smoking,
diet, alcohol consumption), body temperature, use of some medications
(steroids, vasoactive drugs), weight, and history of injury or disability. Some
intrinsic factors can be changed, while others cannot. Extrinsic factors
include such elements as friction and shear, level of moisture, irritating
substances on the skin, and the environment that prevents movement or
turning to relieve pressure.
Assessment Tools and Rating Scales
Multiple rating scales are available to assess patient risk for the development
of pressure ulcers. In the U.S., the Braden scale is one of the most common
tools used to assess whether particular patients are at risk of skin
breakdown or if the skin is no longer intact. The clinician may use the
Braden scale when performing a patient assessment.78 The results are given
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scores based on factors such as the patient’s level of sensory perception,
moisture content of the skin, nutrition levels, and mobility. The lower the
Braden scale score the higher the risk for skin breakdown.
Assessment tools may be used on any patient who may be at risk of
pressure ulcers. Although not all patients may need intervention for pressure
ulcer prevention, it is always better to provide more care to prevent ulcers
than to avoid interventions because a patient is believed to be at low risk.
Increased clinical interventions for prevention of pressure ulcers has been
shown to decrease pressure ulcer development regardless of the patient’s
level of risk.
Arterial Insufficiency
Arterial insufficiency refers to decreased and inadequate blood flow to
tissues and organs. A patient with arterial insufficiency is at increased risk of
developing ulcers when the skin and underlying tissue lacks healthy blood
flow and becomes ischemic. Arterial insufficiency ulcers most commonly
affect the lower extremities, including the legs and feet.10 As blood flow
diminishes, the cells are starved for oxygen and tissue ischemia develops.
Without correction of adequate blood flow, the skin becomes necrotic and
starts to break down, forming a wound.
Arterial insufficiency can develop through various causes and it may occur
suddenly or it can develop gradually. A sudden cause of arterial insufficiency
may result from trauma or injury to a part of the body that disrupts blood
flow to the extremities. Alternatively, chronic arterial insufficiency may
develop over time due to atherosclerosis.9,10
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Several conditions are associated with arterial insufficiency and patients with
these illnesses are more likely to suffer from blood flow abnormalities and
wounds that develop from arterial insufficiency. Examples include
thrombosis of any cause, vasculitis, rheumatoid arthritis, systemic lupus
erythematosus, sickle cell disease, polycythemia, and Raynaud’s
phenomenon. These conditions affect blood circulation through such factors
as abnormalities in blood vessel structure or anomalies within blood cells,
resulting in decreased circulation to peripheral tissues. Despite underlying
abnormalities in blood flow associated with certain diseases, the most
common cause of arterial insufficiency is atherosclerosis.9,10
Frequent sites of ulcers in the lower extremity include the lateral malleolus
of the ankle, the foot, and the toes. Wounds that develop from arterial
insufficiency are often small and round without granulation tissue in the
wound base. They often cause significant pain for the affected patient.
Arterial insufficiency causes symptoms similar to that of peripheral arterial
disease (PAD) and is often affiliated with the condition. PAD develops as a
result of atherosclerosis in the large vessels that supply blood to the lower
extremities; the plaques found in the walls of the blood vessels disrupt blood
flow and decrease circulation. Older adults are at increased risk of PAD and,
ultimately, an increased risk of arterial insufficiency wounds. Older adults
are more likely to develop atherosclerosis, as the incidence increases with
advancing age.7-10
When a wound does develop as a result of decreased blood flow, the healing
process can be slow and difficult. Because oxygen is needed not only to
prevent wounds from forming, but also for wounds to heal properly,
decreased oxygenation from arterial insufficiency results in wounds that heal
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poorly and that do not close properly. When a wound develops because of
trauma, the wound is more likely to close slowly and have difficulties with
healing in a person with arterial insufficiency when compared to someone
with normal circulation. For example, a person with PAD if injured by
stepping on a sharp object may have a wound at the site of the injury.
Decreased circulation to the site may further potentiate spreading of the
wound or it may limit the pace at which the wound heals.
Arterial insufficiency often is paired with other illnesses that all contribute to
wounds and ulcers as a result of impaired circulation. A patient may not only
have arterial insufficiency due to peripheral artery disease or vasculitis, but
may also have other conditions that contribute to wound development, such
as diabetes.8-10 The risk of ulceration and tissue necrosis is often increased
when more than one condition affecting circulation is present.
Wound Risk Factors
Although there are various causes of wounds that result from differing states
of health or disease, there are some risk factors that are more common to
wound development in general. By and large, a poor state of health, whether
because of chronic disease, malnutrition, lack of activity, or poor self-care,
typically contributes to an increased risk of wound development and poor
wound healing when a wound does happen.
Insufficient Oxygen
Poor oxygen perfusion contributes to wound development when the tissues
do not receive enough oxygenated blood. This may more likely occur in a
condition in which blood flow is reduced or blocked due to an occlusion, such
as in the case of arterial insufficiency or peripheral arterial occlusive disease.
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The skin and underlying tissues need oxygen from the blood in order to stay
healthy and to prevent the growth of anaerobic bacteria, which are
microorganisms that can grow in the absence of oxygen. When the skin and
peripheral tissues do not have enough oxygen, the skin is more likely to
break down, causing a wound, and the resultant wound could become
infected more easily.1,12,13
Malnutrition
Malnutrition impacts wound healing due to changes in protein sufficiency and
lack of vitamins that normally act as healing factors in the body. Malnutrition
can develop in some people because of a lack of intake due to a number of
situations, including socioeconomic factors that affect accessibility of food,
stressful events or periods of severe illness, difficulties with feeding,
chewing, or swallowing food, malabsorption syndromes that affect how the
body digests and absorbs nutrients, or mental health diagnoses of eating
disorders, such as anorexia.1,9,54 Alternatively, malnutrition can also occur
among some patients who are overweight or obese. An obese patient may
have malnutrition even when food intake is excessive because he or she may
only be eating certain types of foods that add to weight gain but that do not
provide important nutrients.
When a person is malnourished, protein is used for energy instead of
glucose. To get this protein, the body breaks down its own sources, such as
protein found within skeletal muscle tissue. Because wound healing requires
protein to form a healing matrix through collagen, wounds may heal slower
when the body is focusing its protein sources instead on gaining energy.54
Malnutrition also contributes to wound development through other methods.
Poor nutrition depletes lean body mass and the patient has less muscle
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tissue for activities of daily living; he or she may be more likely to develop
greater degrees of immobility, which can further impair other body
processes and contribute to skin breakdown. Further, decreased protein
intake impairs the immune system and can increase the risk of infection if a
wound develops.8,54
A patient who develops an illness or goes through a surgical procedure loses
a certain amount of protein each day. This protein loss then contributes to
further effects that can lead to wound development. Additionally, certain
procedures, periods of hospitalization, or general lack of intake can affect
how well a wound heals when it does develop.53 Malnutrition has been shown
to impact function of both B and T lymphocytes and prevents proper
functioning of leukocytes in the body, increasing the risk of infection.
Further, if a wound starts to develop skin breakdown may be perpetuated by
loss of protein and malnutrition; as a malnourished state also increases the
length of the inflammation stage of wound healing, it decreases collagen
synthesis and decreases overall strength of the skin.
A patient who is malnourished may also be underweight and may have less
fat tissue to protect bony prominences. Consequently, more bony
prominences increase the risk of pressure ulcers without the extra padding
under the skin. A patient who has decreased muscle mass and more bony
prominences as a result of malnutrition may have less activity when
compared to another person who is not malnourished.54 The increase in
immobility, decrease in muscle mass, and greater number of pressure points
can all contribute to skin breakdown associated with pressure ulcers.
Diabetes mellitus can cause a form of malnutrition because the patient has
abnormal carbohydrate metabolism and is therefore unable to adequately
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use this type of macronutrient in a normal manner needed for the body.
Diabetes, or even a severe state of stress or illness that leads to changes in
blood glucose concentrations, can disrupt the functions of the cells of the
immune system, thereby increasing the risk of infection.18,21 Hyperglycemia
has also been shown to reduce the body’s ability to absorb vitamin C into
leukocytes and fibroblasts in the skin cells.
Several vitamins are also necessary to help the body with wound healing.
Vitamin C, or ascorbic acid, is needed for synthesis of collagen, which
provides a structural framework in the growth of new tissue in the wound
bed. Vitamin C also supports the body’s immune response, and lack of
vitamin C may contribute to increased inflammation when a wound has
developed.
Vitamin A deficiency leads to a decrease in the function of certain types of
immune cells, including macrophages and monocytes. Vitamin D depletion
also leads to decreased strength in the healed wound if one does develop.
Another fat-soluble vitamin, vitamin E, is associated with health of the skin.
Deficiencies in vitamin E are uncommon, but they can cause problems with
the body’s defenses because of its antioxidant properties. Further, vitamin E
deficiency may lead to uncontrolled inflammation in and around the wound.
Fluid volume deficit also has an impact on wound healing. A patient may
have adequate intake of food and may gain enough vitamins, minerals, and
nutrients through eating, but lack of fluid can lead to dehydration, which can
stunt the wound healing process. Dehydration causes a decrease in overall
circulation; in addition to causing other problems such as electrolyte
imbalance, decreased blood volume from dehydration prevents adequate
blood flow from reaching the wound site. The body is less able to send blood
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cells to the site of injury for their part in maintaining immunity, stimulating
wound healing, and preventing infection.
Immobility
Immobility is one of the most common factors associated with pressure ulcer
development, but it also plays a contributing role in wound development for
patients with other chronic diseases, such as venous insufficiency and
diabetes. Lack of movement from immobility decreases overall circulation
and can cause wounds related to incontinence or an inability to perform self-
care measures.1 When a patient is immobile and must rely on caregivers for
movement or repositioning, he or she is at greater risk of skin breakdown
because of an inability to shift positions to take pressure off of certain areas
of the skin. Wounds may be more likely to occur in an immobile patient who
must spend a significant amount of time in bed or sitting in a chair, and who
otherwise can do little to increase circulation in the extremities and support
or maintain proper blood flow.55-57
Many immobile patients have difficulties with getting up to use the bathroom
and are often forced to rely on bedpans, catheters, and/or bedside
commodes for elimination. Immobile patients may be at increased risk of
incontinence if they are unable to access these devices quickly enough or if
they must rely on a caregiver for help.55-57 Urinary and fecal incontinence
contribute to skin breakdown because of the components of these wastes.
Urine is a fluid that, when left on the skin, increases moisture content and
causes skin softening and maceration. The enzymes found in stool, as well
as its pH content can also cause skin breakdown, particularly after times
when fecal matter is left on the skin without being cleaned in a timely
manner.
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Many people think of immobility as affecting older adults who are living in
long-term care facilities and who are dependent on caregivers for help with
turning or with getting out of bed. While this is true in many cases, another
population of patients are at risk of skin breakdown because of immobility in
the healthcare environment are those who receive care in the intensive care
unit. Patients in intensive care environments are at risk of wound
development, often because of the increased amounts of medical equipment
used because of their fragile medical states.1,3 A patient in the intensive care
unit may be at higher risk of pressure ulcers because he or she is typically
immobile because of illness, rather than a chronic disability or advanced age,
as is seen among some other immobile patients. The patient in the intensive
care unit often also needs more medical equipment as part of his or her
care, which may include a ventilator, urinary catheter, sequential
compression device, intravenous line or central catheter, and hemodynamic
monitoring systems. Some of the medications administered to a patient may
also increase the risk for skin breakdown.
Based on the amount of equipment required and the clinical status of acute
illness, the intensive care unit patient is actually quite immobile. Depending
on the level of care required, he or she may not be able to get up or move
out of bed in any way, whether because of illness and level of consciousness
or because of the presence of so many pieces of medical equipment needed
to provide care. For example, a patient who requires mechanical ventilation
typically requires sedation, which places him or her in an altered state of
consciousness and, most likely, restricted to bed rest rather than chair
activity to facilitate position changes. Prevention of pressure ulcers,
therefore, is centered on turning and repositioning the patient frequently and
preventing medical equipment from applying too much pressure at a
particular site.1,3
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In addition to limiting how much a patient in the intensive care unit is able
to get up or move, medical equipment also places pressure on certain parts
of the skin, which can lead to skin breakdown. An endotracheal tube that is
positioned in the same area or that presses against the lip for too long can
cause tissue breakdown in that area. A patient who is turned and who is
accidentally positioned so that the catheter hub of the central line is under
the body can suffer from skin breakdown in a short time due to the
intravenous tubing continuously pressing into the skin until such time the
patient is moved again.62,78 The administration of some vesicant solutions as
part of treatment for complex medical conditions often seen in the intensive
care unit can cause significant skin and tissue damage if extravasation
occurs. For instance, administration of cisplatin can cause tissue damage and
necrosis if it leaks from the intravenous site into the surrounding tissue.
Comorbidities
Certain factors impact wound development and affect healing when a wound
does develop. Comorbidities are diseases that are present in the patient that
may directly cause wound development or may result in a wound becoming
chronic and difficult to heal. Some patients have several comorbidities,
making their risks for wound development much higher than the general
population.
As a wound goes through the phases of healing, a comorbid condition that is
already present in the patient may interrupt the process and either slow or
stop wound healing altogether or cause complications that require further
intervention. For example, a patient who has diabetes and has developed a
foot wound may be on track with wound healing through proper care and
wound management.66,67 However, time spent with uncontrolled blood
glucose levels and improper foot care — both of which are factors associated
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with diabetes as a comorbidity in this case — can lead to a wound infection
and skin breakdown on the wound periphery, further complicating the
healing process.
There are a number of comorbid conditions that can impair and delay wound
healing. These factors may contribute to the cause of the wound or they
may be elements that affect the wound’s healing progress. Examples of
comorbid conditions that can impact wound development and healing include
chronic conditions such as diabetes, vasculitis, systemic lupus
erythematosus, renal failure, various forms of cancer, rheumatoid arthritis,
and scleroderma.66,67
When comorbidities are present in the wound care patient, the health
clinician performs more than one role. Part of wound care management is
controlling the health of the wound, providing supportive care and treatment
through dressing changes and medication administration, and ensuring that
the patient knows how to care for the wound. Additionally, interventions
need to be implemented that address comorbid conditions to prevent
delayed wound healing.
As part of comprehensive care, medical therapy and patient education must
be part of the patient treatment plan to improve health and psychosocial
outcomes.11 As an example, a patient who has renal failure and a lower leg
ulcer not only needs ongoing wound care through assessment and
treatment, but also needs supportive treatment for renal disease. Care of
comorbid conditions will impact wound healing and is a necessary part of
treatment. In addition to providing wound care, medical care and other
interdisciplinary referrals, such as a dietary consult, occupational therapy or
social service support may be needed. In the case of a patient with renal
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failure, a referral to a nephrologist and possible dialysis would be a
reasonable course of care.
Any patient who has a chronic disease and a healing wound must be
educated about how the condition affects wound repair and healing. Because
the patient should be an active participant in the wound care process, he or
she needs to know what factors could possibly delay wound healing. The
patient may or may not understand the correlation between a chronic
disease and a wound involving the skin.3,11 It is the clinician’s responsibility
to educate the patient about how each condition is related to the other. By
educating the patient about the factors that affect wound healing, the
patient can become more involved in his or her treatment regimens and may
take steps to assist not only with wound care, but with care of his or her
chronic disease as well.11
Medications
Certain medications can cause skin breakdown when they cause changes in
the skin because of side effects or when they are inadvertently administered
in a method that the medication interacts with the skin when it is not
supposed to. There are a number of medications that cause rash or eczema
as side effects. While this may not initially cause skin breakdown, the skin
can become more sensitive when a patient takes medications with these
effects. The patient may also scratch the skin in an attempt to soothe the
itching; excessive scratching can eventually lead to skin breakdown, sores,
or lesions.
Some medications, when administered intravenously, can cause significant
wounds if their solutions are accidentally infiltrated into the skin and tissues.
This can happen when, upon administration of the medication into the
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intravenous catheter, the medication leaks out into the tissues and causes
damage. Medications known as vesicants can cause tissue damage and
necrosis of the skin when extravasation occurs during administration.
Extravasation can lead to such a significant wound that the patient requires
debridement and regular dressing changes while the wound heals,
sometimes over a period of weeks or months. When a health clinician must
administer medications intravenously, he or she should be aware of the
potential effects on the skin.52,55 When giving vesicant medications, the
clinician must routinely check the intravenous catheter and monitor the
intravenous site and the tubing for changes to ensure that extravasation
does not develop and cause severe tissue damage to the skin.
Summary
Management of wounds involves a number of considerations, which include
the mechanism of injury and the assessment of the wound. Assessment of
the wound involves the wound size and depth. Additionally, it is important to
consider other complicating factors, such as the presence of foreign objects
or other injuries around the wound, pain management, and the prevention
of bleeding or infection.
The process of wound healing may vary depending on the method of
intention used to close the wound. Wounds are healed by intention, which is
categorized into three different stages, primary, secondary and tertiary;
and, is based on the type of wound, the amount of debris present or if the
wound is contaminated, and the mechanisms of the cause of the wound.
Wounds are typically classified as being either chronic or acute wounds.
Chronic wounds are those that develop after tissue damage has been
ongoing, such as, wounds due to arterial insufficiency, diabetic ulcers,
pressure sores, and venous insufficiency. The point that differentiates
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chronic wounds from acute wounds is that chronic wounds develop over
some period of time.
Risk factors more common to wound development generally include a poor
state of health due to chronic disease or poor self-care. Immobility, the most
common factors associated with pressure ulcer development, also plays a
contributing role in wound development for patients with chronic diseases,
such as venous insufficiency and diabetes. A decrease in overall circulation
due to immobilization can cause wounds related to incontinence or poor self-
care performance. Patients at risk of skin breakdown rely on caregivers to
help with mobility and position change to prevent skin pressure areas.
Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement.
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1. Tertiary intention involves the process of
a. wound closure done by applying physical measures to close a wound.
b. initially leaving the wound open to partial healing. c. leaving a wound open to heal through production of new
granulation tissue to fill in the wound base. d. None of the above
2. When a clinician administers medications intravenously, he or she
should be aware that
a. vesicants are safe because these medications do not cause tissue damage to the skin.
b. it is preferable to administer medications intravenously so they may infiltrate the skin tissues.
c. some medications, when administered intravenously, can cause significant wounds if they accidentally infiltrate the skin and tissues.
d. extravasation does not develop if medications are administered intravenously.
3. The National Pressure Ulcer Advisory Panel (NPUAP) has defined
several classifications of pressure ulcers according to the
a. length of tissue involvement and presence of exudate. b. depth of tissue involvement and the extent of damage. c. circumference of tissue involvement and level of pain. d. world health criteria.
4. The dermis is thicker than the epidermis and
a. it is involved in the wound healing process but not scar formation. b. it is the upper levels that contain collagen fibers. c. is not as tough as the epidermis because of its many structures. d. mostly consists of connective tissue.
5. A patient in an intensive care unit may be at higher risk of
pressure ulcers and this is more likely due to
a. a chronic disability. b. a patient’s advanced age. c. language barriers. d. an illness that has caused the patient to be immobile.
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6. Malnutrition impacts wound healing due to
a. lean body mass (a low BMI). b. the presence of more muscle and less fat tissues. c. changes in protein sufficiency and lack of vitamins. d. autoimmune factors.
7. A patient with a chronic disease and immobility is prone to wound
development due to
a. decreased overall circulation. b. incontinence. c. inability to perform self-care measures. d. All of the above
8. There are three different stages of _____________ for wound
healing based on the type of wound, the amount of debris present, whether the wound is contaminated, and the mechanisms that caused the wound.
a. infection b. closure c. intention d. inflammation
9. Hyperglycemia has also been shown to reduce the body’s ability
to absorb ____________ into leukocytes and fibroblasts in the skin cells.
a. Vitamin C b. Vitamin E c. Vitamin B complexes d. Vitamin A
10. ______________ medication can cause tissue damage and
necrosis of the skin when extravasation occurs during administration.
a. Evacuante b. Vesicant c. Esicant d. Vesic
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11. Wounds are healed by intention, which is categorized in stages of
a. primary, secondary and tertiary. b. principal and complicating. c. initial trauma and secondary infectious. d. non-infected and infected.
12. Fluid volume deficit can stunt the wound healing process
because
a. decrease in overall circulation. b. electrolyte imbalance. c. decreased blood volume to send blood cells to site of injury. d. All of the above
13. Chronic wounds are those that develop
a. due to arterial and venous insufficiency. b. at the time of injury. c. as a category of wound occurring after 3 days. d. due to electrolyte imbalance.
14. _______________ has been shown to impact function of both B
and T lymphocytes and prevents proper functioning of leukocytes in the body, increasing the risk of infection.
a. Dehydration b. Malnutrition c. Acute blood loss d. Blunt trauma
15. Deficiencies in vitamin E
a. are common, and may impact the function of B and T lymphocytes. b. are uncommon, and may lead to uncontrolled wound inflammation. c. are not known to impair the body’s defenses. d. lead to coagulopathy and blood loss.
16. True or False: A severe state of stress or illness that leads to
changes in blood glucose concentrations can disrupt the
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functions of the cells of the immune system, thereby increasing the risk of infection.
a. True b. False
17. _________________ wounds can have tunneling.
a. Stage I b. Stage II c. Stage III d. All of the above
18. True or False: When undermining is present, the wound is
smaller than it appears at the surface.
a. True b. False
19. Primary intention is most often used with linear wounds, such
as when closing
a. pressure ulcers. b. venous ulcers. c. diabetic ulcers. d. a surgical incision.
20. _________________ is needed for synthesis of collagen, which
provides a structural framework in the growth of new tissue in the wound bed.
a. Vitamin D b. Vitamin E c. Vitamin C d. Vitamin A
CORRECT ANSWERS:
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1. Tertiary intention involves the process of
b. initially leaving the wound open to partial healing. “Tertiary intention involves the process of initially leaving the wound open to partial healing. The application of sutures, staples, or glue, brings the wound edges together and closes the wound over time. These types of wounds initially develop some scar tissue as they heal.”
2. When a clinician administers medications intravenously, he or she
should be aware that
c. some medications, when administered intravenously, can cause significant wounds if they accidentally infiltrate the skin and tissues. “Some medications, when administered intravenously, can cause significant wounds if their solutions are accidentally infiltrated into the skin and tissues.... Medications known as vesicants can cause tissue damage and necrosis of the skin when extravasation occurs during administration.... When giving vesicant medications, the clinician must routinely check the intravenous catheter and monitor the intravenous site and the tubing for changes to ensure that extravasation does not develop and cause severe tissue damage to the skin.”
3. The National Pressure Ulcer Advisory Panel (NPUAP) has defined
several classifications of pressure ulcers according to the
b. depth of tissue involvement and the extent of damage. “The National Pressure Ulcer Advisory Panel (NPUAP) has defined several classifications of pressure ulcers according to the depth of tissue involvement and the extent of damage. By understanding the stages of pressure ulcers, the clinician can assess a wound and better understand how it is staged. By staging the wound, the clinician then has a guide for the best form of wound management.”
4. The dermis is thicker than the epidermis and
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d. mostly consists of connective tissue. “The dermis is thicker than the epidermis and it mostly consists of connective tissue.... The dermis is much tougher than the epidermis because of its composition. The lower levels of this layer contain collagen fibers that provide strength for the skin and that take part in wound healing and scar formation.”
5. A patient in an intensive care unit may be at higher risk of
pressure ulcers and this is more likely due to
d. an illness that has caused the patient to be immobile. “A patient in the intensive care unit may be at higher risk of pressure ulcers because he or she is typically immobile because of illness, rather than a chronic disability or advanced age, as is seen among some other immobile patients.”
6. Malnutrition impacts wound healing due to
c. changes in protein sufficiency and lack of vitamins. “Malnutrition impacts wound healing due to changes in protein sufficiency and lack of vitamins that normally act as healing factors in the body.”
7. A patient with a chronic disease and immobility is prone to wound
development due to
a. decreased overall circulation. b. incontinence. c. inability to perform self-care measures. d. All of the above [correct answer]
“Immobility is one of the most common factors associated with pressure ulcer development, but it also plays a contributing role in wound development for patients with other chronic diseases, such as venous insufficiency and diabetes. Lack of movement from immobility decreases overall circulation and can cause wounds related to incontinence or an inability to perform self-care measures.”
8. There are three different stages of _____________ for wound
healing based on the type of wound, the amount of debris
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present, whether the wound is contaminated, and the mechanisms that caused the wound.
c. intention “The process of wound healing may vary depending on the method of intention used to close the wound. There are three different stages of intention for wound healing based on the type of wound, the amount of debris present, whether the wound is contaminated, and the mechanisms that caused the wound.”
9. Hyperglycemia has also been shown to reduce the body’s ability
to absorb ____________ into leukocytes and fibroblasts in the skin cells.
a. Vitamin C “Hyperglycemia has also been shown to reduce the body’s ability to absorb vitamin C into leukocytes and fibroblasts in the skin cells.”
10. ______________ medication can cause tissue damage and
necrosis of the skin when extravasation occurs during administration.
b. Vesicant “Medications known as vesicants can cause tissue damage and necrosis of the skin when extravasation occurs during administration.”
11. Wounds are healed by intention, which is categorized in stages
of
a. primary, secondary and tertiary. “Wounds are healed by intention, which is categorized into three different stages, primary, secondary and tertiary;....”
12. Fluid volume deficit can stunt the wound healing process
because
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a. decrease in overall circulation. b. electrolyte imbalance. c. decreased blood volume to send blood cells to site of injury. d. All of the above [correct answer]
“Fluid volume deficit ... can lead to dehydration, which can stunt the wound healing process. Dehydration causes a decrease in overall circulation; in addition to causing other problems such as electrolyte imbalance, decreased blood volume from dehydration prevents adequate blood flow from reaching the wound site. The body is less able to send blood cells to the site of injury for their part in maintaining immunity, stimulating wound healing, and preventing infection.”
13. Chronic wounds are those that develop
a. due to arterial and venous insufficiency. “Chronic wounds are those that develop after tissue damage has been ongoing, such as, wounds due to arterial insufficiency, diabetic ulcers, pressure sores, and venous insufficiency.”
14. _______________ has been shown to impact function of both B
and T lymphocytes and prevents proper functioning of leukocytes in the body, increasing the risk of infection.
b. Malnutrition “Malnutrition has been shown to impact function of both B and T lymphocytes and prevents proper functioning of leukocytes in the body, increasing the risk of infection.”
15. Deficiencies in vitamin E
b. are uncommon, and may lead to uncontrolled wound inflammation. “Deficiencies in vitamin E are uncommon, but they can cause problems with the body’s defenses because of its antioxidant properties. Further, vitamin E deficiency may lead to uncontrolled inflammation in and around the wound.”
16. True or False: A severe state of stress or illness that leads to changes in blood glucose concentrations can disrupt the
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functions of the cells of the immune system, thereby increasing the risk of infection.
a. True “Diabetes, or even a severe state of stress or illness that leads to changes in blood glucose concentrations, can disrupt the functions of the cells of the immune system, thereby increasing the risk of infection.”
17. _________________ wounds can have tunneling.
c. Stage III “Stage III wounds can have tunneling, in which a hole or tunnel progresses deeper into surrounding tissue. If a second wound is nearby, tunneling may connect the two wounds.”
18. True or False: When undermining is present, the wound is
smaller than it appears at the surface.
b. False “Undermining may also be present at stage III, which occurs when the edges of the wound at the surface cover more of the wound than is present at the base. When undermining is present, the wound is actually larger than it appears at the surface.”
19. Primary intention is most often used with linear wounds, such
as when closing
d. a surgical incision. “Primary intention is most often used with linear wounds, such as when closing a surgical incision.”
20. _________________ is needed for synthesis of collagen, which
provides a structural framework in the growth of new tissue in the wound bed.
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c. Vitamin C “Several vitamins are also necessary to help the body with wound healing. Vitamin C, or ascorbic acid, is needed for synthesis of collagen, which provides a structural framework in the growth of new tissue in the wound bed.”
References Section
The References below include published works and in-text citations of published works that are intended as helpful material for your further reading. [References are for a multi-part series on WOUND CARE].
1. Armstrong, D. and Meyr, A. (2017). Basic principles of wound management. UpToDate. Retrieved online at https://www.uptodate.com/contents/basic-principles-of-wound-management.
2. Brown, MS, Ashley, B. and Koh, A. (2018). Wearable Technology for Chronic Wound Monitoring: Current Dressings, Advancements, and Future Prospects. Front Bioeng Biotechnol. 2018 Apr 26;6:47.
3. Armstrong, D. and Meyr, A. (2018). Basic principles of wound healing. UpToDate. Retrieved from https://www.uptodate.com/contents/basic-principles-of-wound-healing?search=wound%20healing&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.
4. Falconio-West, M. (2013). Kennedy Terminal Ulcer (KTU) is now recognized by CMS for long-term acute care hospitals (LTAC or LTCH). Retrieved from http://mkt.medline.com/clinical-blog/channels/clinical-solutions/kennedy-terminal-ulcer-ktu-is-now-recognized-by-cms-for-long-term-acute-care-hospitals-ltac-or-ltch/
5. Medtronic (2016). PRESSURE ULCER PREVENTION: ADVANCED PATIENT MONITORING TECHNOLOGY FOR REPOSITIONING MANAGEMENT. Medtronic/Covidien. Retrieved from http://www.covidien.com/imageServer.aspx/doc340207.pdf?contentID=83123&contenttype=application/pdf.
6. Mishra, SC., et al. (2017). Diabetic Foot. BMJ. 2017 Nov 16;359:j5064. 7. Checklist for factors affecting wound healing. Adv Skin Wound Care.
2011 Apr;24(4):192.
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