*9.PTA 200-Wound Management Part 2 Flashcards
Designed for use with wounds whose primary cause is something other than pressure. This is typically the classification system for burns, skin tears, lacerations, surgical wounds and vascular ulcers.
Classification by thickness;
Superficial, Partial, Full
into only the epidermis
Superficial
Wounds extend through the first layer of skin (the epidermis) and into, but not through, the second layer of skin (dermis). Wounds heal by re-epithelialization.
Partial thickness
wounds extend through both the epidermis and dermis and may involve subcutaneous tissue, muscle, and possibly bone. (grafting/flaps are necessary)
Full thickness
Designed for use with traumatic, surgical, and other wounds that heal by secondary intention
Classification by Color;
refers to healing in wounds that start out with large surface areas, with distracted edges, or wounds in which a large amount of tissue has been lost.
Secondary Intention
healing occurs in wounds where the edges which have been closely approximated by sutures or staples.
Primary Intention
refers to a wound left open for several days (to insure no infection is present) before wound is closed with suture/steri-strips, etc.
Delayed Primary Intention
Indicates clean, healthy granulation tissue. When a wound begins to heal, a layer of pale pink granulation tissue covers the wound bed, which later becomes beefy red.
Red Wound
Indicates the presence of exudate or slough produced by microorganisms and the need for cleaning. Exudate can be whitish yellow, creamy yellow, yellowish green, or beige.
Yellow Wound
a fluid with a high content of protein and cellular debris which has escaped from blood vessels and has been deposited in tissues or on tissue surfaces, usually as a result of inflammation.
Exudate- in relation with yellow wound
necrotic fatty tissue in the process of being separated from viable portions of the body.
Slough- in relation with yellow wound
Indicates the presence of eschar. Necrotic tissue slows healing and provides a site for microorganisms to proliferate.
Black wound
a slough produced by gangrene.
eschar- in relation with black wound
Document and describe length and width only.
Stage I Measurements for Pressure Ulcers
Document and describe length, width, and depth. Ulcer depth may be documented as > 1mm in depth.
Stage II Measurements for Pressure Ulcers
Document and describe length, width and depth; tunneling (if present)
Stage III Measurements for Pressure Ulcers
Document and describe length, width and depth; tunneling (if present) and underlying support structures (fascia, muscle, and bone.)
Stage IV Measurements for Pressure Ulcers
a term used for moisture saturated skin – usually in the periwound area
Maceration
Wound description color and consistency
Serous: Clear, watery plasma.
Sanguinous: Bloody
Sero-Sanguinous: Plasma and red blood cells.
Purulent: Thick, white blood cells may be yellow, green or brown, if infected.
Wound Tracing Clear food wrap next to wound Transparency over food wrap Transparency is copied Commercial 2-part transparencies are also available.
Photography: Patients would have to sign a release to be photographed; close up photography is then taken.
Other Methods of Wound Documentation(Not a substitute for other written documentation!)This is “above and beyond” documentation
the removal of necrotic, dead or devitalized tissue.
Goal is to remove the dead tissue from the wound.
Debridement
Selective vs. Non Selective
Selective – removes specific devitatlized tissue
Nonselective – removes non-specific areas of devitalized tissue
↓bacterial concentration within the wound bed and the risk of infection
↑the effectiveness of topical antimicrobials
Improve the bacterididal activity of leukocytes
↓the inflammatory phase of wound healing
↓energy required by the body for wound healing
Eliminate the physical barrier to wound healing
↓ wound odor
Purposes for Debridement(page 71, Wound Management Principles and Practice)
edges of the top layer of the epidermis roll down to cover lower edge of epidermis, causing the inability of epithelial cells to migrate from wound edges. Wound healing cannot take place in this circumstance.
Epiboly
