Basic Wound Care Flashcards
The most common wounds that are
treated by a wound care Physical
Therapist are:
- Stage III, IV pressure ulcers (pressure injury).
- Diabetic wounds
- Chronic wounds
- Venous and/or arterial wounds
- Extremity wounds with edema
- Non-healing surgical wounds
What are the members of the wound care team?
- a physician
- nursing
- physical therapists
- registered dietitians
- case managers
- orthotics/prosthetists
- podiatrists
outer most layer formed by keratinocytes regenerates every 4-6 weeks protects against water loss and physical damage sensation
epidermis
Components of the Dermis layer
- collagen
- elastin fibers
- extracellular matrix
- blood/lymphatic vessels
- nerve endings
- hair follicles
- sebaceous/sweat glands
- fibroblasts
Components of the SubQ/Hypodermis layer
- adipose and connective tissue
- major blood/lymphatic vessels
- nerves
What are the functions of the skin?
Protection Excretion Sensory Perception Thermoregulation Metabolism Absorption
Which vitamin does the skin synthesize?
Vitamin D
Type of wound closure that involves a delayed primary closure. used in case of infection.
Tertiary Intention
Migration of cells over the wound edge, begins to
occur within 24 hours of injury.
Epithelialization
Formation of a new tissue and capillaries around the
wound edge-usually pink in color.
Granulation
Phase 1: Inflammation
- 1-5 days
- edema and necrosis
- initial vasoconstriction
- phagocytes cells to clean wound
What are some causes for abnormal inflammatory responses in wounds?
- Immunosuppressive medications
- Arterial Insufficiency
- Medical conditions that alter the immune response
Phase 2: Proliferation
- 3-20 days
- fibroblasts secrete collagen (type III)
- angiogenesis
- granulation
- epithelialization
Phase 3: Remodeling / Maturation
- 9 days to 2 years
- type III collagen converts to type I
- decreased capillaries
- scar tissue contracts and matures
Involves some degree of tissue loss, needs a second change to get it right. Formation of granulation tissue to fill in scar.
Secondary Intention
In the early inflammation stage
immediately following an injury, which
comes first? Vasoconstriction or Vasodilation?
Vasoconstriction
The development of new blood vessels
Angiogenesis
Type of wound that involves pain, swelling and discoloration. The skin is not broken.
Contusion
Mass of blood usually caused by a break in a blood vessel
Hematoma
Darkening of skin due to accumulation of iron-containing pigment. Common in venous ulcers
Hemosiderin staining
What should you evaluate in the Peri-wound area of a wound?
– Sensation
– Peripheral Pulses
– Skin temperature
– Dryness of surrounding tissue
Abnormal exudation that are signs of infection.
- seropurulent: cloudy, opaque, yellow or tan, thin watery
- Purulent: yellow or green, thick, viscous
Intrinsic factors that cause abnormal wound healing
– COPD-Hypoxemia – DM: loss of protective sensation – CA: Decreased Immune Function – Peripheral artery disease or Venous insufficiency
Medications that can cause poor or prolonged inflammatory response
anti-inflammatory immunosuppressive steroids anti-coagulants oral contraceptives
Signs of Infection
- bright red streaks
- change in drainage
- swelling
- increased pain
- fever, nausea, fatigue or loss of appetite
abnormal passage between an
organ or vessel and another organ, vessel,or area
Fistula
Most important external factor in optimal
wound healing
Moisture
Nutrients necessary for wound healing
- iron
- vitamin B12
- vitamin C
- zinc
- high protein
- folic acid
Pressure relief support surfaces
- air and foam mattresses
- avoid synthetic sheep skin pads, donuts
- natural sheepskin may assist in prevention
- use a pressure redistributing seat cushion
Explain the rule of 30 for Pressure Injury Prevention
Positioning: Rule of 30 (>30 = increased
shearing)
˃ In supine: 30 degrees incline bed
˃ In sidelying: 30 degrees offloaded, so weight
on the buttocks, not the bones- use wedges
and pillows to protect all bony prominences
Intact skin
˃ Non-blanchable redness in localized area
(usually bony prominence)
˃ Different that surrounding skin
May be different color
May be painful, firm, soft, warmer, cooler
˃ Darkly pigmented skin: May be difficult to
detect
Stage 1 Pressure Injury
Partial thickness loss of dermis
shallow open ulcer with red-pink wound bed, without slough.
Shiny or dry without bruising
Stage 2 Pressure Injury
Full thickness tissue loss
subcutaneous fat may be visible.
Bone, tendon, muscle not exposed.
Slough possible but does NOT obscure depth of tissue loss
Stage 3 Pressure Injury
Full thickness tissue loss with visible but
bone, tendon or muscle exposed.
Slough and eschar present. Often has tunneling and undermining. Can extend into muscle
Stage 4 Pressure Injury
Full thickness skin or tissue loss - depth unknown.
Depth completely obscured by slough/eshcar.
Unstageable Pressure Injury
