Basic Wound Care (week 11) Flashcards
What is debridement
The removal of devitalized tissues from or adjacent to a traumatic or infected lesion to expose healthy tissue
What is Erythema
Redness of the skin
caused by the congestion of the capillaries in the lower layers of the skin
What is eschar
dry scab
devitalized tissue
What is Lymphedema
Functional overload of the lymphatic system in which lymph volume exceeds transport capabilities
results in obstructed lymph flow
What is Necrosis
the morphological changes indicative of cell death
What is a Pressure Ulcer
A localized injury to the skin usually over a bony prominence as a result of pressure or pressure in combo with shear force and/or friction
What is Sterile
To be free from any microorganisms; aseptic
What are the basic goals of wound care and management
-Protect the wound and surrounding tissue from additional trauma
-Provide an optimal environment for wound healing
-reduce strain on tissues near wound
-protect the tissue in the area of the wound from mechanical stress or movement
-reduce the number of pathogenic microorganisms
-expedite the healing process
-decrease or reduce the formation of scar tissue
What are the phases of healing
- Inflammatory
-Proliferative phase
-Remodeling Phase
What are the stages in the inflammatory process
-Vascular stage
-Exudate stage
-Reparative Stage
What is the inflammatory phase
The process that initiates wound healing
function: Limit tissue damage, remove injured cells and repair injured tissue
Bodys initial local defense response to injury or trauma and begins immediately after
What is the vascular stage
Characterized by hyperemia because of change in cellular filtration pressures and an increase in permeability of cells
What is the exudate stage
Where fluid passes through the walls of vessels into adjacent tissues of spaces to help deposit fibrins and leukocytes which are necessary to initiate wound healing
What is the reparative stage
Damaged cells are replaced and true wound healing begins
What are the cardinal signs of inflammation
Tumor (swelling)
Rubor (redness)
Color (heat)
Dolor (pain)
Functio Laeso (loss of function)
What is the proliferative phase
It overlaps the inflammatory phase with granulation, angiogenesis to re-establish capillary buds, contraction and epithelization of the wound site
What are extrinsic factors that affect wound healing
-Pressure overlies a bony prominence
-Shear force applied to the skin, especially to the heels and sacrum
-Maceration of the skin
-infection
-Reduced activity leading to prolonged immobility
What are intrinsic factors that affect wound healing
_general health of the patient
-condition of skin
-body build and composition
-nutritional status
-hydration status
-distance between the edges of the wound
-location of the wound
-adequacy of blood flow to the wound
What is the difference between primary and secondary lymphedema
Primary lymphedema is a congenital malformation while as
secondary lymphedema is acquired after surgical removal of lymph nodes, infection of lymphatics, radiation therapy for cancer or trauma
What are the indications for lymphedema treatment
-primary/secondary lymphedema
-After a trauma, radiation
-After a burn
-after obstruction resulting from a tumor, scar, inflammation or parasite
-idiopathic lymphedema
postoperative edema
-venous or arterial ulcer
-scar treatment
What are the contraindications for lymphedema treatment
-Acute infection
-Active cancer
-Presence of congestive heart failure or kidney failure
-After radiation treatment
What are the physiologic causes for Rubor and Color
Vasodilation; increased blood flow
What are the physiologic causes for Dolor
Circulatory Impairment (Ischemic pain)
Formation of edema with pressure on the nociceptors nerve endings
What are the physiologic causes of functio laeso
Decreased ability to contract muscle
Pain spasm-pain cycle
