Caring for an Individual with a Chronic Wound Flashcards
Causes of wounds
- Hypoxia / ischemia
- heat/cold
- mechanical trauma
- Abrasion, laceration, contusion, puncture, avulsion, incision
exudate (drainage) can be described in the following 4 ways
- serous
- purulent
- serosanguinous
- sanguinous
serous drainage
clear, watery plasma
purulent drainage
thick, yellow, green, tan, or brown drainage
sero-sanguinous drainage
pale, red, more watery drainage
sanguinous drainage
indicates fresh bleeding, bright red
what are the 4 stages of wound healing
- hemostasis
- inflammatory
- proliferative
- remodeling
hemostasis (stages of healing)
- blood vessels constrict; clotting factors activate to stop bleeding.
- platelets release growth factors to begin repair process
inflammatory (stages of healing)
- vasodilation occurs; edema, erythema, and exudate can be noted in the wound
- leukocytes arrive
- result: clean wound bed in a patient with a noncomplicated wound
Proliferative (stages of healing)
- epitheliazation (construction of the new epidermis
- new granulation tissue is formed
- new capillaries created (angiogenesis)
- collegen synthesized
Maturation / remodelling (stages of healing)
- collegen is remodelled to become stronger and provide tensile strength to the wound.
- outer appearance of an uncomplicated wound is a well healed scar
primary intention
- occurs when the edges of a clean surgical incision remain close together
- wound healing is quick
- tissue loss is minimal or absent
secondary intention
- wounds that are left open )not approximated) and heal from scar formation
- heal by granulation tissue formation and contraction of wound edges
tertiary intention
- occurs when surgical wound are not close immediately to allow edema or infection to diminish
- wound edge are stapled or sutured together
what are the wound classification categories
- underlying cause (surgical/non surgical)
- duration of inflammation (acute / chronic)
- depth of tissue involvement (superficial, partial thickness, full thickness)
- pressure ulcers (stages I, II, II, IV, unstageable)
- color (red, yellow, black)
superficial
partial thickness heal by
process of regeneration
full thickness heal by
scar formation
complications during wound healing
- infection
- fistula formation
- dehiscence
- evisceration (emergency)
- adhesions
- contractures
- hyper-granulation
- hemmorage
- formation of hypertophic scars and keloids
potential causes of delayed wound healing
- nutrition
- inadequate blood / oxygen supply
- smoking
- corticosteroid drugs
- infection
- anemia
- advanced age
- obesity
- diabetes mellitus
- poor general health
- mechanical friction on wound
- cold temperature
- excessive moisture
Negative Pressure Wound Therapy
Pulls on cells so they divide faster
- absorbs drainage
- fills dead space
- keeps moist environment
Psychological impact of Chronic Wounds
- anxiety
- depression
- pain
- sleep disturbances
- negative coping behaviours
- self concept
- hygiene
- mobility issues
- ADLs
- worry about odour and drainage
dehiscence
care strategies for supporting the psychological effects of a wound
- social support and emotional disclosure
- increased social interaction
- adequate sleep
- adequate nutrition
- support with ADL’s and hygiene needs
- use appropriate dressing to absorb drainage and odour
tertiary intention is also called
delayed primary intention
how is wound healing advanced
debridement
types of debridement
- enzymatic, mechanical, autolytic, or sharp
enzymatic debribment
- topical application of enzymes such as collagenase over the necrotic tissue
When should patients be given analgestics before a dressing change
30 mins prior
chronic wounds typically result form
burns, pressure injuries, or leg ulcers
chronic wounds
wounds that fail to move past the inflammatory phase of wound healing
