Ch55 - PRESSURE INJURY, WOUNDS, & WOUND MANAGEMENT Flashcards
STAGES OF WOUND HEALING
- inflammatory stage
- proliferative stage
- maturation or remodeling stage
INFLAMMATORY STAGE
Begins with the injury and lasts 3 to 6 days.
Hemorrhage control –> vasoconstriction, retraction of blood vessels, fibrin accumulation, clot formation.
Oxygen, WBC, & nutrients delivered to the area via blood supply. Phagocytosis. Stage prolonged –> too little or too much inflammation.
PROLIFERATIVE STAGE
Lasts the next 3 to 24 days.
Lost tissue replaced with connective/granulated tissue + collagen. Contract wound edges to heal area. New epithelial cell resurfacing.
MATURATION/REMODELING STAGE
Occurs on/around day 21. Collagen scar strengthening. Restoration of a more normal appearance. Duration depends on extent of the original wound.
HEALING PROCESS INTENTIONS
Primary intention
Secondary intention
Tertiary intention
PRIMARY INTENTION HEALING
little or no tissue loss
edges approximated, as with a surgical incision
heals rapidly
low risk of infection
no or minimal scarring
SECONDARY INTENTION HEALING
loss of tissue
wound edges widely separated, unapproximated (pressure injury, open burn areas)
longer healing time
increase for risk of infection
scarring
heals by granulation
TERTIARY INTENTION HEALING
widely separated
deep
spontaneous opening of a previously closed wound
closure of wounds occurs when they are free of infection and edema
risk of infection
extensive drainage and tissue debris
closed later
long healing time
TYPES OF DRAINAGE
serous drainage
sanguineous drainage
serosanguineous drainage
purulent drainage
purosanguineous drainage
SEROUS DRAINAGE
the portion of the blood (serum)
watery/clear or slightly yellowed
example: fluid in blisters
SANGUINEOUS DRAINAGE
serum and RBC
thick/reddish
brighter drainage: active bleeding
darker drainage: older bleeding/drainage
SEROSANGUINEOUS DRAINAGE
serum and blood
watery/pale and pink
PURULENT DRAINAGE
result of infection
thick/WBC, tissue debris, bacteria
may have foul odor
color reflects organism present
PUROSANGUINEOUS DRAINAGE
pus and blood
newly infected wound
DEHISCENCE
a partial or total rupture (separation) of a sutured wound, usually with separation of underlying skin layers.
EVISCERATION
a dehiscence that involves the protrusion of visceral organs through a wound opening
PRESSURE INJURY STAGES
Stage 1, nonblanchable erythema of intact skin
stage 2, partial thickness skin loss with exposed dermis
stage 3, full-thickness skin loss
stage 4, full-thickness skin and tissue loss
PRESSURE INJURY STAGE 1
intact skin
persistent, nonblanchable redness
warmer/cooler than adjacent tissue
swollen/different texture
possible discomfort/altered sensation
PRESSURE INJURY STAGE 2
epidermis/dermis involvement
reddish-pinkish wound bed w/o tissue
no slough + adipose or granulation tissue + eschar
intact or ruptured blister
PRESSURE INJURY STAGE 3
visible adipose tissue
possible granulation tissue/epibole
some slough, eschar present
w/o exposed muscle, tendon, ligament, cartilage, bone
possible undermining or tunneling
PRESSURE INJURY STAGE 4
skin/tissue loss
muscle, tendon, ligament, cartilage, bone visibility
epibole, tunneling, undermining are common
