Class 13: Wound Care Flashcards
abrasion
superficial with little bleeding and considered a partial thickness wound (scrape)
blanching
occurs when normal red tones of light skinned patients are absent
contusion
happens when an injured capillary or blood vessel leaks blood into the surrounding areas. blunt object injury.
erythema
redness of skin or mucous membranes caused by hyperemia in superficial capillaries
hyperemia
increased blood flow
laceration
a jagged, unintentional (non surgical) wound, sometimes bleeds more profusely, depending on depth and location (cut)
penetrating wounds
caused by objects that penetrate the body, causing an open wound (deep)
pressure ulcer (pressure injury)
localized to skin and underlying tissue, usually over a bony prominence, as a result of shear, pressure or friction
puncture wound
usually small, circular wound with edges coming together toward centre.
skin tear
traumatic injury caused by friction, or a combination of shear and friction forces strong enough to separate the epidermis from the dermis. can happen easily
approximation
skin edges are closed, decreased risk of infection
epithelialization
surface of skin is repaired
exudate
describes the colour, consistency and odour of wound drainage, and it part of the wound assessment
fibrin
formed by clots to later provide a framework for cellular response
granulation tissue
red, moist tissue composed of new blood vessels, which indicates progression toward healing
hemostasis
injured blood vessels constrict, and platelets gather to stop bleeding
purulent
thick, yellow, green, tan or brown
serous
clear, watery plasma
serosanguineous
pale, red, watery. mix of clear red fluid
impaired mobility - affects on metabolism
bone wasting can occur - use weight bearing activities
effects of impaired mobility for infants and children
physiological growth and development
effects of impaired mobility for adolescents
impact social development/sexuality
effects of impaired mobility for young and middle adults
impacts social networks/ work ability
effects of impaired mobility for older adults
rapid decrease of independence, and rapid losses
impaired mobility - affects on respiratory
fluid build up, risk for pneumonia
impaired mobility - affects on cardiovascular system
edema or blood clot risk, movement to keep blood flowing
impaired mobility - affects on musculoskeletal
whole body muscle atrophy, contractures, weakened bones
impaired mobility - affects on urinary elimination
incontinence, pooling of urine (stasis), increased risk of UTI
impaired mobility - affects on integumentary
huge risk factor. encourage self movement
impaired mobility - physiological effects
loss of independence, depression, isolation, behavioural changes, sleep-wake disturbances, altered coping patterns
friction
two surfaces rubbing against each other
how does moisture affect skin tissue
incontinence , decreased skin resistance to other physical factor
shear
tissue over bone is moving, force exerted against the skin, while the skin remains stationary and bone moves
what factors affect skin tissue
friction, moisture, and shear
what factors affect skin integrity
nutrition, infection, age
cachexia
generalized malnutrition
nutrition
if you have a protein deficiency, soft tissue becomes vulnerable to breakdown
infection
a fever increases metabolic needs of the body which puts hypoxic tissue at risk and an increase of moisture
diaphoresis
increased moisture
what happens to the skin with age
structures changes
- decrease in dermal thickness
- increase in skin tears
what can you do to decrease the risk of skin breakdown
- pat dry, don’t rub
- make sure no folds in linens
- increase fluid intake
- bed position make sure knees are up to avoid slips
- hygiene
tissue ischemia
occurs when capillary blood flow is obstructed by pressure
reactive blanching hyperaemia *****
this is a normal process that causes the blood vessels to dilate in the injured area and prevents tissue trauma. caused by crossed legs the underneath leg is red and then apply pressure it goes white (moving of blood to area).
non blanching reactive hyperaemia ***
indicates tissue damage. redness stays
skin assessment
check the whole body, but pay special attention to bony areas. assess the skin in the morning and evening when dressing or undressing or changing position. check more frequently
SIRA/Braden scale
skin integrity risk assessment used for predicting pressure ulcer risk
acute wounds
wound from trauma or a surgical incision. usually easily cleaned and repaired. orderly and timely healing process
chronic wounds
wound from a vascular compromise, chronic inflammation or repetitive insults to tissue. continued exposure to insult impedes wound healing. not an orderly or timely healing process
stages of pressure ulcer
stage 1: skin is unbroken but inflamed
stage 2: skin is broken to dermis or epidermis
stage 3: ulcer extends to subcutaneous fat layer
stage 4: ulcer extends to muscle or bone. undermining is likely
steps of wound healing
injury - hemostasis - inflammation phase - proliferative phase - remodelling stage - wound healed
wound action
blood cells vessels constrict - bleeding stops - removal of debris begins - plus damaged vessels q
inflammatory phase
3 days.
- WBC clean wound of debris and bacteria
- exudate (wound drainage)
- pain (due to pressure from swelling, nerve involvement)
- heat (due to metabolic activity and blood flow)
- erythema (vasodilation)
- swelling (increased vessel permeability)
proliferative phase
3-24 days
- new blood vessels appear
- wound fills in with granulation tissue
- wound contracts (pale and pink)
- resurfacing of the wound by epithelialization
remodelling phase
one year or more
- maturation of the wound
- closure of defect
fact about scar tissue
scar tissue is only 80% as strong as normal tissue
primary intention
wound edges well approximated, healing occurs by epithelization, heals quickly with minimal scar formation
secondary intention
wound heals by granulation tissue formation, wound contraction and epithelialization
tegaderm
film dressing for wounds
macerated
wound is too wet underneath
tertiary intention
closure of wound is delayed until risk of infection is resolved
linear or flap tear
can be repositioned to cover the wound bed
partial flap loss
can’t be repositioned to cover wound
total flap loss
exposing entire wound bed
sanguineous
bright red, active bleeding
treatment of wounds
- reduce risk factors
- improve nutritional status
- cleanse with normal saline
- cover, protect and cushion the area
what to do for dressing changes
- medical asepsis: dressing change
- meticulous hand washing
- maintain clean field, clean gloves, sterile supplies
- use in home care settings, LTC, for chronic or simple wounds
documentation for wound care
- date and time
- describe old dressing, drainage, approximation of wound edges
- cleansing and solution
- condition of wound
- new dressing applied
- clients tolerance of procedure
skin care aids
improve circulation, decrease pressure, provide comfort
compression (TED) stockings
- maintain internal pressure on muscles of lower extremities
- promote venous return
- removed and reapplied at least two times a day
- stockings must be clean and dry
- avoid wrinkles
- requires physicians order
