Final study guide Flashcards
what are the Phases of healing and what days do the correspond to?
- Hemostasis 0-3 days
- inflammation 4-6 days
- Proliferation 4-24 days
- remodeling/maturation 3weeks to 2 years
Hemostasis
- 0-3 days
-o Vasocontriction
o Platelet aggregation
o Fibrin seals lymph vessels
o Migration of leukocytes
Inflammation
4-6 days o Release of histamine o Neutrophils early o Macrophages late o Phagocytosis: removal of bacteria, debris, and foreign bodies
Proliferation
- 4-24 days o Fibroblast proliferation o Fibroplasia o Angiogenesis o Reorganization of extracellular matrix o epithelialization
remodeling/maturation
3weeks to 2 years
- o Collagenase breaks down inappropriately oriented collagen mollecules
o New collagen, initially laid down in a chaotic disorganized way, becomes oriented along the lines of contour stress; has more tensile strength
o Scar tissue is = 80 % as atrong as original tissue
Stages of a wound
1: non-blanchable erythema of intact skin
2: partial -thickness skin loss with exposed dermis
3: full-thickness skin loss
4: full-thickness skin and tissue loss
Pressure injury stage 1
: Pressure injury: non -blanchable erythema of intact skin.
o Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or marron discoloration; these may indicate depp tissue pressure injury
Pressure injury stage 2
partial-thickness skin loss with exposed dermis
o The wound bed is viable, pink or red, moist and may also presen as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are bot visible.granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel.
Pressure injury stage 3
full-thickness skin loss
o Adipose tissue is visible in the ulcer and granulation tissue and epibole are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location;areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury
Pressure injury stage 4
o Full-thickness skin and tissue loss with exposed or directly papable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole, undermining and /or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an unstageable pressure injury
Define sharp debridement
- Performed by PT, PTA, MD,PA,RN
- Requires training and skill. Must have goof knowledge of anatomy and ability to differentiate viable and nonviable tissue.
- Sharp debridement tools: scapel, forceps, scissors, curette
- Important to know lab values before debridement. May indicate that debridement is contraindicated. Such as condition that will delay healing.
Precautions for sharp debridement
- Prior to debridement look for: Decr Hemoglobin (<12) , Incr INR (>2), Decr platelets (<130)
- PRECAUTIONS o Low RBC count, hematocrit, or hemoglobin o Marginal platelets level o Poor medical status/poor prognosis o On coumadin with marginal INR o Near deep structures o Hands, genital area
COntraindications for sharp debridement
- CONTRAINDICATIONS o Stable eschar o Poor medical status/ poor prognosis o Patient on IV Heparin o Low platelet count o INR above 2.0 o Gangrene of toes or fingers
Arterial ulcer possible locations
over toe joints, anterior shin, over malleoli, under heel
arterial ulcer predisposing factors
- PVD, smoking,diabetes, advanced age, male, hypertension
