how wounds heal/ wound assessment Flashcards
wound definition
any disruption to the layers of the skin and underlying tissues
types of wounds?
pressure venous arterial diabetic or neuropathic incisional dehiscence trauma (includes skin tear)
three layers of skin?
epidermis, dermis, subcutaneous
superficial skin tears are confined to the layers of the?
epidermis and dermis
superficial skin tears heal by?
reepithelialization
wound healing past the dermis is a process known as?
scar formation
three ways wounds heal?
primary intention
secondary intention
tertiary intention
primary intention?
wounds that are surgically closed or approx by sutures/staples
secondary intention?
wounds that have been left open and are left to hear by scar formation
tertiary intention?
wound is intentionally opened for a number of time and closed surgically
woulds that heal by secondary intention?
pressure, venous, arterial, diabetic or neuropathic, surgical dehision
what does epithelialization mean
the wound healing process
healing process (4)
hemostasis–> inflammation–> proliferation–> remodeling
each phase of healing process must?
be completed in order for wound to close. if process is interrupted, wound will not close
what is hemostasis?
immediate response, wound bleeds and begins clotting process
- fibrin clot seals off bleed
- calcium and vitamins are important
failure to clot in hemostasis may be because?
medications (anticoagulant) or low platelet count
inflammatory response?
can last up to 4 days, occurs after bleeding is controlled
inflammatory response is characterized by?
-erythema, induration, heat, pain
-focus: clean the wound bed
there is a break down of bacteria, foreign debris, damaged tissue
factors that delay inflammatory response?
-steroids, chemo, advanced age, diabetes, necrotic tissue, foreign bodies, wound infection
proliferation response?
starts around 4 days and can occur until 21 days
-filling in phase by granulation tissue. edges contract and wound starts to get surfaced by epithelial cells
neoangiogenesis?
HUGE factor in wound healing. Wound needs good nutrients and protein/
remodeling response?
after wound closure and up to 2 years
- after wound closes, collagen is added to make it stronger
- edges contract and the wound gets smaller
factors that create the most risk to further damage?
infection and trauma
to plan your care for a wound and figure out the goals, what must you know?
the history and etiology, “cause” of the wound
surgical discence and trauma (skin tears) can occur where?
anywhere on the body
where are pressure ulcers found
typically over bony prominences and occur anywhere there is pressure on skin that is not relieved
where do arterial ulcers occur
prominent in the lower legs and feet due to decreased blood flow, restricted amount of oxygenated blood going to legs and feet causing harm
where do venous ulcers occur
prominent in the lower legs (calf/ankle area) due to difficulty for blood to flow back up, impairs circulation returning to heart
-valves of the veins in the calf muscle fail causing edema
combo of arterial and venous ulcers?
often found due to circulatory issues in lower limbs; “mixed venous arterial”
neuropathic/diabetic ulcers are found?
due to peripheral neuropathy, due to foot changes, trauma or pressure
-often person can not feel their foot
-
furthest from center of body term
lateral
closest to center of body term
medial
when is wound assessment done?
weekly
what is assessed in a wound assessment
wound pain, wound size, wound bed, wound exudate, wound edge, wound odour, periwound skin
will pain affect wound healing?
yes due to hypoxia, identify type, cause, duration, location to help heal wound
involving patient with wound care helps?
- allow them some control
- reduces anxiety
- adheres to care plan
controlled pain increases risk of?
infection and delayed healing
how is a wound measured?
in centimeters
- length x width x depth (using simple disposable ruler)
- always measure longest measurement and widest measurement
how do you measure the depth of a wound
sterile swab or probe
what is undermining?
destruction of tissue occuring underneath intact skin of the wound edge
what is a sinus tract?
channel that extends in any part of wound base and tracks into deeper tissue
to document the wound we use a imaginary..
clock, 12 oclock is head of the patient and 6 oclock is feet
expected healing rate?
20-40% in 2-4 weeks
eschar tissue?
dry, dead tissue (black or brown)
slough tissue?
dry or wet, loose or firmly attached yellow or brown dead tissue
granulation tissue?
desirable for healing, firm red and moist pebbled healthy tissue
superficial pink, red tissue
desirable for healing, right at the surface, no depth
tissues that dont help healing?
hypergranulation: raised above level of skin
non-granulated tissue: moist red pale to bright, smooth look
friable: unhealthy fragile skin that bleeds easily
non-visible wound bed parts?
- tunnel
- sinus tract
- undermined area
what is a blister
separation/elevation of the epidermis containing fluid
wound exudate types?
- consider the amount and appearance
- serous, sanguinous sero-sanguinous, purulent, sanguinous purulent
wound edges?
- diffuse
- epithelialized
- rolled
- undermined
- demarcated
- callused
attached wound edges?
-examples are diffuse and epithelialized, wound edges appear flushed with the wound bed
unattached wound edges?
-examples are undermined and rolled, wound is not attached with wound bed
unattached or attached wound edges?
demarcated and callused
things that can cause rash on periwound skin?
frequent washing with soap/irritation
contact dermatitis
bacterial/fungal/inflammatory rashes= need more attention
