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n232 > how wounds heal/ wound assessment > Flashcards

how wounds heal/ wound assessment Flashcards

1
Q

wound definition

A

any disruption to the layers of the skin and underlying tissues

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2
Q

types of wounds?

A 
pressure
venous
arterial
diabetic or neuropathic
incisional dehiscence 
trauma (includes skin tear)
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3
Q

three layers of skin?

A

epidermis, dermis, subcutaneous

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4
Q

superficial skin tears are confined to the layers of the?

A

epidermis and dermis

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5
Q

superficial skin tears heal by?

A

reepithelialization

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6
Q

wound healing past the dermis is a process known as?

A

scar formation

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7
Q

three ways wounds heal?

A

primary intention
secondary intention
tertiary intention

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8
Q

primary intention?

A

wounds that are surgically closed or approx by sutures/staples

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9
Q

secondary intention?

A

wounds that have been left open and are left to hear by scar formation

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10
Q

tertiary intention?

A

wound is intentionally opened for a number of time and closed surgically

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11
Q

woulds that heal by secondary intention?

A

pressure, venous, arterial, diabetic or neuropathic, surgical dehision

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12
Q

what does epithelialization mean

A

the wound healing process

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13
Q

healing process (4)

A

hemostasis–> inflammation–> proliferation–> remodeling

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14
Q

each phase of healing process must?

A

be completed in order for wound to close. if process is interrupted, wound will not close

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15
Q

what is hemostasis?

A

immediate response, wound bleeds and begins clotting process

  • fibrin clot seals off bleed
    • calcium and vitamins are important
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16
Q

failure to clot in hemostasis may be because?

A

medications (anticoagulant) or low platelet count

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17
Q

inflammatory response?

A

can last up to 4 days, occurs after bleeding is controlled

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18
Q

inflammatory response is characterized by?

A

-erythema, induration, heat, pain
-focus: clean the wound bed
there is a break down of bacteria, foreign debris, damaged tissue

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19
Q

factors that delay inflammatory response?

A

-steroids, chemo, advanced age, diabetes, necrotic tissue, foreign bodies, wound infection

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20
Q

proliferation response?

A

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

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21
Q

neoangiogenesis?

A

HUGE factor in wound healing. Wound needs good nutrients and protein/

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22
Q

remodeling response?

A

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
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23
Q

factors that create the most risk to further damage?

A

infection and trauma

24
Q

to plan your care for a wound and figure out the goals, what must you know?

A

the history and etiology, “cause” of the wound

25
Q

surgical discence and trauma (skin tears) can occur where?

A

anywhere on the body

26
Q

where are pressure ulcers found

A

typically over bony prominences and occur anywhere there is pressure on skin that is not relieved

27
Q

where do arterial ulcers occur

A

prominent in the lower legs and feet due to decreased blood flow, restricted amount of oxygenated blood going to legs and feet causing harm

28
Q

where do venous ulcers occur

A

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

29
Q

combo of arterial and venous ulcers?

A

often found due to circulatory issues in lower limbs; “mixed venous arterial”

30
Q

neuropathic/diabetic ulcers are found?

A

due to peripheral neuropathy, due to foot changes, trauma or pressure
-often person can not feel their foot
-

31
Q

furthest from center of body term

A

lateral

32
Q

closest to center of body term

A

medial

33
Q

when is wound assessment done?

A

weekly

34
Q

what is assessed in a wound assessment

A

wound pain, wound size, wound bed, wound exudate, wound edge, wound odour, periwound skin

35
Q

will pain affect wound healing?

A

yes due to hypoxia, identify type, cause, duration, location to help heal wound

36
Q

involving patient with wound care helps?

A
  • allow them some control
  • reduces anxiety
  • adheres to care plan
37
Q

controlled pain increases risk of?

A

infection and delayed healing

38
Q

how is a wound measured?

A

in centimeters

  • length x width x depth (using simple disposable ruler)
  • always measure longest measurement and widest measurement
39
Q

how do you measure the depth of a wound

A

sterile swab or probe

40
Q

what is undermining?

A

destruction of tissue occuring underneath intact skin of the wound edge

41
Q

what is a sinus tract?

A

channel that extends in any part of wound base and tracks into deeper tissue

42
Q

to document the wound we use a imaginary..

A

clock, 12 oclock is head of the patient and 6 oclock is feet

43
Q

expected healing rate?

A

20-40% in 2-4 weeks

44
Q

eschar tissue?

A

dry, dead tissue (black or brown)

45
Q

slough tissue?

A

dry or wet, loose or firmly attached yellow or brown dead tissue

46
Q

granulation tissue?

A

desirable for healing, firm red and moist pebbled healthy tissue

47
Q

superficial pink, red tissue

A

desirable for healing, right at the surface, no depth

48
Q

tissues that dont help healing?

A

hypergranulation: raised above level of skin
non-granulated tissue: moist red pale to bright, smooth look
friable: unhealthy fragile skin that bleeds easily

49
Q

non-visible wound bed parts?

A
  • tunnel
  • sinus tract
  • undermined area
50
Q

what is a blister

A

separation/elevation of the epidermis containing fluid

51
Q

wound exudate types?

A
  • consider the amount and appearance

- serous, sanguinous sero-sanguinous, purulent, sanguinous purulent

52
Q

wound edges?

A
  • diffuse
  • epithelialized
  • rolled
  • undermined
  • demarcated
  • callused
53
Q

attached wound edges?

A

-examples are diffuse and epithelialized, wound edges appear flushed with the wound bed

54
Q

unattached wound edges?

A

-examples are undermined and rolled, wound is not attached with wound bed

55
Q

unattached or attached wound edges?

A

demarcated and callused

56
Q

things that can cause rash on periwound skin?

A

frequent washing with soap/irritation
contact dermatitis
bacterial/fungal/inflammatory rashes= need more attention

n232 (12 decks)

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