M3 D2 Flashcards
overview of the skin
Epidermis
- Protection
- Moisture balance
- More likely to shear off
Dermis
- Structure/elasticity
Subcutaneous adipose tissue
- Cushioning
- Temperature regulation
- Adipose storage
Wound healing trajectory
Hemostasis, inflammation,
Hemostasis
- Begins immediately
- Platelets begin cutting off the bleeding
- Vasoconstriction occurs
- Thrombin is released, turning fibrinogen into fibrin
- Growth factors are released to progress to next phase
Inflammation (1-4 days)
- Vasoconstriction shifts to vasodilation to allow better blood flow to injured area
- Can be confused with an infection
- Red, swollen, painful
- Neutrophils, macrophages and monocytes begin phagocytosis–> getting rid of foreign particles
wound healing trajectory
proliferation , remodeling
Proliferation (4-21 days)
- Collagen and granulation tissue begin to form
- Wound contracts due to fibroblasts creating collagen network
- Collagen fills wound from bottom up and epithelial cells start to proliferate in layers
Remodeling (21 days-2 years)
- Collagen III is replaced by collagen I –> forms scar tissue
- Networks formed that cross link in order to increase the strength of the tissue
- Until process is complete–> area is weak, prone to re-injury
9 types of wounds
- Pressure injuries
- Venous ulcers
- Arterial Ulcers
- Surgical incisions
- Skin tears (Shearing)
- Diabetic wounds (Diabetics have delays in wound healing bc of increased blood sugar)
- Malignant wounds
- Burns
- Traumatic wounds
wound assesment
exudate amount, type and appearanceof tissue
Exudate:
Note Amount
- None
- Scant (moist but no measurable exudate)
- Small (wound tissues wet)
- Moderate (wound tissues saturated)
- Large (wound tissues fully bathed in fluid, may be draining outside the wound)
Type of exudate
- Sanguineous (bright red, bloody)
- Serosanguineous (pale, red, thin)
- Serous (clear, watery, thin)
- Purulent (thin or thick, opaque, tan to yellow)
- Foul Purulent (thick, yellow/green, odorous)
Appearance
- Granulation tissue (red/pink, meaty, healthy)
- Slough (yellow, stringy tissue, non adherent or loosely adherent to wound bed, necrotic)
- Fibrin (yellow stringy, but is adherent to wound bed)
- Eschar (soft or firm black tissue, necrotic)
wound assesment
undermining/tunneling and risk factors, edges/peri wound skin
Undermining/tunnelling
- Undermining–> tissue destruction under intact skin that involves larger portion of wound edge, forms a pocket
- Tunnelling–> tissue destruction under intact skin that involves smaller portion of wound edge
Risk Factors
- Infection
- Poor immune function
- Poor circulation
- Poor wound management
Edges
- Defined or undefined
- Attached or unattached
- Epibole (rolled)
- Fibrotic
- Hyperkeratosis
Peri Wound Skin
- Color
- Edema (pitting vs non pitting)
- Induration (abnormal firmness)
- Excoriation (“raw”)
- Macerated (pale, fragile, soft)
cleansing wounds
no infection, w infection
Wounds without infection..
- Nontoxic solution should be used
* (NS, Sterile water)
- Irrigation
* (PSI–> cleaning wound w/ pressure)
Infected wounds may require…
- Surfactant
- Antiseptic
*Polyhexanide
* Superoxide
* Iodine
* Chlorhexidine
- Antimicrobial
5 types of debridement
surgcial, mechanical, autolytic, enzymatic, biological
Surgical Debridement
- Most effective
- Stimulates epithelialization
- Silver nitrate used–> cauterizes, decreased risk of bleeding
- Contraindicated if risk for bleeding
Mechanical Debridement
- Using gauze to remove non viable tissue (wet to dry dressing)
- Short term, painful, time consuming (needs to be done multiple times a day)
Autolytic Debridement
- Application of nu gel helps trigger enzymes in the body to breakdown non viable tissue
- Slow method but pain free
- Contraindicated for immunocompromised and pts w/ tunnelling/infections
Enzymatic Debridement
- ointment has the enzymes that breakdown necrotic tissue
- Ideal for those at risk for bleeding
- Needs moisture to work, enzymes less effective in dry environments
Biological Debridement
- Medical maggots (Maggots contain the enzymes that digest necrotic tissue)
- Painless, fast, effective
dry wound dressings
Goal? contraindications? Examples
Dry Wound Dressings
- Goal–> rehydrate
- Contain water to help maintain a moist environment
- Protect surrounding skin from maceration
- Available in gel, sheet, guaze
Contraindications
- Infected wounds
- Moderate-high exudate wound
- Lower limbs w/ poor circulation
Examples
- Hydrogels
- Nu gel
mosit wound dressinngs
Goals, Contraindications, examples
Moist Wound Dressings
- Goal–> maintain moist environment
- Protect new epithelial cells
- Can be adhesive or non adhesive
- Extended wear time (14-21 days)
Contraindications
- Infected wound
- Fragile skin
Examples
- Acrylic dressings
* Tegaderm–> allows air into wound, doesn’t allow fluid to escape
- Hydrocolloid dressings
* Duoderm–> can be damaging to fragile skin
debridement and undermining dressings
Goals? Examples?
Debridement Dressings
- Goal–> promote removal of non-viable tissue
- Maintain moist environment–> assists in natural autolytic debridement
Examples
- Acrylic
- Hydrocolloid
- Foam
- Occlusive dressings to prevent moisture loss
Tunneling or Undermining Dressings
- Goal–> fill dead space in wound (and possible antimicrobial tx)
Examples
- Gauze
- Antimicrobials
- Calcium alginates
High Drainage and odourous Wound Dressings
High drainange
- Goal–> control excess moisture
Examples
- Gelling Fibers
* For moderate to high exudate
* Turn into gel as they absorb and maintain moisture
* May contain silver
- Calcium Alginates
* may contain silver
- Hypertonic
* draws in fluid via osmosis
Odorous Wound Dressings
- Goal–> minimize odour
Contraindications
- High exudate wounds
Examples
- Charcoal Dressings
- Can have silver as well (antimicrobial)
infected and superficial wound dressings
Infected Wound Dressings
- MUST come in contact w/ wound bed
Examples
- Silver
- Honey
- Gentian violet/methylene blue
- Iodine
- Hydrophobic
Superficial Wound Dressings
- Impermeable to liquid and bacteria
Contraindication
- Highly exudating wounds
Examples
- Tegaderm
Negative Pressure Wound Therapy
what is it? Types of foams? Contraindications ?
VAC
- Increased circulation, oxygenation, elasticity of wound
- Foam placed in wound and covered w/ transparent dressing
- Hose attached to dressing and to machine, creates vacum seal
Foams
- Black–> moist wounds, stimulates granulation
- Silver–> reduce bacterial infection
- White–> pre-moistened and less porous, protects fragile and underlying tissue, used for tunneling, suction is less effective
Pressure Settings
- Intermittent or continuous
- 75-175mmHg of pressure
contraindications
- ANY BLOOD STOP IMMEDIATELY
Braeden scale
Severe risk–> 9
High risk–> 10-12
Moderate risk–> 13-14
Mild risk–> 15-18
