Module 1 - Wound Assessment Flashcards
What are 3 aspects that should be considered in a comprehensive wound assessment
Client
Wound
Enviroment
What does 1 square CM of skin contain?
- 15 sebaceous glands
- 1m blood vessels
- 100 sweat glands
- 3000 sensory cells
- 4m nerves
- 300,000 epidermal cells
- 25 pressure sensory cells
- 200 pain sensors
- 2 cold sensors
- 12 heat sensors
- 10 hairs
What are the 2 major processes of wound healing
- Haemostasis
2. Tissue Repair
What are the three phases of tissue repair?
- inflammation
- Reconstruction
- Maturation or remodelling
How long does the inflammation phase generally last?
0 - 4 days
Whats involved in the early phase of inflammation?
- Vasoconstriction
- Vasodilation
- Coagulation
Whats involved in the late phase of of inflammation?
-Recruitment and activity of inflammatory cells
How long does the reconstruction phase last?
2-24 days
What’s involved in the reconstruction phase?
- Angiogenesis
- Granulation
- Contraction
- Epithelialisation
How long does the maturation phase last?
24 days - 1 years >
Give some examples of some aberrant wound healing?
- hypergranulation
- contracture
- hypertrophic scar
- keloid
define an acute wound?
An acute wound is any surgical wound that heals by primary intention, or any traumatic or surgical wound which heals by secondary intention, and which proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical integrity.
Define Chronic wound
A chronic wound occurs when the reparative process does not proceed through an orderly and timely process as anticipated and where healing is complicated and delayed by intrinsic and extrinsic factors that impact on
THE PERSON
THE WOUND
THE ENVIRONMENT
Give a brief description of the epidermis?
- outer layer of the skin
- comprised of stratified, squamous epithelial cells or keritanocytes
- thinnest on the eyelids and thickest on the sole of the palms and feet.
- avascular and receives its nutrients from the under lying dermal layer
- continuously replacing outer cells which lasts 4 weeks
- there are 4 to 5 layers
What are the layers of the epidermis
- stratum germinativum
- stratum spinosum
- stratum granulosum
- stratum lucidum
- stratum corneum
What are the functions of the skin?
- protection
- sensation
- communication
- thermoregulation
- metabolic synthesis
- cosmesis
Explain Haemostasis?
rapid response to physical injury and is necessary to control bleeding.
What are the three components involved in haemostasis?
- Vasoconstriction
- Platelet response
- Biochemical response
Describe Vasoconstriction in haemostasis?
Vasoactive substance such as catecholamine’s and serotonin influence receptors on the endothelium to produce vasoconstriction of the arteries, arterioles and capillaries in or adjacent to the wound to stop the bleeding.
Describe the platelet response in haemostasis?
- the damaged endothelium of vessels exposes collagen fibres
- platelets stick to each other and the collagen fibres forming a plug
- the platelets release chemicals such as serotonin and prostaglandins to enhance the vascular spasm therefore reducing blood flow.
- phospholipids and adenisone diphosphate (ADP) are also released to attract more platelets therefore increasing the platelet plug.
- The platelet plug is compromised of fibrin, fibronectin, virtonectin, von willebrand factor, and thrombospondin forming the extracellular matrix
- the platlet also releases multiple cytokines, hormones and chemokines which attract inflammatory cells and fibroblasts therefore promotes wound healing
Describe the biochemical response in haemostasis?
it involves the formation and degradation of a blood clot which involves:
- intrinsic clotting factor
- extrinsic clotting factor
- clot retraction
- fibrinolysis
this cycle sees the development of a clot, the retraction and compaction of the clot and the breakdown of the clot by fibrinolysis
Explain the early phase of inflammation?
- starts from the moment of injury
- ischaemia in capillaries contract and thrombose to facilitate haemostasis
- ischaemia in the wound also causes a release of histamine and other vasoactive chemicals to vasodilate the surrounding tissue to facilitate the influx of leukocytes, erythrocytes and plasma proteins into the wound
Classic signs and symptoms of inflammation?
- excess blood flow into the wound and surrounding areas therefore demonstrates the classic signs and symptoms of inflammation
- redness,
- swelling
- erythema
- heat
- discomfort (throbbing sensation)
Define a wound?
A wound is an injury to the integument or underlying structures that may or may not result in a loss of skin. physiological function of the tissue is impaired
Explain angiogenesis
angiogenesis occurs to establish a new vascular network
explain granulation stage of the reconstruction phase
granulation / scar tissue is formed
growth of blood vessels and connective tissue
Explain contraction
myofibrolasts draw the wound edges together in an attempt to reduce the surface area of the wound thus reduce the amount of tissue replacement required
define epithleliaisation
regeneration of epithelium over a wound
explain maturation phase?
collagen is slowly replaced in a more organised manner, resulting in increased tensile strength.