Module 1 - Wound Assessment Flashcards
(74 cards)
1
Q
What are 3 aspects that should be considered in a comprehensive wound assessment
A
Client
Wound
Enviroment
2
Q
What does 1 square CM of skin contain?
A
- 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
3
Q
What are the 2 major processes of wound healing
A
- Haemostasis
2. Tissue Repair
4
Q
What are the three phases of tissue repair?
A
- inflammation
- Reconstruction
- Maturation or remodelling
5
Q
How long does the inflammation phase generally last?
A
0 - 4 days
6
Q
Whats involved in the early phase of inflammation?
A
- Vasoconstriction
- Vasodilation
- Coagulation
7
Q
Whats involved in the late phase of of inflammation?
A
-Recruitment and activity of inflammatory cells
8
Q
How long does the reconstruction phase last?
A
2-24 days
9
Q
What’s involved in the reconstruction phase?
A
- Angiogenesis
- Granulation
- Contraction
- Epithelialisation
10
Q
How long does the maturation phase last?
A
24 days - 1 years >
11
Q
Give some examples of some aberrant wound healing?
A
- hypergranulation
- contracture
- hypertrophic scar
- keloid
12
Q
define an acute wound?
A
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.
13
Q
Define Chronic wound
A
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
14
Q
Give a brief description of the epidermis?
A
- 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
15
Q
What are the layers of the epidermis
A
- stratum germinativum
- stratum spinosum
- stratum granulosum
- stratum lucidum
- stratum corneum
16
Q
What are the functions of the skin?
A
- protection
- sensation
- communication
- thermoregulation
- metabolic synthesis
- cosmesis
17
Q
Explain Haemostasis?
A
rapid response to physical injury and is necessary to control bleeding.
18
Q
What are the three components involved in haemostasis?
A
- Vasoconstriction
- Platelet response
- Biochemical response
19
Q
Describe Vasoconstriction in haemostasis?
A
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.
20
Q
Describe the platelet response in haemostasis?
A
- 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
21
Q
Describe the biochemical response in haemostasis?
A
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
22
Q
Explain the early phase of inflammation?
A
- 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
23
Q
Classic signs and symptoms of inflammation?
A
- 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)
24
Q
Define a wound?
A
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
25
Explain angiogenesis
angiogenesis occurs to establish a new vascular network
26
explain granulation stage of the reconstruction phase
granulation / scar tissue is formed
| growth of blood vessels and connective tissue
27
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
28
define epithleliaisation
regeneration of epithelium over a wound
29
explain maturation phase?
collagen is slowly replaced in a more organised manner, resulting in increased tensile strength.
30
characteristics of matrix metaloproteinases (MMP)
Wound debridement and facilitating cell migration by Degrading extracellular matrix components following trauma -
31
Factors that inhibit wound healing
- Ageing process
- comorbidities
- nutritional status
- body mass index extremities
- medications
- allergies
- mobility and activities
- radiotherapy/chemotherapy
- psychosocial factors/lifestyle choices
- psychological state
32
Describe effects of the aging process of the skin?
-Thinning & flattening of the epidermis
-Decreased epidermal proliferation
-Cells in the horny layer lose elastin
-Atrophy of the dermis - decreased contraction
-Decreased vascularity of dermis
-Changes to & loss of collagen
-Decreased number of oil & sweat glands
-Vascular response is compromised
-Altered or reduced sensation
Fragility
33
Comorbidities that inhibit wound healing
- Diabetes Mellitus
- Anemia
- Malignancy
- Rheumatoid disorders
- Auto-immune disorders
- hepatic failure
- Ureamia
- Inflammatory bowel disease
- Reduced vascularity
- Respiratory disorders
- Neuropathy
- Radiation damage
- Disorders of sensation
34
Medications that impact wound healing?
```
Corticosteroids
Cytotoxic agents
Non-steroidal inflammatory agents
Some antibiotics
Nicotine
```
35
The effects of corticoid steroids on wound healing?
Decrease :
- Macrophages
- collagen production
- angiogensesis
- Wound Contradiction
- Epithelial migration
- Tensile strength of healed wound
- Immune responses
- chemotaxis
- proliferation of T lymphocytes
Increases -
Susceptibility to infection
36
The effects of cytotoxic agents on wound healing?
-Affects rapidly replicating cells (cancer cells, hair and epithelial cells)
-Haematological changes which impact on healing
Reduces tensile strength
37
The effects of NSAIDS on wound healing?
Suppress inflammatory phase of healing
| by blocking prostaglandin synthesis
38
The negative effect of antibiotics on wound healing?
Penicillamine & penicillin -impairs cross linking of collagen
Increases risk of micro-organism resistance
Increased risk of topical sensitivity or systemic allergy
39
The positive effect of antibiotics on wound healing?
Controls infection
40
The effects of nicotine on wound healing?
Reduces vasoconstriction
Increases platelet aggregation
Impairs collagen synthesis
Impairs epithelialization
*smoking for 10 minutes delays wound healing by 1 hour*
41
Psycho-social implications of wound healing?
```
Fatigue impairs healing
Anger impairs healing
Self-esteem alterations
Familial responsibilities challenged
Social responsibilities challenged
Employment issues
Economic constraints
```
42
Local factors that inhibit healing?
- Reduced temperature
- Desiccation of wound
- Alteration in wound pH 4.2-5.6 normal, 7-9 deep wound
- Tissue hypoxia/poor vascularity
- Foreign bodies present/infection/malignancy
- Mechanical stress/Chemical stress
43
Wound Assessment Parameters?
```
Type of wound
Aetiology
Mode of healing
Duration of wounding
Location
Dimensions (length, width, depth)
Clinical appearance
Wound edges
Exudate
Odour
Surrounding skin
Pain
```
44
What are the different types of wounds?
```
Incision
Laceration
Abscess
Skin Tear
Fistula/Sinus
Dehiscence
Penetrating/Perforating
Leg/Foot Ulcer
Graft/Flap
Donor Site
Abrasion
Contusion
Burn
Tumour
Bite/Sting
Allergy
```
45
What are the 3 different types of wounds that you can stage?
Pressure Injury
Burns
Skin tears
46
mode of healing techniques?
```
Primary intention
Secondary intention
Delayed primary intention
Skin grafts
Flaps
Bioengineered tissue
```
47
Clinical appearances of the wound?
```
Necrotic
slough
granulation
epitheliating
hypergranulation
eschar
```
48
Clinical signs of a localized infection
```
Pain
Heat
Oedema
Erythema
Exudate - purulent or
increased
```
49
Clinical signs and symptoms of a systemic infection
```
Elevated temperature
Tachycardia
Rigor
Malaise
Elevated leukocyte levels
```
50
Bacterial reaction to threats?
adaption - develop resistance
| self-protection - form biofilms
51
Mechanisms of resistance
INTRINSIC OR INHERENT RESISTANCE
bacterium is naturally resistant to the antimicrobial agent
-ACQUIRED RESISTANCE
development of resistance in previously susceptible
Vertical evolution: a mutation in the organism
Horizontal evolution: genetic transfer of resistant genes from
one bacterium to another, even to different species of bacteria
52
What is biofilm
The bacteria secrete glycocalyx which forms a biofilm
(an extracellular polysaccharide) that protects the
organisms from immune responses by phagocytes and
from antibiotics
53
What is the Bio Film Process?
```
Bacteria form strongly attached
micro-colonies in 2-4 hours
Develop extracellular polymeric
substance in 6-12 hours
Form a mature resistant biofilm in
2-4 days
Following disruption can reform in
24 hours
```
54
Wound Exudate assessment?
Amount of exudate
```
Type/colour of exudate?
Serous -clear fluid, no blood or pus
Haemoserous -slight blood stained serous fluid
Sanguineous-bright red,frank blood
Purulent -thick, cloudy, yellow, green
```
55
List possible causes of malodour in the wound?
- Fistula
- Autolysis
- Infection
56
What's involved in assessing the wound edges?
Colour, thickness, raised, rolled edges, undermining
57
Clinical appearance of the surrounding skin
```
Erythema
Oedema
Macerated
Dry / fragile
Dermatitis / eczema
Pigmentation
Induration
Neuropathy
Perfusion / pallor
```
58
Wound healing - Protein
Amino acids required for:
- Fibroblastic growth
- Collagen synthesis
- Lymphatic function
- Remodeling
- Immune responses, phagocytosis & antibodies
59
Wound healing - Lipids (fats)
```
Essential unsaturated fatty acids:
- Linolenic
- Linoleic
- Arachidonic
Required for:
- Cell energy
- Cell proliferation
- Phagocytic activity
- Metabolism
- Circulation
- Inflammation
```
60
Wound healing - carbohydrates
Carbohydrates required for:
- Cellular energy for leukocytes & fibroblasts
- Synthesis of DNA & RNA
- Nerve tissue
- Red cells
- Regulation of blood glucose
- Modulation of nutrient absorption
- Fibre -gut function
61
Wound healing - Vitamin C
```
Required for:
- collagen synthesis,
- fibroblast production,
- capillary formation
Sources:
Kiwi fruit, citrus, strawberry, parsley, rockmelon, b/currants
```
62
Wound healing - Vitamin A
```
Required for:
- Epithelialisation,
- collagen synthesis
Sources:
Liver, eggs, yellow & dark
green vegetables, cod liver oil
```
63
Wound healing - Vitamin B complex
```
Required for:
- antibodies,
- lymphocyte function
Sources:
Legumes, grains, meats, poultry, fish
```
64
Wound healing - Vitamin D
```
Required for:
- Metabolism of calcium
Sources
Sun, salmon, sardines, egg
yolk
```
65
Wound healing - Vitamin E
```
Required for:
- Corpuscles (an unattached cell, especially of a kind that floats freely, as a blood or lymph cell)
Sources:
Wheat germ, polyunsaturated
vegetable oils, nuts, oysters,
```
66
Wound healing - Vitamin K
```
Required for:
- Synthesis prothrombin
- Clotting factors
Sources:
Green leafy vegetables, egg
yolks, cauliflower
```
67
MAJOR TRACE ELEMENTS - Calcium
Required for:
- Bone growth
Sources:
Sardines, salmon, milk, cottage cheese
68
MAJOR TRACE ELEMENTS - Iron
```
Required for:
- Hemoglobin & tissue
oxygenation
- Collagen synthesis
Sources:
Liver, beef, oysters, spinach
```
69
MAJOR TRACE ELEMENTS - Magnesium
Required for:
- Collagen synthesis
Sources:
Seafood, nuts
70
MAJOR TRACE ELEMENTS - Phosphorus
Required for:
- Bone and tissue growth
Sources:
Whole milk, chicken, pork, tuna, cheese
71
MAJOR TRACE ELEMENTS - Iodine
Required for:
- Thyroid function
Sources:
Iodised salt
72
MINOR TRACE ELEMENTS - Zinc
```
Required for:
- cell mitosis & proliferation
- cell membranes
Sources:
Seafood, organ meats, mushrooms, sunflower & pumpkin seeds
```
73
MINOR TRACE ELEMENTS - Copper
Required for:
- Collagen cross links
Sources:
Seafood, nuts, raisins
74
MINOR TRACE ELEMENTS - Folic acid
```
Required for:
- red blood cells
- metabolism of proteins
- cellular growth & division
Sources:
Dark leafy & root vegetables, milk, salmon
```
