Module 2: Surgical wound care, suture and staple removal Flashcards
What are the phases of wound healing?
- Inflammatory phase
- Proliferative phase
- Maturation/remodeling
What happens in the inflammatory phase?
Vasodilation occurs, which allows for the WBC and plasma to enter the wound and clean the wound bed, this can be seen as edema, erythema, and exudate.
Macrophages work to regulate the cleanup
In the proliferative phase of wound healing, what are the four important processes?
How long does this phase last?
- Epithelialization: new epidermis and granulation tissue are developed
- New capillaries: angiogenesis Occurs to bring oxygen and nutrients to the wound
- Collagen formation: this provides strength and integrity to the wound
- Contraction: wound reduces in size
(Day 3-14/21)
What happens in the maturation/remodeling phase?
Collagen continues to strengthen the wound and the wound forms into a scar.
Early: 2-3 weeks to 6 weeks, Collagen is reorganized into a more orderly structure, raised scar formation
Later: 6 weeks, to 1-2 years, Scar tissue has 80% of original tissue strength, flat, thin scar
Describe wound healing by primary intention
- Wound is clean with straight edges, as in a surgical incision
- Edges can be approximated with sutures, Staples, or tape
- Healing is rapid and primarily by collagen synthesis
- Scars usually thin and flat
Describe wound healing by secondary intention
- Wound is large and irregular with considerable tissue loss, as in pressure ulcer or deep abrasion
- Healing involves inflammation, filling with granulation tissue, and epithelialization
- Scar is usually large and pronounced
Describe wound healing by tertiary intention
- Wound is left open because of possible contamination or debris
- Healing involves some granulation tissue and increased inflammation and risk of infection
- Edges are approximated as well as possible with sutures once wound is clean
- Scar varies with wound
What do you assess on the wound?
Redness Edema Ecchymosis Drainage Approximation
What is the drainage assessment?
Type
Amount
Colour and consistency
Odour
How do acute wounds heal?
Orderly and timed repair process, resulting restoration of anatomical and functional integrity (trauma, surgical incision]
How does a chronic wound heal?
Fails to proceed through and orderly and timely repair process
(Causes - vascular compromise, chronic inflammation, or repetitive insults to the tissue)
What is an abrasion?
Superficial with little bleeding and it’s considered a partial thickness wound. Appears weepy because of plasma leakage from damaged capillaries
Describe a laceration Wound?
Jagged, unintentional (i.e. nonsurgical) wound, sometimes bleeds more profusely, depending on the wounds depth and location.
Within 7 to 10 days, or normal healing wound resurfaces with
Epithelial cells and edges close
What are some intrinsic factors affecting wound healing
Health status, diabetes, circulation, anemia, immune status, age, etc.
What are some extrinsic factors that affect wound healing?
Mechanical stress, debris, micro organisms, temperature, infection, medication
What is a hemorrhage and when is the risk for it the highest?
Bleeding from a wound site, normal during and immediately after initial trauma but not after hemostasis has occurred.
Risk is high during first 24 to 48 hours after surgery or injury
What is dehiscence?
Partial or total separation of layers
- Patient at risk for poor wound healing are at risk for poor nutrition, infection, obesity
Evisceration is? As a nurse what do you do to reduce infection?
Protrusion of visceral organs through a wound opening.
Surgical repair: As a nurse you must play sterile towels so soaked and sterile saline over the extruding tissue to reduce chance of infection
What is this fistula?
Abnormal passage between two organs or between an organ and the outside of the body
Clear, watery plasma is what type of drainage?
Serous
Pale, red, watery: mixture of clear and red fluid is the Appearance of what type of drainage?
Serosanguineous
Thick, yellow, green, tan, or brown drainage is what type
Purulent
Bright red: indicates active bleeding is known as what type of drainage?
Sanguineous
Describe suspect a deep tissue injury
Intact or nonintact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister
Stage one pressure injury
Intact skin with a localized area of non-blanchable erythema. Color changes do not include purple or maroon discoloration
Stage 2 pressure injury
Partial thickness loss of skin with exposed dermis. Wound bed is viable, pink or red, and moist and me also present as an intact or ruptured serum filled blister. NO granulation tissue, slough, eschar visible.
Stage III pressure injury
Full thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough, eschar or both may be visible
Stage four pressure injury
Full thickness skin and tissue loss with exposed or directly palpable faster, muscle, tendon, ligament, cartilage, or bone in ulcer.
Describe granulation tissue
Red and white tissue, composed of new blood vessels, indicating progression of wound healing
Describe slough tissue
Soft yellow, or white stringy tissue which needs to be removed before wound healing occurs (dead tissue)
Describe eschar tissue
Black or brown necrotic tissue, which needs to be removed before wound will heal
Differentiate between nonabsorbent and absorbent sutures
Nonabsorbent: must be removed, and are usually removed within 7 to 14 days
Absorbent: Can be dissolved and do not have to be removed
What is the purpose of steri strips?
Support the wound tension across the wound and eliminate scarring.
This allows the wound to heal by primary intention
They should extend 1.5 to 2 cm on each side of the incision
