Module 4: Wounds Flashcards
What is the difference in healing between an acute, subacute and chronic wound?
- Acute wounds – Heal in 2–3 weeks – Usually no residual damage (normal healing)
- Subacute wounds – Acute process but lasts longer
- Chronic wounds – Lasts for weeks, months or even years (failed healing)
What are the 3 phases of wound healing?
> Inflammatory phase
- commences when skin integrity is disrupted
- 0-3 days
- characterised by heat, redness, oedema, and pain
- maybe loss of function
- wound ooze may be present (normal body response)
> Proliferative phase
- 3-24 days
- reconstruction and epithelialisation
- wound will become smaller as it heals
> Maturation phase
- 24days - 1 year
- Scar tissue formation
- Realignment of collagen fibres
- Still at risk, needs protection
List and describe 6 mechanisms of wound healing:
Primary Intention
Primary intention:
- wound margins are neatly approximated (surgical incision, paper cut)
- may have associated drainage systems
- minimal loss of tissue and scarring results
List and describe 6 mechanisms of wound healing:
Secondary Intention
Secondary intention:
- Surgical or traumatic wound left to heal spontaneously
- Occurs slowly by granulation, contraction & re-epithelialisation
- May need debridement
- results in larger scar formation
- Need to create an environment to support healing
List and describe 6 mechanisms of wound healing:
Tertiary Intention
Tertiary Intention:
- occurs with delayed suturing of a wound where two layers of granulation tissue are sutured together
- results in larger and deeper scar than primary or secondary
List and describe 6 mechanisms of wound healing:
Skin graft
Skin Graft:
* removal of partial or full thickness segment of epidermis and dermis from its blood supply - transplanting it to another site to speed up healing and reduce the risk of infection
List and describe 6 mechanisms of wound healing:
Skin flap
Skin Flap
* surgical relocation of skin and underlying structure to repair a wound
List 11 factors that will affect wound healing
- Nutritional deficiencies ( Vit-C, protein, zinc)
- Inadequate blood supply
- Corticosteroid drugs
- Infection
- Smoking
- Mechanical friction on wound
- Advanced age
- Obesity
- Diabetes mellitus
- Poor general health
- Anaemia
what are the signs & symptoms of an infected wound?
‒ Increased swelling, redness, warmth
‒ Painful, even though there is no visible evidence (early sign)
‒ High or low temperature, low blood pressure, or a fast heart rate
‒ Discharge/ odour from the wound
‒ Does not improve with treatment
What are the 4 items that are assessed in a wound assessment?
> Wound bed:
- granulating
- epithelializing
- sloughy
- necrotic
- hyper granulating
> Wound edges:
- colour
- raised edges
- rolled edges
- contraction
- sensation (pain/numbness)
> Exudate:
- colour
- quantity
> Wound measurement:
- 3 dimensional
- length
- width
- depth
What actions should be undertaken to preserve a skin flap from a skin tear?
STAR skin tear classification guidelines.
1) Control bleeding and clean the wound accordingly
2) Realign (if possible) any skin flap
3) Assess degree of tissue loss and skin flap colour
4) Assess the surrounding skin condition for fragility, swelling, discolouration or bruising.
5) Assess the person, their wound and their healing environment
6) If skin flap is pale, dusky or darkened - reassess in 24-48hrs or at first dressing change.
Describe the differences between arterial, venous and diabetic/neuropathic ulcers.
> Arterial:
- due to inadequate blood supply to the affected area (ischaemia)
- tend to occur on the lower legs and feet, and maybe acute, recurrent or chronic
> Venous:
- the result of malfunctioning venous valves
- causes pressure in the veins to increase
- typically occur in the lower leg (medial or lateral distal)
> Diabetic / neuropathic:
- a result of peripheral neuropathy
- typically seen in diabetics
- localised to the feet
what are the 6 risks that are assessed for obtaining a pressure injury?
1) Sensory perception (ability to respond meaningfully to pressure related discomfort)
2) Mobility ( ability to change and maintain own position)
3) Activity ( degree of physical activity)
4) Moisture (degree to which skin is exposed to moisture)
5) Friction shear
6) Nutrition
describe the 6 stages of pressure injuries:
Stage 1
> Stage 1:
- sores are not open wounds.
- maybe painful
- skin appears reddened and does not blanch
- in a dark skinned person, skin may appear darker than surrounding skin, but may not look red.
- skin temperature is often warmer
- can feel either firmer or softer than surrounding skin
describe the 6 stages of pressure injuries:
Stage 2
> Stage 2:
- skin breaks open, wears away, or forms an ulcer
- tender and painful
- sore expands to deeper layers of the skin
- can look like a scrape (abrasion), blister, or shallow crater.
