Power Points info. Flashcards
Phases of healing (3)
1) Inflammatory phase
2) Proliferative phase
3) Remodeling
Inflammatory phase (3)
a) hemostasis
b) inflammation
c) cell migration
Proliferative stage (2)
a) regeneration
b) replacement with scar tissue
Epithelialization( constructing of new epidermis) begins. At the same time new granulation tissue is formed. New capillaries (angiogenesis) are created, restoring the delivery of oxygen and nutrients to the wound bed. Collagen is synthesized and begins to provide strength and structural integrity to the wound. Contraction, which occurs in open wounds and reduces the size of the wound.
Remodeling aka (maturation phase)
- Collagen is remodeled to become stronger and provide tensile strength to the wound.
- Outer appearance of an uncomplicated wound that will be that of a well-healed scar.
Hemostasis
- Blood vessels constrict; clotting factors activate coagulation pathways to stop bleeding.
- Clot formation seals the disrupted vessels so blood loss is controlled and acts as temporary bacterial barrier.
- Platelets release growth factors, which attract cells needed to begin the repair process.
Inflammation
- Vasodilation occurs, allowing plasma and blood cells to leak into the wound, noted as edema, erythema, and exudate.
- WBC (leukocytes) arrive in the wound to begin wound cleanup.
- Macrophages, appear and begin to regulate the wound repair.
- The result of the inflammatory phase is a clean wound bed in a patient with a noncomplicated wound
Complications of wound healing (4)
1) Hemorrhage
2) Infection
3) Dehiscence/eviceraiton
4) Fistula
Types of wound drainage (4)
1) Serous (clear watery plasma)
2) Sanguinous (bright red, fresh bleeding)
3) Serosanguinous ( pale, red, more watery)
4) Purulent (thick yellow, green or brown)
Factors Affecting Wound Healing (10)
1) Vasulature
2) Anemia
3) Age
4) Compromised host
5) Nutrition
6) Obesity
7) Drugs
8) Smoking
9) Stress
10) Infection
4 things you assess for wounds
1) Appearance
~Approximated edges?
~color
~wound closures
~presence of drain or tubes
2) Drainage
~amount
~color
~odor
~consistency
3) Pain
4) Other
~vitals, labs (WBC & C&S)Factors affecting wound care (6)
1) Type of wound
2) Size
3) Amount of exudate
4) Open vs closed
5) location
6) Physicians orders
5 goals of wound care
1) Prevent and manage infection
2) cleanse the wound~ do not use cleaners that are cytotoxic
3) remove nonviable tissue
4) manage exudate
5) protect the wound
(4&5) ~ Application of dressing
~purposes
~types
~Changing dressings
~Securing dressings
Debridement methods (4)
1) mechanical
2) Autolytic
3) chemical
4) surgical
Skills page 924
Autolytic debridement
Uses synthetic dressings over a wound to allow eschar to be self-digested by the action of enzymes that are present in wound fluids.
- Can be accomplished by using dressings that support moisture at the wound surface. If the wound base is dry use a dressing that adds moisture; if there is excess moisture use a dressing that absorbs moisture while maintaining moisture at the wound bed.
- Some examples are: transparent film, and hydrocolloid dressings.
Chemical debridement (Enzymatic debridement)
- The only enzyme available in the US is Collagenase which digests the necrotic tissue by dissolving the collagen in the dead tissue.
- The use of a topical enzyme preparation, Dankin’s solution, or sterile maggots.
- Depending on the type of enzyme used they either dissolve or breakdown the necrotic tissue.
- Dankin’s placed on a gauze pad and placed on wound breaks down and loosens dead tissue.
- Sterile maggots eat dead tissue.
Mechanical debridement
- The use of wet-to-dry saline gauze dressings.
- Place moistened gauze into the wound and let dry thoroughly before removing, it adheres to dead and viable tissue (so this method is not used routinely).
- NEVER use this method on clean, granulating wound.
- Other methods of mechanical; are wound irrigation (high-pressure irrigation and pulsatile high-pressure lavage) and whirlpool treatments.
Purpose of dressings (7)
1) Protect wound from contamination
2) promote hemostasis
3) Absorb drainage and debride wound
4) Support and splint the wound site
5) Approximate wounds edges
6) Cover unpleasant wound sites
7) Provide moist environment
Types of Dressings (5)
1) Gauze sponge dressings
2) Nonadherent gauze dressings
3) Self-adhesive transparent films
4) Hydrocolloid dressings
5) Hydrogel dressings
Gauze sponge dressing
- Are the oldest and most common dressing.
- They are absorbent and are especially useful in wounds to wick away the wound exudate.
- Diff. sizes and shapes, most common 4X4.
Nonadheherent gauze
- Such as Tefla over a clean wounds with little or no drainage.
- Tefla gauze has a shiny, nonahherent surface that does not stick to incisions or wound openings but allow drainage to pass through the gauze topper.
Transparent films
Adhesive membrane dressing; waterproof, impermeable to fluids and bacteria; allow oxygen and moisture vapor exchange For: Shallow wounds Dry to minimally exudative wound Promote autolytic debridement Stage I or II pressure ulcer
It has the following advantages:
- easy apply/remove without damage to underlying tissue
- Create second skin; protect from friction
- Creates moist wound that softens thin slough and eschar
- protective shield to external fluids and bacteria
- Permits viewing a wound
Hydrocolloid dressing
-Made of gelatin, pectin, and carboxymethylcellulose particles suspended in adhesive base
- Maintain moist environment by forming a gelatinous mass
For: Autolytic debridement
Absorption of minimal to moderate exudate
Advantages; Lots of sizes *promotes autolytic debridement *reduce pain *impermeable to fluids/bacteria *thermal insulator Disadvantages; *Potential for periwound maceration if left in place to long * Drainage (gelatinous mass) often mistaken for pus/infection * Adhesive possibly to aggressive for fragile skin
- Change every 3-5 days
Hydrogel dressing
-Composed of water or glycerin- based polymers
- provides moistures to wound beds
- available in sheets or amorphous gel ( usually in a tube)
-autolytic debridement
-For partial or full thickness wound; shallow or deep.
Advantages;
* Nonadherent
* Cool and soothing
* decrease pain
* Facilitates autolysis
* Conform to wound
Disadvantage
Potential for maceration or candidiasis of periwound area
Dressing change steps (16)
1) Administer analgesic
2) Explain procedure to pt
3) Do not touch open without sterile gloves
4) Provide for privacy
5) Wash hands-90 seconds
6) Drape pt
7) Don clean gloves
8) Remove tape
9) Remove dressing 1 layer at a time
10) Observe drainage and wound
11) Place dressing and gloves in bag
12) Open sterile dressing
13) Cleanse wound if ordered
14) Don sterile gloves
15) Apply sterile dressing
16) Secure the dressing
Bandages
Strips of cloth, gauze or elasticized material used to wrap a body part
Binders
- Bandages made of large pieces of material to fit a specific part
- Ex: slings and abdominal binders
Purposes of bandages and binders (6)
1) create pressure
2) immobilize body part
3) support wound
4) decrease/prevent edema
5) secure splint
6) secure dressing
Principles of bandages and binders (6)
1) Unclean bandages and binders may cause infection if applied over an open wounds
2) Prolonged heat and moisture on skin will damage epithelial cells
3) Place and support body parts in normal functional position
4) Blood flow is decreased by applying excessive pressure
5) Tension of each turn should be equal
6) Pins or knots should be placed away from wounds or pressure points
Binders
- Specially designed for body part
* Abdominal binder the most common
Slings
- Support arms with stains or fractures
- commercially prepared sling
- triangular sling
Roller bandages
- Secure or support dressings over irregularly shaped body parts
- each roll has a free outer end and a terminal end at the center of the roll
- outer surface of bandage is placed against the client
Therapeutic uses of local Heat
- Decreased pain
- Decreased muscle tone
- Promote healing
- Relieve Deep Congestion
Therapeutic uses of local Cold
- Decreased pain
- Decreased muscle tone
- Decreased oxygen to area
- Decreased metabolism
- Prevent edema
- Enhance coagulation
- Decreased circulation to area
- Retards bacterial growth
Rebound Phenomenon (HEAT & COLD)
HEAT
1) Maximum vasodilation in 20-30 minutes
2) After 30-60 minutes, reflex vasoconstriction occurs
COLD
1) Vasoconstriction occurs for 30-60 minutes
2) After 30-60 minutes, vasodilation occurs
Factor influencing Effects of heat and cold application (10)
1) Intensity of temperature
2) Body part
3) Damage to the body surface
4) Body surface area
5) Prior skin temperature
6) Age
7) Physical condition
a) arteriosclerosis
b) neurological impairments
c) metabolic disorders
8) Skin coloring
9) Rapidity of temperature change
10) Duration of application
Contraindications in Use of Heat Therapy (9)
1) Malignances
2) Non-inflammatory edema
3) During the first 24 hours after traumatic injury
4) Active hemorrhage
5) Acutely inflamed area
6) Testes
7) Developing fetus
8) Skin disorder causing redness or blisters
9) Metallic implants
Contraindications in Use of Cold Therapy(3)
1) Open wounds
2) Impaired circulation
3) Allergy or hypersensitivity to cold
Local Physiologic effects from application of Heat (8)
1) Vasodilation
2) Increase Capillary permeability
3) Increase Tissue Metabolism
4) Decrease Blood Viscosity
5) Muscle relaxation
6) Increase Nerve conduction
7) Increase Lymph Flow
8) Increase Leukocyte Motility
Local Physiologic effects from application of Cold (8)
1) Vasoconstriction
2) Capillary Permeability
3) Decrease Tissue Metabolism
4) Increased Blood Viscosity
5) Muscle relaxation
6) Decrease nerve conduction
7) Decrease Lymph flow
8) Decrease Leukocyte motility
Advantages & Disadvantages of Wet and Dry local applications
DISADVANTAGES
Prolonged exposure can cause maceration (softening) of the skin
Moist heat will cool rapidly because of moisture evaporation
Moist heat creates a greater risk for burns to the skin since moisture conducts heat
ADVANTAGES
Dry heat increases body fluid loss through sweating
Dry applications do not penetrate deep into tissues
Dry heat causes increased drying of the skin
Precautions in the use of cold therapy
Sensory impairment
Impaired mental status
Low cold tolerance
Complications of Heat application
- Pain
- Burns
- Vasoconstriction (pallor or mottled)
- Redness which does not blanch with pressure
- Maceration (with moist heat)
- Edema
Complications of Cold applications
- Pain
- Blisters and skin breakdown
- Vasodilation (redness)
- Ischemia, mottling (grey or bluish discoloration)
- Maceration (with moist heat)
- Thrombi (blood clots)
Penrose drain
- Open-drain system removes drainage from the wound and deposits it onto the skin surface.
- Insert a sterile safety pin through this drain, outside the skin, to prevent the tubing from moving into the wound.
Jackson-Pratt or Hemovac
- Closed-drain systems, drain relies on the presence of a vacuum to withdraw accumulated drainage from around the wound bed into the collection device.
- Jackson-Pratt: 100-200 ml/24 hr
- Hemovac: 500mk/24 hr
Primary and Secondary dressing
Primary dressing is a protective cover that comes in direct contact with the wound
Secondary serves as a protective or therapeutic function by holding primary in place and increasing the ability to meet wounds needs
Alginate or Foam dressings do what?
Highly absorbent to manage wound drainage
Removing dressing
pull tape parallel to skin and towards dressing. If hairy pull in direction of hair growth
Precautions for Heat
- Sensory Impairment
- Impaired mental status
- Impaired circulation
- Low heat tolerance
- Open wounds
- Impaired kidney, heart, lung function
- Stomas and scar
What wound care products promote Autolytic debridement (3)
Transparent films
Alginates
Hydrogels
