Principles of Wound Care Flashcards
Angiogenesis
Formation of new granulation, vessels form from pre-existing vessels
Colonization
Presence of bacteria with no signs of infection
Acute wound
Heals uneventfully within expected time fram
Chronic wound
Underlying pathophysiology causes the wound or interferes with the course of healing
Primary Intention
Surgical Wound
Secondary intention
Wound edges are too far apart to be surgically closed,, healing through natural granulation and epithelialization
Tertiary intention
Delayed in wound closure resulting in granulation of wound edges, later surgical closure results in more scar formation. Wound may be left open for several days to allow edema and infection to resolve or exudate to drain.
Arterial ulcer (aka ischemic ulcer)
- Insufficient arterial perfusion (DM or PVD)
- Wound commonly found between toes, phalangeal heads or lateral malleolus.
- Pallor or cyanosis to limb, punched out appearance
Diabetic ulcer
Usually found of the plantar aspect of the foot, heals or metatarsal heads. Even well defined wound margins.
Venous ulcers
- Caused by a disturbance to return blood flow from the legs
- found on the medial lower leg above the medial malleolus
- Can be edematous, have dilated veins and lack of pain
- Irregular wound margins, ruddy granular tissue, moderate to heavy exudate.
Deep tissue injury
Purple, maroon or discolored blood blister, painful firm or mushy.
Stage 1 pressure ulcer
Intact skin with non-blanchable redness
Stage 2 Pressure Ulcer
Partial thickness tissue loss, shallow open wound, pink wound bed with no slough
Stage 3 Pressure Ulcer
Full thickness tissue loss, exposed fat but no bone or tendon, may be slough in the wound.
Stage 4 Pressure Ulcer
Full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar present
Unstageable Pressure Ulcer
Full thickness loss of tissue, base covered with slough or eschar
Wound Healing Process
- Injury
- Hemostasis
- Inflammatory phase
- Proliferative phase
- Epithelial closure
- Maturation
Hemostasis
Period of vasoconstriction when the body tried to prevent bleeding
Inflammatory phase of healing
2-6 days post injury with increased blood flow, heat, redness and swelling.
Proliferative phase of healing
Granulation and epithelialization begin
Hydrogel dressing
Non-adherent dressing composed of water and a polymer with absorbent properties. Treats full to partial thickness wounds that are dry or minimally draining.
Foam Dressing
Some absorptive properties, for full or partial thickness wounds, minimal to heavy drainage.
Hydrocolloid dressing
Adhesive and moldable wafer for full to partial thickness wounds with minimal or moderate drainage.