Test 1 Flashcards
Three phases of healing
Inflammation
Proliferation
Maturation/Remodeling
PMNs (polymorphonuclearneutrophils)
1st to site of injury, kill bacteria, clean wound, degrade debris
Macrophages
kill pathogens, direct repair process
Mast cells
produce histamine and secrete enzymes to accelerate riddance of damaged cells
Angioblast
New blood vessels
Fibroblast
lay down extracellular matrix
myofibroblast
pull wound margins together
maturation of tissue healing
type 3 collegen replaced by type 1, up to 2 years following wound closure, 80% full strength, no sweat, less sensitive.
Age slowing healing
slowed immune response, decreased collagen synthesis, skin atrophy, less sweat, decreased pain perception
Systemic factors
Immunocomprimised: HIV/AIDS
Oxygen perfusion: PVD, Anemia, COPD, Cardiac Conditions.
Medications delay healing
Steroids, chemotherapy, NSAIDS.
Clinician induced factors affecting healing
Prolonged use of antiseptic
Wrong dressing selection
Failure to detect infection
Poor wound exploration
Poor temp management
Three wound closures
Primary Intention: Wound edges are closed directly with sutures, staples, or glue for quick healing.
Secondary Intention: Wound is left open to heal naturally from the inside out.
Tertiary Intention: Wound is initially left open and later closed after ensuring it is clean.
DIME
Debridement: safe to debride?
Inflammation: What stage?
Moisture balance: Tissue type, masceration?
Edge effect: Stalled/rolled(Epibole), Callus, Attached.
Key questions within history specific to wound care
General Demographics
Lifestyle and Functional Status
Past and Current Medical History
Test and measures for wound assessment
location, dimensions, tissue type, wound edges, drainage, odor, periwound skin, edema.
Undermining, tracts, and tunnels
Undermining: tissue under wound edge is eroded.
Tracts: narrow passageway, extension of wound
Tunnels: entrance and exit
Wound bed tissue types
Undermining documentaion
Document the length of undermining using the clock method to note location.
Ex. Underming noted measuring 4.2 cm from 12 oclock to 3 oclock.
Wound edges examples
Four types of drainage
Serous: Clear-pale yellow watery, protein rich
Sanguineous: Blood or drying blood, red dark brown.
Serosanginous
Purulent: Indicator of infection, white-pale yellow, viscous or creamy
Documentation: Type, color, consistency, amount.
Acute vs Chronic Wound
Acute progress sequentially through the natural phases of healing in timely manner.
Chronic do not progress sequentially through healing; frequently stuck in inflammatory phase.
Wound bed preparation model
How to tell if a wound is healable?
Adequate blood supply
universal vs standard precautions
universal: all body fluids are considered contaminated.
standard: hand washing and PPE
Clean vs sterile technique
Clean: standard for wound care, wash hands and use PPE.
Sterile: use everything sterile, much higher detail than clean.
What are the common types of irrigaiton?
Normal saline: water/salt
Sterile water: must use with silver dressing
Tap water: caution with immunocompromised
Wound Cleansers
Antiseptics: can kill everything on skin.
When is immersion or soaking contraindicated?
Recent skin graft, surgical incision, diabetic feet, bleeding wounds, dry gangrene.
safe psi for wounds
4-15
Whirlpool contraindicated
clean granulating wounds, uclers, active bleeding, venous insufficiency, multi wounds same area, seizures, bowl and bladder issues.
Pulsed lavage with suction/ ultrasonic mist therapy.
PLWS: irrigation with suction. Expensive
Ultrasonic Mist: irrigation with ultrasonic waves. Expensive
PLWS contraindications
Aerosolization risk, confined space, cover horizontal surfaces.
re-black system
six types of debridement
Sharp
Mechanical
Enzymatic
Autolytic
Biologic
Surgical
Contraindications for debridement
Arterial supply, ABI, Types of tissue
Mechanical debridement
solft abrasion, wet to dry, hydrotherapy
enzymatic debridement
do not use with dressing containing silver, iodine, HP, acetic acid.
use of creams, collagenase santyl, prescription
Autolytic Debridement
Contraindications: infection, dry gangreene, deep cavity wounds.
Biosurgical Debridement
maggots. blood vessels to organs, near eyes respiratory tract and Gi are contraindications.
