Venous Insufficiency and Surgical Wounds - Class 4 Flashcards
venous insufficiency ulcers are caused by
unrelieved venous hypertension in LEs
–> d/t incompetent perforator valves
venous insufficiency ulcers are usually located
medial ankle
gait area
venous insuff LE presents w/
firm edema
dilated superficial veins
possible dermatitis
hyperpigmentation
venous insufficiency ulcers are
highly draining
venous ulcers present as
superficial wound
irregular margins
ruddy granular
venous ulcers –> exudates
usually w/ heavy exudates
venous ulcers –> pain
no pain
tests for venous vasculature
venous doppler
Trendelenburg test
percussion test
cuff test
venous insufficiency intervention
reduce venous hypertension
compression therapy
leg elevation
re-establishing calf-muscle pump
exercise activity
local wound care to absorb heavy exudates
venous insufficiency interventions –> compression therapy
obtain ABI
–> if <0.8 –> no compression tx
acute surgical wound
incision
heal w/in a specific time frame
types of surgical wound closure
primary (acute surgical wound)
secondary (left open)
tertiary (delayed primary) (cut them, let infection resolve, let soft tissue edema resolve then close them)
assessment of acute surgical wound
suture/wound
surrounding skin tissue
as it related to the 3 phases of healing
how do we asses an acute wound
measurement of incision
wound tissues
wound closure
exudate
palpation of suture line
palpation and color of surrounding tissue
exudate –> assessment
amount and type
palpation of suture line –> assessment
presence of healing ridge
raised tissue firmness from collagen deposition
inflammatory phase of incisional wound
first 3-4 days
inflammatory phase will be accompanied by
normal signs of inflammation
warmth, redness, edema, pain
what does absence of inflammation point to –> inflammatory phase
trouble
inflammatory phase –> wound edges
approximation of wound edges
-epithelialization
-no tenson on sutures
type of draining –> inflammatory phase
sanguineous to serosanguinous
incisional wound in the proliferative phase
presence of healing ridge
draining
asses for swelling and induration
asses skin color for erythema ecchymosis
presence of healing ridge –> proliferative phase
firmness along incision extending 1 cm on either side from deposition of new collagen
when does the presence of a healing ridge appear
post op day 5-9
proliferative phase –> drainage
should be serosanguinous –> serous –> nil
asses for nearly draining incision once closed
how long does the remodeling phase occur
1-2 years
incision color –> remodeling phase
changes from red/pink silvery –> gray to white
remodeling phase –> healing ridge
gradually softens
remodeling phase –> wound strength
80% of pre wounded stage
what should we asses for in the remodeling phase
signs of abnormal scarring
keloid or hypertrophic
keloid scarring
raised
goes beyond borders of initial wound
hypertrophic scarring
raised
stays w/in wound borders
wound management for acute surgical wound
primary dressing
secondary dressing
primary dressing
absorbent of wound exudate
protects incision from further trauma
non-adherent to wound
maintains sterile wound environment
limits frequent dressing changes
secondary dressing
absorbs excess drainage wicked away by primary dressing
secures primary dressing in place
