Week 3 - Wound Classification Flashcards
What is a wound?
- Any break in the skin can be classified as a wound.
- Our goal is to facilitate healing and prevent the risk of complications.
Define a Primary Intention Wounds
(Intentional)
- Tissue surfaces have been approximated; there is no or minimal tissue loss, includes:
- Superficial Wounds
- Closed Surgical Incisions
- Wounds Joined by Adhesive ‘Glue’
- Healing Process is Predictable
- Healing Time 4 -14 days
- Minimal Scarring
Define a Secondary Intention Wounds
(Unintentional)
- Greater tissue damage, loss
- Edges not easily approximated
- Delayed healing time
- Scarring
- More chance of complications such as infection
- Pressure injury, traumatic injury, burns, dehisced surgical wounds
Define a Tertiary Intention Wounds
- Wounds that are left open for 3-5 days to allow fluids or infection to drain
- Are then closed with sutures, staples or adhesive skin closures
What are the phases of wound healing?
- Haemostasis & Inflammatory phase
- Proliferative phase
- Maturation & Remodelling phase
What is the Haemostasis & Inflammatory phase?
- Starts immediately after injury & lasts 3-6 days.
- Removes debris & prepares for new tissue:
o Haemostasis (cessation of bleeding)
o Blood supply increases (oxygen, nutrients, macrophages)
o Phagocytosis (engulf microorganisms & cellular debris)
What are the clinical observation for Haemostasis & Inflammatory phase?
- Pain
- Redness
- Swelling
- Heat
- Exudate (clear)
- These descriptive terms are often used in documentation of wounds in progress notes.
What is Proliferative phase?
- Second phase; from day 3 to day 21 post injury.
- Laying down of new cells, connective tissue:
o Fibroblasts synthesize collagen (adding strength) & deposit fibrin
o Capillary formation & increased blood supply
What are the clinical observation for Proliferative phase?
- Wound appears beefy, red, moist
o granulation tissue - Fragile tissue that bleeds easily
o Angiogenesis - Wound paler, tissue is thin, pink
o epithelialisation
What is the Maturation & Remodelling phase
- Occurs from around day 21 up to 1-2 years after the injury.
- Strengthening and reorganising collagen fibres:
- New tissue continues to grow and develop
- Normal blood supply recreated
- Scar formation and wound contraction
What are the clinical observation for Maturation & Remodelling phase?
- Scar appears smaller, flatter and paler
What are the different types of wounds?
- Abrasions
- Lacerations
- Pressure injuries
- Skin tears
- Suture lines
- Burns
- Surgical Wounds: suture lines, drains
- Ulcers- Venous, Arterial Wounds
- Pressure Ulcers
- Incontinence Associated Dermatitis (IAD)
What are the components of a wound assessment?
- Type of wound - Acute or Chronic
- Aetiology - Surgical, ulcer, burn, pressure injury, bite, skin graft, skin tear
- Location - Where on the body
- Surrounding skin - Dry, tissue paper
- Wound edge - Macerated, Dry, Raised
- Exudate
- Pain
- Odour
- Measurement and dimensions - Length, width, depth
Define an acute wound
- Primary intention or
secondary intention - <4 weeks
Define a chronic wound
- Secondary intention
- Normal healing disrupted
- > 4 weeks
How to describe the surrounding skin and wound edge
- Dry and Flakey
- Oedema
- Blistered
- Bruised
- Fragile
- Calloused
- Wound Edge - normal, rolled, punched out’, raised
- Macerated
- Undermining
How to tell how healthy a wound is
- Viable, healthy - Red Pink
- Nonviable, unhealthy - Yellow Red
- Infected - Black Yellow
Define wounds that are viable, healthy?
- Granulation
- Epithelialisation
What are the characteristics of granulating tissues?
- Ruddy (reddish)
- Beefy, bumpy, lumpy,
- Firm (attached)
- Pebbled (whitish spots)
- Moist
- Shiny
- Fragile
What are the characteristics of epithelialising tissues?
- Pinkish,
- Tissue is thin, shiny, translucent
Define wounds that are non viable, unhealthy?
- Slough
- Necrosis
What are the characteristics of slough tissues?
- Comprised of multiple elements
- Waste, Fibrin, white blood cells
- Firmly attached or loose
- ‘chicken fat’
- Creamy/yellow
- Slimy, stringy, clumpy, gelatinous, fibrous
- Moist
- Thick & sticky (viscous)
- Slows healing; potential site for microorganism
What are the characteristics of necrotic tissues?
- Dead tissue
- Adheres firmly to wound
- Hard and leathery OR soft & wet
- Black, brown, tan
- Slows healing; potential site for microorganism proliferation
- Full thickness tissue destruction
- Eschar – dry, dark scab of dead tissue
What are the characteristics of infected tissues?
- Persistent redness, swelling, pain
- Viscous discharge, yellowish/green
- Malodorous
How to classify a skin tear?
- Type 1 - No skin loss
- Linear or flap tear which can be repositioned to cover the wound bed
- Type 2 - Partial flap loss
- Partial flap loss which cannot be repositioned to cover the wound bed
- Type 3 - Total flap loss
- Total flap loos exposing the entire wound bed
What are the stages of pressure injuries?
- Stage 1
- Stage 2
- Stage 3
- Stage 4
How to assess exudate (TACO)
- Type
- Serous (clear, odourless)
- Haemoserous (thin, red/ pink)
- Haemorrhagic (thick, red)
- Purulent (thick, viscous, yellow/ green)
- Amount
- Colour
- Odour - Odourless / malodour
How to determine a patient wound pain
- Ask patient about pain levels – on a scale of 0-10, zero being no pain, 10 being extreme pain, what number would you give the pain at rest? on movement?\
- Document this in both the SAGO (Standard Adult General Observation Chart) and in the Progress Notes.
- Observe – non-verbal cues, reluctance to mobilise.
What are factors impeding wound healing?
- Co morbidities
- Impaired Tissue Perfusion
- Malnutrition
- BMI
- Disorders of Sensation or Movement
- Medications
- Radiation Therapy
- Stress, Anxiety and Depression
- Poor Wound ManagementPractices
- Moisture Balance
- Wound Temperature and pH
- Infection
- Pressure, Friction and Shearing
- Foreign Bodies
