Wound Flashcards
What is the def of a wound?
Break or disruption in normal integrity of skin and tissue
How to classify wounds?
- Intentional vs unintentional
- open vs closed
- acute vs chronic
- superficial vs partial thickness vs full-thickness
- degree of contamination
What is an intentional wound?
- Purposefully by surgeon (not always)
- Therapeutic purposees
- under sterile conditions w/sterile equipment and skin prep
- Wound edges clean, bleeding controlled
- Lower infection risk
What is an unintentional wound?
- By accident, unexpected trauma
- Not part of therapeutic intervention
- occur in unsterile environment
- Wound edges are jagged, bleeding uncontrolled
- High risk for infection
What is a closed wound?
- skin intact but soft tissue damage
- from blow, force or strain
- internal injury and hemorrhage may occur
What is an open wound?
- Actual break in the skin
- from unintentional or intentional trauma
- bleeding and tissue damage
- Entry for microorganisms
What is an acute wound?
- Occur quickly & heal rapidly
- Heal within days to weeks
- Usually move through the healing process without difficulty
- Wound edges are often well approximated
What is a chronic wound?
- Occur over time & healing process is impeded
Cause of the wound has
not been identified or
removed - Remain unhealed for longer than 6 weeks
- Do not progress through the normal sequence of repair; remain in the inflammatory phase of healing
- Wound edges are often not approximated
What are degrees of contamination?
- Clean wounds
- Clean-contaminated wounds
- Contaminated wounds
- Infected wounds
- Colonized wounds
What is a clean wound?
- No infection
- Respiratory, GI, GU body systems are not entered (bacteria-containing systems)
- Risk for developing an infection is low
(as per CDC: less than 5%) - Minimal inflammation
What is a clean-contaminated wound?
- no infection
- Surgical wound in resp. sys, GI, GU body systems
- Surgery involved organ sys likely contain bacteria => infection risk higher
(per CDC: up to 11%)
What is a contaminated wound?
- open, fresh, accidental wounds
- wound from surgery: break in sterility
- perforation of colon or small intestine bowel => spillage of bacteria into wound
- incisions with non-purulent inflammation
(per CDC: up to 10-17%)
What is an infected wound?
- clinical signs of infection
- increased drainage (purulent or not)
- elevated bacteria count in cultured
What is a colonized wound?
- One or more organisms present on wound surface when culture obtained => NO signs of infection
What is partial thickness?
- Confined to the dermis and epidermis
- Heal quickly
What is full-thickness?
- Involve derms, epidermis, subcut tissues and possible muscle bone
- Require CT and repair to progress through wound closure
- Heal more slowly
What is regeneration?
Tissues are made w/same cells/tissues
What is repair?
Loss cells replaced w/CT (potential loss of fct)
What are the phases of healing?
- hemostasis
- inflammation
- proliferation
- maturation
*first two phases attached
What is the inflammatory phase?
- rxn within minutes of injury to 3-6 days
- remove necrotic material, environment for healing and repair
- Hemostasis and phagocytosis
What is hemostasis?
- GOAL: Cessation of bleeding
- vasoconstriction
- retraction
- deposit of fibrin (CT)
- blood clots
What is phagocytosis?
- GOAL: Obtain a clean wound bed
- WBC (leukocytes) arrive first
- after 24 h, macrophages (larger) enter and remain longer
What are gen body responses in inflammatory response?
- mildly elevated temp
- malaise
- leukocytosis
What proliferative phase?
D3/4 - D21 after injury
GOAL: Production of granulation tissue to fill wound space, resurfacing of wound (epithelization) & contraction of wound
- fibroblasts => healing site and synthesize collagen
What is granulation tissue?
- Wound pink and vascular
- Easily friable (bleed easily)
What is phase three?
Maturation phase
D21 and last 1-2 years
- Collagen fibres organized into orderly structure
What are the wound healing classification?
- Primary intention
- Secondary intention
- Tertiary intention
What is primary intention?
- Tissue surface approximated (closed), min or no tissue loss
- clean incision, heals quickly
- min granulation tissue and scarring
- low infection risk
How is healing done throuhg primary intention?
initial phase => granulation phase => maturation phase & scar contraction
What is secondary intention?
- Extensive wound, edges of wd not approximated,
- healing by granulation formation
- Contrature of wound edges
What is tertiary intention?
Delayed closure
- belay b/w wound and suturing
- wound left open for several days , ensure clean and uninfected => approximated
What is a pressure injury?
Localized to skin and underlying tissue. Usually over bony prominence
- Results of intense/prolonged pressure + shear
What is a suspected deep tissue injury?
- unknown depth
- purple or marron localized area
- intact skin or blood-filled blister (underlying soft tissue damage from pressure or shear)
What is stage 1 of pressure injury?
- Intact skin w/nonblanchable erythema usually over bony prominence
- darkly pigmented skin not have visible blanching: color diff from surrounding area
What is stage 2 pressure injury?
- partial thickness loss of dermis
- shallow open ulcer w/red/pink wound bed, no slough
- intact or open/ruptured serum-filled blister
What is stage 3 pressure injury?
- Full thickness tissue loss
- subcut fat may be visible
- Bone, tendon, muscle not visible
- Slough maybe present BUT not obscure depth of tissue loss
- may include undermining and tunneling
What is stage 4 pressure injury?
- full thickness loss w/exposed bone, tendon, muscle
- Slough, eschar may be present
- Oftne have undermining and tunneling
- May extend into muscle and/or supporting structures => osteomyelitis (bone infection)
What is unstageable pressure injury?
- depth unknown until slough and/or eschar removed
- full thickness tissue loss
- ## base of ulcer coverred by slough and/or eschar in wound bed
What are adhesions?
- Bands of scar tissue between or around organs
- May occur in abdominal cavity or between lungs & pleura.
What are contractures?
Shortening of muscle or scar tissue from excessive fibrous formation (especially near joint).
What is dehiscence?
- partial or total separation of wound layers
- before collagen formation: 3-11 days after injury, 4-5 days post-op
- after sudden strain (coughing, vomiting, sitting up)
What is wound evisceration?
- Protrusion of visceral organs through wound opening
What are hypertrophic scars?
- excess collagen production
- hyperthrophic scare: large, red, raised, hard
- restricted to wound edges
What are keloids?
- Scar tissue with greater protrusion beyond wound edges
- hereditary disposition
- more often in darker skin
- fibroblasts produce excessive collagen
How to assess exudate based on amount?
What is epithelia tissue?
- new surface skin tissue
- Pale pink, white silver
- Dry
- Very fragile
What is slough?
- Dead tissue
- Stringy
- May adhere to wound base
- White, grey, brown, yellow, or beige
- Wet
What is the diff b/w undermining and tunneling?
undermining: from wound margins and beneath
