Wound Flashcards
Wound
Is a damaged soft tissue or skin
How does the wound occur
It occurs as a result of trauma and tissue trauma maybe because of
1. Cuts
2. Blows
3. Poor circulation
4. Strong chemical
5. Excessive heat or cold
Wound classification based on (ccd)
- Causes ( intentional , unintentional )
- Cleanliness ( contaminated or infected )
- Depth ( superficial , partial , thickness or full thickness )
Body wound are either
Intentional : occurs during therapy ex. Operation
Unintentional : accidental fracture an arm in an automobile collision
Closed wound ;
Tissue are traumatised without a break in the skin
Open wound :
When the skin is open
Types of wounds
Open
Closed
Surgical
Open wounds
A wound in which the surface of the skin is no longer intact it may be intentional such as an incision by surgeon or unintentional by accident
Type of open wounds (iLA-UP)
- Incision wounds
- Laceration wounds
- Abrasion wounds
- Ulceration wounds
- Puncture wounds
Incision wound
A clean separation of skin and tissue with smooth even edges cause by sharp instruments can be shallow or deep
Laceration wounds :
A separation of skin and tissue in which the edges are torn and irregular
Abrasion wounds :
A wound in which surface layer of the skin are scraped away could be intentional or unintentional
Ulceration wounds
A shallow crater in which skin is missing
Puncture wounds
Penetration of skin and often the underlying tissue causes by a sharp instrument intentional or unintentional
Closed wounds
One in which there is no opening in the skin or mucus membrane
How closed wounds occur
Due to blunt trauma or pressure
Types of closed wounds
Contusion wounds
Contusion wounds
Injury to soft tissue underlying the skin from the force of contact with a hard object sometimes called a bruise because of damaged blood vessels
Surgical wounds
Results from incising tissue with a laser or instrument called a scalpel
Surgical care involves :
Use of dressing
Caring for drains
Removing suture or staples
Applying bandages
Administration of irrigations
Wound repair is dependent on
- Magnitude of tissue damage
- The integrity of the skin
- Regen or scar formation
Resolution
A reparative process in which cells that are slightly injured recover and reestablish their normal function
Regeneration
Occurs when some cells are destroyed and duplicates are produced to take their place
Scar formation
When cells are extensively destroyed and there is no potential for regeneration the integrity is restored by replacing it with scar tissue
Healing is referred to as
Regeneration of tissues
The ______ of healing are the same for all wounds
Phases
The rate depends on factors including :
- Type of healing
- Location
- Size
- Health of client
Phases of healing
- Inflammatory
- Proliferative
- Maturation or remodeling phase
Inflammatory phase
• Starts after an injury immediately
• Lasts 3-6 days
• there are two major process occur in this phase called hemostasis( stopping of bleeding ) which results from Vado contraction of large blood vessels in the affected area
• phagocytosis cells engulf microorganisms other cells or foreign bodies
Proliferative phase
• lasts from 3-4 to 21 post injury
• collagen begin to synthesise
• granulation tissues start to grow
Maturation phase :
• starts by 21 day and can extend to 2y
• fibroblasts continue to make collagen
Goals of wound care
- Removal of necrotic tissue to promote wound healing
- Prevent , eliminate , control infection
- Absorb drainage (exudates )
- Maintain a moist wound environment
- Protect the wound from further injury
- Protect the surrounding skin from infection and trauma
Complications of wound healing
- Infection : become apparent 2-11 post op
- Haemorrhage : normal when some escape of blood from wound when abnormal caused by dislodged clot ,slipped stitch , erosion(تاكل)of blood vessels
- Dehiscence : factors : obesity , poor nutrition, multiple trauma , failure of suturing , excessive coughing , vomiting and dehydration , occur 4-5 day post op
Dressing a wound
The process of applying a protective sterile to a wound and giving a necessary care by using a septic technique when used
Purposes of wound dressing
- Keep the wound clean
- Control bleeding
- Protecting the wound injury
- Maintaining a moist environment
- Asses the healing process by keeping edges of wound in close approximation
- Absorb drainage or discharge from a wound
Drains
Tubes that provide means for removing blood and drainage from a wound
Types of drains
Open
Closed
Debridement
Physical removal of affected tissue by debridement is the most effective method of cleaning the wound
Infected tissue is best removed by
Surgical debridement
Methods of debridement includes
Chemical
Enzymatic
Mechanical
Autolytic
Pressure ulcer
Specific tissue injury caused by an impairment in blood supply or any lesion caused by unrelieved pressure resulting in damage to the underlying tissue
Common sites of ulcer
- Bony Prominences of the low spine
- Posterior pelvis
- Hips
- Heels
- Elbows
- Shoulders
- Ear and back if head
Why tissue in that area is more vulnerable
Because they have less body fat to act as a pressure - absorbing cushion
Factors developing ulcer sores
- Pressure
- Friction
- Shearing
- Moisture
Risk for development of ulcer sores
- Inactivity
- Immobility
- Malnutrition
- Dehydration
- Sedation
- Vascular disease
Pressure sore stages
4 stages
S1
Cellular damage has occurred if skin is not able to resume its normal colour when pressure is relived
S2
• Blistering or a shallow break in skin (skin tear)
• impairment of skin may lead to colonisation or infection
S3
• serous drainage from leaking plasma or purulent drainage
• white or green tinged fluid caused by wound infection
• area is painless
S4
• tissue is deeply ulcerated exposing muscles and bones
• dead tissue may produce a rank odor
• local infection which is the rule rather than infection easily spreads through the body causing a fatal condition as sepsis
Client education
- Assessment of pressure ulcer
- Managing tissue kids
- Ulcer care
- Bacterial colonisation and infection
5 operative repair of pressure ulcer
