Wound Flashcards
ischemia
deficiency of blood supply to tissue
reactive hyperemia
bright red flush that skin take on after it has been compressed
flush = vasodilation → xtra blood rushed to area to bring nutrients
Redness stays = tissue damage
Redness disappears = no tissue damage
maceration
tissue softened by prolonged wetting or soaking
makes epidermis more eroded and susceptible to injury
excoriation
a.k.a “denuded area”
loss of superficial layer of the skin
primary intention healing
approximated
tissue surfaces have approximated and there is minimal tissue loss
formulation of minimal granulation and scarring
secondary intention healing
wound is extensive, involves considerable tissue loss - edges cannot or shouldn’t be approximated
- repair time is longer than primary intention
- ↑ scarring
- ↑ risk for infection
tertiary intention
a.k.a. delayed primary intention
wound left open for 3-5 days to allow for drainage (edema, infection, exudate)
then closed with sutures, staples or adhesive wound closures
serosangnuineous drainage
pink, watery fluid, a mixture of serous and sanguineous
blood-tinged drainage
exudate
fluid & cells that have escaped from blood vessels during inflammatory phase and deposited on tissue surface or inside tissue
purulent exudate
pus
suppuration
pyogenic bacteria
purulent exudate - thicker than serous exudate b/c of presence of pus
pus - consists of leukocytes, liquified tissue debris, dead and living bacteria
suppuration - pus formation
pyogenic bacteria - pus producing bacteria
hematoma
localized collection of blood underneath the skin
may appear reddish blue swelling (bruise)
dehisence
partial or total rupturing of a sutured wound
- usually abdominal where layers of skin can separate
- most likely occurs 4-5 days post-op sudden straining (coughing, sneezing) may precede it
- large sterile dressing soaked in NS should be applied
- place pt in bed w/ knees bent to ↓ pull on incision
Factors Affecting Skin Integrity
- genetics & hereditary
- age
- chronic illness (ie. poor circulation)
- treatments (surgery, IV lines)
- medications
- poor nutrition
Types of Wounds
How They Come About
Intentional: surgery, venipuctures
Unintentional: accidental trauma
How They Came About: Incision - sharp instrument Contusion - bruise from blunt instrument Abrasion - surface scrape Puncture - penetration w/ sharp object Laceration - tissues torn apart Penetrating Wound - penetration of the skin and underlying tissue ie. bullet wound, stabbing etc.
Types and Phases of Wound Healing
Types: primary, secondary, tertiary
Phases: inflammatory, proliferative, maturation
Inflammatory Phase
immediately after injury: lasts 3-6 days
- Hemostasis
- cessation of bleeding
- blood clots
- fibrin forms
- scab forms while epithelial tissue underneath protects wound from invasion by MO - Phagocytosis
- macrophage repairs injured blood vessels
Proliferation Phase
post injury, days 3 or 4 until day 21
- collagen synthesis strengthens wounds
- granulation tissue formation, capillary growth ↑ blood supply to wound and fibrin deposited
- wound is fragile, red and bleeds easily
- 2nd intention wound heals by granulation then epitheliazation. If epi… doesn’t occur, wound’s covered in eschar
Maturation Phase
From day 21 until 1-2 yrs post injury
- collagen organization
- wound remodels and contracts
- scar stronger
- scar shrinks over time
- overgrowth of collagen causes a hypertrophic scar called keloid
Types of exudate
serous: mostly serum, watery and few cells
purulent: thicker, suppuration, pus (WBCs, dead debris bacteria, color varies)
sanguineous: hemorrhagic, large # RBCs indicates sever damage to capillaries
Mixed exudate
serosanguineous: clear and blood-tinged drainage
purosanguineous: pus and blood new infected wound
