WOUND AND WOUND CARE Flashcards
two types of wound according to intent
intentional
unintentional
two types of wound according to skin surface
open wound
closed wound
Result of planned therapy or treatment that requires
invasive measures ; edges are clean and bleeding is controlled ; risk of infection is decreased ; ex. surgical incisions, IV, punctures
intentional wound
accidental, occurs from unexpected trauma ; jagged edges and bleeding is uncontrolled ; high risk for infection and longer healing time ; ex. accidents, burns
unintentional wound
classfications of wound according to possibility and degree of contamination
clean wound
clean contaminated
contamined
dirty or infected
uninfected wound in which minimal inflammation is
encountered ; not enter respi, alimentary, genital, and urinary tracts ; close wounds
clean wounds
surgical wound which enter respi, alimentary, genital, and urinary ; no evidence of infection
clean contaminated wound
open, fresh, accidental, or surgical wound involving a
major break in sterile technique or with a major
contamination from the gastrointestinal system ; inflamed tissue and high risk for infection
contaminated wound
wound containing dead tissue and with evidence of clinical infection
dirty or infected wound
confined to skin (epidermis an dermis) and heals by regeneration
partial thickness
involves dermis, epidermis subcu, and possibly muscle and bone ; requires connective tissue repair
full thickness
classification of wound according to healing time
acute
chronic
what are the 2 classfications of wound
partial thickness
full thickness
this type of wound usually hels within days to weeks, edges are well approximated ; risk for infection is lessened
acute wound
do not progress through normal sequence of repair ; edges are not approximated ; infection is increased ; healing time is delayed
chronic wound
it is an open wound, edges in close approximation and aligned ; cutting by sharp instrument
incision
open wound ; tissues are torn and edges are jagged ; blunt instrument, machinery
laceration
open wound ; rubbing or scraping the epidermal layer of the skin
abrasion
open wound, penetration of the skin and often underlying tissues by a sharp instrument such as a needle
puncture
it is an open wound ; penetration of the skin and undelying tissues usually unintentional
penetrating wound
open wound ; tearing a structure from normal anatomic position causing possible damage to blood vessels, nerves and other structures
avulsion
close wound ; results in soft tissue damage and ruptured blood vessels ; blow from a hard object
contusion or bruise
open or closed wound ; secretion and release of toxins by living organisms
microbial
open or closed wound ; chemical agents such as acids
chemical
open or closed wound ; extremely high or low temperature
thermal
open or closed wound ; ultraviolet light or radiation exposure
irradiation
what are the 4 phases of wound healing
hemostasis
inflammation
proliferation or granulation
remodeling or maturation
it is a process of tissue response to injury ; injured tissues are repaired by physiologic mechanisms that regenerate functioning cells and replace connective tissue cells with scar tissue
wound healing
type of healing that occurs where the tissue surfaces have been approximated and there is minimal or no tissue loss ; formation of minimal granulation and scarring
primary intention healing
For wound that is extensive and involves considerable tissue loss and in which edges cannot or should not be approximated ; closure is undesirable due to poor circulation ; wounds are sutured after the initial stage ; ex. pressure ulcer
secondary intention healing
for delayed or secondary closure or late closure ; reason to delay suturing a wound or whe primary closure or a wound is undesirable
tertiary intention healing
the phases of wound healing
inflammatory
reconstruction
maturation
Vascular and cellular responses are immediately initiated when tissue is cut or injured ; transient vasoconstriction ; dilation of small venules ; localized vasodilation ; lasts 1-5 days
inflammatory
fibroblasts multiply ; endothelial budding occurs ; granulation tissue ; active collagen synthesis ; by 3 weeks skin obtains 30% of preinjury tensile strength ; lasts 2-20 days
proliferation
scar tissue ; lysis and regeneration ; formation of scar ; collagen production drops off ; normal maturation ; lasts 21 days
maturation phase
The physiological changes ; reduced skin elasticity and collagen replacement
age
drugs that reduce healing rates by interrupting cell division or the clotting process.
immunosupression
impairs wound healing by diminishing sensation and arterial inflow
diabetes
bacterial contamination
infection
steroids and antimetabolites impede proliferation or fibroblasts and collagen synthesis
drugs
protein calorie malnutrition and deficiencies of vitamins
nutritional problems
resulting from local or systemic ischemia or radiation injury,
impairs wound healing.
tissue necrosis
Inadequate tissue oxygenation due to local vasoconstriction resulting from sympathetic overactivity may occur because of blood volume deficit, unrelieved pain, or hypothermia,
especially involving the distal extent of the extremities.
hypoxia
this leads to local tissue ischemia and necrosis
excessive wound edges
Competition between several healing areas for the substrates required for wound healing impairs wound
healing at all sites.
another wound
relatively low tissue temp in distal aspects of the upper and lower extremities
low temprature
oxygenation and tissue perfusion
smoking
Bleeding from an acute wound is normal during
and immediately after initial trauma but
hemostasis, which is cessation of bleeding by
vasoconstriction and coagulation usually occurs
within several minutes.
hemorrhage
symptoms of internal bleeding are
hypovolemic shock
swelling of the affected body part
a collection of clotted blood,
is a localized collection of blood
underneath tissues, often reappearing as a
bluish swelling or mass.
hematoma
Bacterial wound infection inhibits healing
by increasing tissue damage and altering
healing process ; symtoms include purulent drainage, increased drainage, pain, redness, swelling
infection
It is the partial or total separation of layers
of skin and tissue above the fascia in a
wound that is not healing properly ; When
serosanguineous drainage increases from a
wound
dehiscence
It occurs when wound layers separate
below the fascial layer and visceral organs
may protrude through the wound opening ; medical emergency which requires placement of sterile towels soaked in sterile saline
evisceration
an abnormal passage from an internal
organ to the skin or from one internal
organ to another ; can result from wound healing problem
fistula
