WOUND ASSESSMENT Flashcards
Wound healing when vessels constrict and induce clotting factors for temporary bacterial barrier.
Hemostasis
Wound healing when vasodilation occurs to allow entry of leukocytes and plasma for cell clean up. Edema, Erythema, and Exudate.
Inflammatory
Wound healing Epithelization begins forming new granulation tissues. Capillaries and collagen are also created to reduce wound site by contraction.
Proliferative
Wound healing when collagen is remodeled to provide strength to the wound, appearing to be a well-healed scar.
Maturation/Remodeling
Factors of wound healing
- Perfusion and oxygenation hindrance.
- Nutritional Status.
- Diabetes mellitus
- Corticosteroid medicines.
- Age
Type of healing
Clean, uninfected, linear, scanty graulation, and minimal tissue loss.
Closed immediately
Primary Intention
Type of healing
Unclean, infected, irregular margin, exuberant, with tissue loss.
Left opened for scar formation
Secondary Intention
Type of healing
Wound is not closed to wait for inflammation or edema to subside.
Delayed primary intention or closure
Tertiary Intention
What to assess in the wound bed?
Tissue type, exudates, and infection.
Black or brown tissue representing full destruction.
Necrotic
Yellow or cream colored with a purulent discharge.
Sloughy
Red tissue with increasing amount of blood vessels.
Granulating
Closing of the wound can be observed with tissue formation.
Epithelializing
How to describe an exudate?
Level: Dry, low, medium, and high
Type: Thin/Watery, thick, cloudy, Purulent, and pink/red
Types of wound edge?
Maceration, dehydration, undermining, and rolled edges.
