Wound Assessment and Documentation Flashcards
• Differentiate between primary, secondary and tertiary wound healing.• Describe the three phases of wound healing(inflammatory, proliferative, maturation).• Define wound types• Discuss wound management and assessment• Discuss evidence-based practice approaches topromoting wound healing
What are Primary Wounds?
(intentional wounds)
* Tissue surfaces have been approximated;
there is no or minimal tissue loss, includes:
* Superficial Wounds
* Closed Surgical Incisions
* Wounds Joined by Adhesive ‘Glue’
* Healing Time (predictable) 4 -14 days
* Minimal Scarring
what are Secondary wounds?
(unintentional)
- Greater tissue damage, loss
- Edges not easily approximated
- Delayed healing time
- Scarring
- More chance of complications; infection
- Pressure injury, traumatic injury, burns,
dehisced surgical wounds
What are Tertiary wounds?
- Wounds that are left open for 3-5 days to allow fluids or infection to drain
- Are then closed with sutures, staples or adhesive skin closures
what are the Phases of wound healing?
- Haemostasis &
Inflammatory phase - Proliferative phase
- Maturation & Remodeling phase
What is the Inflammatory phase?
- Starts immediately after injury & lasts 3-6 days.
- Removes debris & prepares for new tissue:
- Haemostasis
- Blood supply increases
- Phagocytosis
Clinical Observations Can Include the Following:
* Pain
* Redness
* Swelling
* Heat
* Exudate (clear)
what is the Proliferative phase?
- Second phase; from day 3 to day 21 post injury.
- Laying down of new cells, connective tissue:
- Fibroblasts synthesize collagen & deposit fibrin
- Capillary formation & increased blood supply
Clinical Observations:
* Wound appears beefy, red, moist = granulation tissue
* Fragile tissue that bleeds easily = Angiogenesis
* Wound paler, tissue is thin, pink = epithelialisation
What is the Maturation Phase?
- Occurs from around day 21 up to 1-2 years after the injury.
- Strengthening and reorganising collagen fibers:
- New tissue continues to grow and develop
- Normal blood supply recreated
- Scar formation and wound contraction
What are some Types of wounds (do not need to name all)
- Abrasions
- Lacerations
- Pressure
injuries - Skin tears
- Suture lines
- Burns
- Surgical Wounds:
suture lines, drains - Ulcers- Venous,
Arterial Wounds - Pressure Ulcers
What are the components of wound assessment?
- Type of wound
( Acute or Chronic) - Aetiology (cause)
( Surgical, ulcer, burn) - Location
- Surrounding skin
(Dry, tissue paper) - Wound edge
(Macerated, Dry, Raised) - Exudate
- Pain
- Odour
- Measurement and dimensions
what is Acute and what is Chronic
Acute
* Primary intention or
secondary intention
* <4 weeks
Chronic
* Chronic
* Secondary intention
* Normal healing disrupted
* >4 weeks
Name some Surrounding skin and wound edge characteristics
- Dry and Flakey
- Oedema
- Blistered
- Bruised
- Fragile
- Calloused
- Wound Edge
- normal, rolled,
- ‘punched out’, raised
- Macerated
- Undermining
What is the wound appearance for Viable tissue (healthy)
Granulation:
* Ruddy (reddish)
* Beefy, bumpy, lumpy,
* Firm (attached)
* Pebbled (whitish spots)
* Moist
* Shiny
* Fragile
Epithelialisation:
Pinkish,
Tissue is thin, shiny,
translucent
What is Infected wound appearance
- Persistent redness, swelling,pain
- Viscous
discharge,
yellowish/green
Malodorous
What is Non Viable tissue wound apearance?
Slough:
* Comprised of multiple
elements
* Firmly attached or loose
* ‘chicken fat’
* Creamy/yellow
* Slimy, stringy, clumpy,
gelatinous, fibrous
* Moist
* Thick & sticky (viscous)
* Slows healing; potential site
for microorganism g
Necrosis:
* Dead tissue
* Adheres firmly to wound
* Hard and leathery OR soft & wet
* Black, brown, tan
* Slows healing
* Full thickness tissue destruction
Eschar – dry, dark scab of dead tissue
What are the skin tears classification
Type 1= No skin loss
Type 2= Partial flap loss
Type 2 = Total flap loss
