Wound assessments Flashcards
What is the first phase of wound healing and what occurs during it?
Hemostasis
Thrombin converts fibrinogen to fibrin, leading to coagulation from dilated vessels
Lasts for 0-2 days
What is the second phase of wound healing and what are signs of this?
Inflammatory Phase
Pain, redness, heat, swelling, and loss of function at the injury site.
From 2 to 4 days
What is the third phase of wound healing and what occurs during it?
Proliferative Phase
Rebuilding tissue through granulation, wound contraction, and epithelialization
From 4 to 21 days
What is the fourth phase of wound healing and what happens during it?
Maturation Phase
It strengthens the wound, even after it appears healed.
Can last up to 2 years
What is involved in wound assessments?
*Assessment the Whole Person
*General condition of the patient
*Medical and surgical history (diabetes, poor circulation)
*Contributing factors that may impair healing (age, chronic illnesses, medications, and lifestyle choices etc)
*Pain
*Wound Assessment and Plan (Size, depth, appearance, drainage, and signs of infection)
What does dry eschar and/or black necrosis indicate in a wound?
*May indicate necrosis and typically needs debridement
*Dead tissue that appears black, often indicating a lack of blood supply
What is yellow slough?
A soft, yellow tissue that may be necrotic and is often a sign of infection or tissue breakdown
What is granulation tissue?
New tissue that forms during wound healing, characterised by a pink or red color and a bumpy texture.
What does epithelising tissue indicate in a wound bed?
The process of new skin cells forming over the wound, indicating healing is progressing
What should be the main aim of a wound dressing?
Debride
Donate Moisture
Reduce bacterial burden
Absorb Moisture
Protect New Tissue
What are the principles in wound care to fill dead space?
*Dead space must be filled with dressing
material to ensure that wound closure is
delayed until the space has been replaced with
granulation tissue:
*Cavity
*Undermined tissue
*Tracts
*Make sure you can get it out in one piece!
