Wound Care Flashcards
Principles of wound healing
- intact skin is the first one a defense against microorganisms
- carful hand hygiene is used in caring for a wound
- the body responds systematically to trauma of any of its parts
- adequate blood supply is essential for normal body response to injury
- Normal healing is promoted when the moon is free of foreign materials
- extent of damage and the persons state of health affect wound healing
- Response to wound is more effective and proper nutrition is maintained
Health status that delay wound healing
Corticosteroids and postoperative radiation therapy
Tissue repair
1) primary intention
- best healing
- clean, surgical incision
2) secondary invention
- edges do not close, heals from inside out
- jagged edge, no surgery, takes longer
3) tertiary intention
- delay in surgical suturing, but is eventually sutured
- May have an infection that needs draining before canned suture
Phases of wound healing
1) Hemostasis
2) inflammatory
3) proliferation, reconstruction, or granulation phase
4) maturation or wound remodeling phase
Hemostasis
- occurs immediately after initial injury
- involved blood vessels constrict and blood clotting begins
- exudate is formed, causing swelling and pain
- increased perfusion results in heat and redness
- platelets stimulate other cells to migrate to the injury to participate in other phases of healing
Inflammatory phase
- follows Hemostasis and last about 4-6 days
- WBC move to wound
- macrophages enter area and remain for an extended period
• they ingest debris and release growth factors that attract fibroblast to fill in the wound - generalized body response
Proliferation phase
- begins within 2-3 days of injury and may last up to 2-3 weeks
- New tissue is built to fill the wound space through the action of fiber blast
- capillaries grow across the wound
- thin layer of epithelial cells form across the wound
- granulation tissue forms the foundation for scar tissue development
Maturation or remodeling phase
- final stage; begins about 3 weeks, months and up to 2 years after injury
- collagen is remodeled
- new collagen tissue is deposited
- scar becomes a flat, thin, white line
Local factors affecting wound healing
Pressure Desiccation ( dehydration) Maceration (over hydration) Trauma Edema Infection Excessive bleeding Necrosis ( death of tissue) Presence of biofilm ( thick grouping of micro organisms)
Wound dehiscence
Wound separate
Evisceration
Protrude out
Assessment of wound drainage
Serous- clear
Sanguineous- contain RBC, fresh blood, full thickness wound
Serosanguinous- thin, watery, pale, red-pink color
Purulent- contain pus, cloudy, yellow- tan color
Exudate
Accumulation of fluid, dead tissue cells, WBC
Wound assessment
- inspect for sight and smell
- palpating for appearance, drainage, and pain
- types of exudate/ drainage
- sutures, drains or tubes and manifestation of complications
Presence of infection
- wound is swollen
- wound is deep red in color
- wound feels got on palpation
- drainage is increased and possibly purulent
- foul odor
- edges may be separated, with dehiscence present
Factors affecting the response to hot and cold treatment
- method and duration
- degree of heat or cold
- patients age / physical condition
- amount of body surface covered
Effects of applying heat
- dilates peripheral blood vessels
- increase tissue metabolism
- reduce blood viscosity and increase capillary permeability
- reduce muscle tension
- helps relieve pain
Effects of applying cold
- constructs peripheral blood vessels
- reduces muscle spasms
- promote comfort
C diff
- seen largely in older adults
- symptomatic and asymptomatic reservoir
- prolonged antibiotics kill “ helpful” bacteria in intestine the c diff grows
- watery diarrhea, fever, abnormal cramps
Preventing c diff
- avoid use of hard to clean equipment
- disinfect care items between patients
- PPE
- hand hygiene- soap and water, not killed by alcohol
- keep environment clean
- educate health care provider
Multi drug resistant organisms
- prevent infections, thereby preventing the spread of resistance
- Tracking
- improving antibiotic prescribing/stewardship
- develop new drugs and diagnostic test
Airborne precautions
- infection spread via air( TB, rubeola, varicella)
- Private room
- monitor negative air pressure
- 6-12 Air changes per hour
- monitored filtration if air recirculated
- door closed, patient stays in your room
- if the patient comes out of room must have on surgical mask
Droplet precautions
- spread in large droplets
- private room if available door may be open
- if patient must come out room must wear surgical mask
- PPE and keep visitors 3 feet from patient
Contact precautions
- spread by direct or in direct contact with patient or patient’s environment
- used with multi drug resistant organisms
- limit movement out of the room
- avoid sharing patient care equipment
