wound care Flashcards
how can wounds be classified?
- the underlying cause
- the duration of healing
- depth of tissue affected
what is a superficial wound?
only the epidermis is involved
what is a partial-thickness wound?
wound extends into the dermis
what is a full-thickness wound?
extends to the deepest layer of tissue involving the subcutaneous tissue and sometimes even the fascia and underlying tendons such as muscle, tendon or bone
explain haemostasis in wound healing
hemostasis is the rapid response to physical injury and is necessary to control bleeding. involves vasoconstriction, platelet response and biochemical response
what is tissue repair and regeneration in wound healing?
involves 3 phases:
1) inflammation phase (0-4 days):
2) reconstruction phase (2-24 days)
3) maturation phase (24 days - 1 year)
explain the inflammation phase of wound healing
body’s normal response to injury. activates vasodilation leading to increased blood flow causing heat, redness, pain, swelling and loss of function. wound exudate may be present and this is also normal body response
explain reconstruction phase (proliferation) of wound healing
the when the wound is healing. the body makes new blood vessels, which cover the surface of the wound. this phase includes reconstruction and epithelialization. wound becomes smaller as it heals
explain the maturation phase of wound healing
the final phase, when scar tissue is formed. wound is still a risk and should be protected where possible
what are some factors delaying wound healing?
- nutrition deficiency, inadequate blood supply, smoking, corticosteroids, infection, anemia, advance age, obesity, diabetes, poor overall health, friction over wound, cold temperatures, excessive moisture
what are contractures?
contraction is a part of the healing process; however, it can become excessive resulting in a deformity or contracture. shortening of muscle or scar tissue, especially over joints, results from excessive fibrous tissue formation (more common in burns)
what is dehiscence?
separation of previously joined wound edges due to infection, weakness of granulation tissue from a fluid pocket between the tissue layers or obesity
what is evisceration?
occurs when wound edges separate to the extent that intestines protrude through the wound
what is excess granulation?
excessive tissue growth that interferes with epithelialization and wound healing
what is a fistula?
abnormal passage that forms between organs or hollow organ and the skin
what is involved in a wound assessment?
type of wound, etiology of wound, location and appearance of surrounding skin, tissue loss, appearance of the wound bed, stage of healing, measurement and dimensions, exudate, presence of infection and pain
what is exudate?
it is produced by all acute and chronic wounds as part of the natural healing process. it contains nutrients, energy and growth factor for cells, has high quantities of WBCs, cleanses the wound, maintains a moist environment and promotes epithelialisation
what are signs of infection in a wound?
redness
exudate
localised heat
edema
what is primary intention of healing?
healing occurs when margins of the wound fit neatly together
what is secondary intention of healing?
healing occurs when wounds have wide or irregular margins that can’ be approximated
what is tertiary intention?
healing occurs when a wound is intentionally left open because if it is closed, contamination may be trapped, edema may be present or there is poor circulation
what is the goal of wound cleansing?
remove visible debris and devitalised tissue, remove dressing residue
remove excessive or dry crusting exudate
reduce contamination
what are the principles of wound cleansing?
aseptic technique, cleanse in a way that minimized trauma, cleanse the wound using an irrigation method
when is gauze used?
on infected wounds, wound that require packing, wounds that are draining, wounds needing frequent dressing changes
what are the pros and cons of gauze?
pros: conforms to the wound well, can stay in place for a week, prevents friction against wound bed, keeps wound bed dry and prevents bacterial contamination of the wound
cons: may stick, not suitable for heavy draining
what are foam dressings?
they are non-occlusive and less likely to stick to wound beds
what are pros and cons of foam dressings?
pros: comfortable, won’t stick to wound bed, highly absorbent
cons: may require a secondary dressing to hold the foam in place, if not changed enough can promote periwound maceration
what are hydrocolloid dressings?
very absorbent, contains colloidal particles that swell into a gel-like mass when they come in contact with exudate. promotes debridement, provides insulation to the wound bed, is waterproof and impermeable to bacteria, urine and stool.
what are the pros and cons of hydrocolloid dressings?
pros: encourages autolytic debridement, provides insulation to the wound bed, waterproof and impermeable to bacteria, urine, stool
cons: leave a residue present in the wound bed which may be mistaken for infection
what are hydrocolloid dressings used for?
burns, pressure ulcers, venous ulcres
what are foam dressings used for
pressure ulcers, minor burns, skin grafts, diabetic ulcers, venous ulcers
what are alginates dressing?
extracted from seaweed. form a gel when they come in contact with exudate. can be used when infection is present
what are alginate dressings used for?
venous ulcers, wounds with tunneling, wounds with heavy exudate
what are the pros and cons of alginates dressings?
pros: highly absorbent, may be used when infection is present, non-adherent, encourage autolytic debridement
cons: always require a second dressing, may cause desiccation of the wound bed, as well as drying exposed tendon, capsule or bone
