WOUND CARE Flashcards
Acute wound
intentional or uninentional
closed wound
no break in skin
open wound
break in skin
3 conditions associated with chronic wounds
venous disease, arterial disease, neuropathic disease
True or false? surgical wounds are acute and intentional.
true.
4 classifications of surgical wounds
clean
clean-contaminated
contaminated
dirty
What causes moisture-associated skin damage?
skin exposure to irritants
can moisture-associated skin damage lead to pressure injuries?
yes
combination of friction and pressure commonly associated with Fowler’s positon
shearing forces
excoriation
secondary to fecal matter and being wet, exudate, deep skin folds, etc
maceration
think of the ceviche, the soaking in acidic fluid caused the food to macerate (cook) except we don’t want our skin to cook
3 pressure related factors
pressure intensity, pressure duration, tissue tolerance
Stage 1 pressure ulcer
nonblanching, discloration, skin texture and color inconsistent with surrounding skin
Stage 2 pressure ulcer
partial thickness skin loss. pink or red tissue viable in wound bed. tissue is moist, deeper tissues are not visible. may have serum-filled blister
True or False : stage 2 should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation
true
stage 3 pressure ulcer
full-thickness skin loss, visible fat, granulation tissue may be present, wound edges may be rolled, dead tissue may have formed, slough may be present, undermining and tunneling may be present
Stage 4 pressure injury
muscle, fascia, tendons, ligaments, cartilage and/or bone is visible
Which stage of pressure injury usually requires surgical repair?
4
When are DTPI (deep tissue pressure injuries) and ulcers unstageable?
when the base of the wound is not visible due to eschar in the wound bed, when there is a mucosal membrane pressure injury
hemostatic/inflammatory phase of wound healing
lasts up to 5 days. exudate and edema should decrease. scab forms protective barrier so that phagocytosis can occur underneath. in a clean wound, this phase establishes a clean wound bed.
when can staples be removes?
day 9-14.
proliferative phase of wound healing
Granulation tissue matures. vascular bed is re-established. collagen added to injury site to strengthen tissue. from 5 days to 14 days.
Maturation/ remodeling phase
begins day 21 and can last over a year. this is where keloids can form in individuals who have an abnormal amount of collagen formation.
complications of wound healing
hemorrhage, hematoma, infection, dehiscence, evisceration
what to do in the event of evisceration
have client flex knees, cover area with a sterile saline soaked dressing
risk factors for dehiscence/evisceration
obesity, poor surgical technique, poor nutrition, mulitple trauma, suture failure, excessive coughing, infection, vomiting, dehydration. mortality rate 30%
Wound irrigation : clean or sterile technique?
sterile, required due to break in skin integrity.
4 types of wound debridement
mechanical, autolytic, chemical, sharp/surgical
