wound care Flashcards
Stratum corneum
the outermost layer on skin
stratum lucidum
the second layer
Stratum granulosum
the third layer
Stratum spinosum
the 4th layer
Stratum germinativium
the inner most layer of the skin
when does granulation tissue form
during wound healing
what is granulation tissue
the new skin that grows during the healing process
Partial thickness wound
limited to epidermis
Full thickness wound
total loss of skin layer
4 phases of wound healing
homeostasis, inflammatory, proliferative, maturation
Homeostasis
-right after the injury
-clots form to seal off blood vessels
-platlets
-release growth factor and begin repair
inflammatory
- Redness, swelling, warmth
- Not infection
- This is 1-4 days after
- Neutrophils, macrophages, monocytes
- Laborers clean up the sit (random with no specific job)
proliferative
- Pebbled red tissue
- 4-21 days after
- Macrophages, pericytes, lymphocytes, angiocytes, neurocytes, fibroblasts, keratinocytes, epithelial
- Now we have our very distinct labors (plumbers, framers) here to do their job
- Fill defect, re-establish skin function, closure
Maturation
- Remodelling stage
- 21-years
- Scar tissue
- Deep pink
- Fibrocytes and blasts, building tissue strength
- Remodel or mature the skin
- Tissue strength is only 80% of the old skin
healing can be delayed by
infection
-poor tissue
-poor nutrition
-smoking
-obesity
-medication
-chemo
-immunosuppressants
-NSAIDs
treatment goal for wound healing
maintain moisture balance (not too moist)
-Prevent infection
-protect surrounding skin
-reduce pain
-minimize odor
Wound round
the edges of the wound
analogy
the collagen is remodelled to become stronger. A scar may form. the tissue strength is only 80% of the old skin
primary intention
- wound healing occurs when the edges of a clean surgical incision remain close together, tissue loss is minimal or absent
secondary intention
wounds that are open and have tissue loss. Granulation tissue gradually fills in the area of the wound. Skin loss is present
3rd intention
the wound is purposely left open for 3-5 days to allow edema or infection to decrease and then the wound edges are sutured or stapled shut
venous ulcers
above ankle, medial lower leg
Arterial ulcers
lower leg dorsum, foot, lateral border or foot, toe joint
Neuropathic ulcers
plantar surface, lateral border of foot
When doing a wound assessment note:
location, odor, size, undermining, tunnelling, wound base appearance, temp, peri wound
Laceration wound
a cut, jacked edge
Abrasion wound
scratch surface of skin
contusion
bruise
hematoma
collection of blood
tunneling
A separation of the fascial planes leading to sinus tracts
Usually involves a small % of the wound margins
Usually narrow and long, and seems to have a destination
Undermining
Usually involves a greater % of the wound margins, with more shallow length than tunnelling
Usually involves subcutaneous tissues
An erosion under the edge of the wound
hyperkeratosis
when a wound edge is callus like
maceration
softening of tissue by fluids
exudate terminology
scant, moderate, large, copious
Colours of exudate
serous, sanguineous, serosanguineous, purulent
Serous
light yellow to clear
sanguineous
bright and fresh
Serosanguineous
light red or pink
Purulent
thick, yellow, green, tan, brown
granulation tissue
The growth of small blood vessels and connective tissue into the wound cavity
what does healthy granulation tissue look like
bright, beefy red, shiny, and granular with a velvety appearance
A pale granulation tissue indicates
ischemia, infection, or a co-morbidity such as anemia
Hyper granulation tissue
A building up of tissue that prevents epidermal migration or resurfacing across the wound, by proliferating above the intact margins of the skin
-excessive moisture
Necrotic tissue
physical barrier to granulation, can harbour bacteria
slough
Indicates less severity
Yellow to tan mucinous or stringy material
Loosely adherent to wound bed
If non-adherent will be scattered through out wound
Eschar
Indicates deeper tissue damage
Black, gray, brown in color
Usually adherent or firmly adherent
May be soggy and soft or hard and leathery
Smell of necrotic tissue
foul
Smell of pseudomonas
sickening sweet with blue and green exudate
wound irrigation PPE
-face shelf and mask and gloves
stage 1 pressure ulcer
non blanching erythema with intact epidermis
Stage 2 pressure ulcer
partial thickening ulcer involving epidermis and dermis
stage 3 pressure ulcer
full thickness extending through dermis into subcutaneous tissue
Stage 4 pressure ulcer
deep tissue destruction extending through fascia may involve muscle bone tendon
unstageable pressure ulcer
depth of injury unknown to presence of necrotic tissue and eschar
Pressure ulcer prevention
Encourage or assist with position changes, at least every 1–2 hours.
Avoid prolonged moisture; protect skin from urine, stool or wound drainage if present.
Utilize specialized mattresses, pads or cushions to relieve and redistribute pressure.
Maintain tissue integrity with a well balanced, protein-rich diet.
what is the sterile border
1 inch
when cleaning a wound what should be cleaned first
inside then outside
what happens if drainage accumulates in the wound bed
wound healing is delayed
Open drain
drain fluid on to a gauze pad or into a stoma bag (ex Penrose)
Closed drains
The collection device is connected to a clear plastic drain with multiple perforations. Drainage collects within a closed reservoir or a suction bladder.
Drainage collects in a closed reservoir or a suction bladder
When to change closed drain
when bag is half full
How much can a JP drain hold
100 to 200 mL/24 hr;
How much can a Hemovac drain hold
500mL/24hr (Accordion looking)
serous
clear, watery. normal of healing
serosang
pale, pink, water, mix of clear and red
sang
Bright red, recent or active
Purlent
Thick, yellow, green, foul odour infection
Documenting drainage
Document emptying or re-establishing of vacuum in suction device; amount, colour, and odour of drainage; dressing change to drain site; and appearance of drain insertion site.
Document amount of drainage on intake and output (I&O) record.
Document to the health care provider a sudden change in amount of drainage, either output or absence of drainage flow.
Also report to the health care provider pungent odour of drainage or new evidence of purulence, severe pain, or dislodgment of the drainage tube.
