wound care Flashcards
Layers of epidermis
Stratum corneum
Stratum lucidum
Stratum granulosum
Stratum spinosum
Stratum basale
Basement membrane
Stratum corneum
o Tough outer layer – acts as primary barrier
o Promotes protection from mechanical and chemical injury
o Constantly sloughing
o Consists of dead keratinized cells (15-20 layers)
o Can indicate hydration
Stratum lucidum
o Transparent, thin, transitional layer
o Present only at “stress points” (palms, soles of feet)
Stratum granulosum
o Metabolically active
o Contain keratinocytes & Langerhans cells
Develops keratin
Important for immune function/macrophage activity
Stratum spinosum
o Contains desmosomes that function as a cell to cell junction
o “spiky” or “spiny” projections
o Also contains Langerhans immune cells
Stratum basale (basal layer)
o Innermost, most continuous layer of epidermis
o 1-3 layers of active keritanocytes (regenerates the epidermis)
o Merkel cells (touch receptors)
o Melanocytes (pigment production)
o Cells take 2-3 weeks to migrate from basal layer
o Rete ridges/rete pegs protrude downward into dermis
Anchor epidermis to dermis
Dermis contents
o Blood vessels
o Lymphatic vessels
o Nerve endings
o Appendages
Hair
Sebaceous glands
Sudoriferous glands
Nails
Dermis primary functions
o Thermoregulation
o Storage of water/maintaining hydration
o Provides nutrients and waste removal
o Houses epidermal appendages
o Assists with infection control
o Provides sensation
Dermis
thickest layer
papillary region
reticular region
Hypodermis
- Subcutaneous tissue
- Attaches skin to underlying bone and muscles
- Contains loose connective tissue, adipose, elastin
o Contains 50% of body fat - Insulation and shock absorption
- Pacinian cells and free nerve endings for cold and pressure
Keratinocytes
develop keratin
Langerhans cells
immune cells, fight infection, macrophage activity
Melanocytes
produce melanin, protects from UV radiation
Merkel cells
mechanoreceptors for light touch sensation
Phases of wound healing
inflammatory
proliferative
maturation
inflammatory phase
- Begins when the wound develops
- 4-6 days
- Edema, erythema, inflammation, pain
- Healing process triggering
- Immune system works to prevent microbial colonization
proliferative phase
- 2-24 days
- Angiogenesis: capillaries form buds and grow
- Granulation tissue fills in the wound
- Fibroblasts lay collagen in the wound bed, strengthening new granulation tissue
- Wound edges begin to contract (myofibroblasts)
- Epithelial cells migrate from the wound margins (epithelialization)
maturation phase
- 21 days to 2 years
o Greatest change in 6-12 months - Collagen fibers transform from immature type 3 to mature type 1 and reorient along lines of stress
- Length of time depends on patient and wound related complicating factors
- Filled-in wound is covered and strengthened
- Scar tissue forms
Primary intention
- Clean, straight line
- Edges well approximated with sutures
- Rapid healing
- Usually best cosmetic outcome
secondary intention
- Larger wounds with tissue loss
- Edges not approximated
- Heals from the inside out
- Granulation tissue fills in the wound
- Longer healing time
- Larger scars
tertiary intention
(delayed primary)
- 3-5 day delay before injury is sutured
- Used to manage infected or unhealthy wounds
- Larger scars
local factors affecting wound healing
circulation
sensation
mechanical stress
red skin color indicates
o Infection
o Inflammation
o Cellulitis
Flat texture, shiny
o Dermatitis
Raised bumps
o Erythema
o Stage 1 pressure injury
o 1st degree burn
localized edema indicates
sign of infection
inflammatory response in immediate wound area
unilateral edema indicates
dvt
venous insufficiency
poor IV placement
bilateral edema indicates
renal insufficiency
heart failure
induration
extreme edema
starts to feel hard/firm
tissue changes
chronic edema
signs of infection
disproportionate edema
broad area that is hot to touch
fever
large amounts of drainage
broad, blistering erythema
severe pain, disproportionate to wound
wound measurement methods
perpendicular
clock (most common)
volumetric
tracing
photography
length x width x depth
granulation tissue
o Red, “beefy” looking
o Result of angiogenesis
o Composed of new capillaries and extracellular matrix
o Carefully protected in good wound management
slough
o Soft, lighter necrotic debris
Difficult to grasp with forceps
o Byproduct of autolysis
o Usually seen beneath eschar
o Inflammatory phase of healing
necrotic tissue
o Composed of dead cells and fibrin
o May be dry and hard or soft and rubbery/leathery
o Dry or wet gangrene
muscle
o Striated
o Reddish when healthy
o Brown/gray or black when devitalized
o Sensate when healthy, painful when exposed
tendons
o Shiny/stringy when healthy
o Dull/dry/leathery when devitalized
o Covered with fibrous sheath of connective tissue containing synovial flid or fatty fluid
bone
o Dark brown when necrotic
o Can soften/appear moth eaten
o Covered with periosteum when healthy
adipose
o Shiny, yellow-white globules when healthy
o Shriveled/dry when devitalized
o Frequent source of abscess formation
even border wound edge
o Typical of arterial wounds
o Typically around ankle/foot
irregular wound edge
o Typical of venous wounds
o May occur as the wound epithelializes
epibole
rolled
o Signs of a halted healing process
o Cells are termed senescent (unable to reproduce)
hyperkeratosis
o Overdevelopment of stratum corneum (outermost layer of epidermis)
o Appears as thickened skin around the edge of a wound or as a callus
maceration
o Softening of skin due to prolonged/excessive moisture
arterial ulcer
impaired arterial blood flow
muscle atrophy
shiny skin
reduced hair growth
cold skin
absent/weak pulse
brittle nails
punched out wound
venous ulcer
chronic venous insufficiency
brownish discoloration and scaling of the skin
warm skin
edema
varicose veins
neuropathic ulcer
diabetic neuropathy
dry, scaly skin
sensory loss
cracked calluses
charcot foot
cause of arterial wounds
ischemia
micro/macro vascular disease
artery obstruction
causes of venous insufficiency wounds
DVT
recent surgery
prolonged standing
pregnancy
congestive heart failure
causes of neuropathic/diabetic wounds
diabetes
peripheral vascular disease
hansen’s disease
spina bifida
lupus
CMT
Stage 3 wound
- Tunneling/undermining
- Fat tissue exposed
- No muscle or bone
Stage 4 wound
- Muscle/tendon/bone visible
- Slough/eschar
- Tunneling/undermining
sanguineous exudate
thin, bright red
serosanguinous exudate
Thin, watery, pale red to pink
serous exudate
Thin, watery, clear
purulent exudate
Thick or thin
Opaque tan to yellow
foul purulent exudate
Thick opaque yellow to green with offensive odor
penrose drain
passive
soft, flexible tube that drains fluid from a surgical site
pigtail catheter
passive
Smaller, less invasive alternative to a chest tube
Drainage for pleural effusion
gastrostomy
passive
“g-tube”
Delivers nutrition directly to the stomach
Type of enteral nutrition
Active drains
o Negative pressure
o Connected to collection device
Jackson-pratt (JP)
Hemovac
purpose of debridement
o Remove necrotic tissue/bacteria
o Shorten inflammatory phase
o Decrease energy required by the body for healing
o Increase ability to assess wound bed
indications for debridement
o Necrotic tissue
o Foreign material
o Debris
o Residual topical agents
o Blisters
o Callus
contraindications for debridement
o Granular tissue
o Viable tissue
o Stable, hard, dry eschar in ischemic limbs
o Need for surgical debridement (gangrene, osteomyelitis)
o Electrical burns
o Deeper tissue
non-selective/mechanical debridement
Wet to dry (like waxing a wound)
Irrigation
Hydrotherapy
Abraded technique
selective - autolytic
- Occlusive (hydrocolloid)
- Transparent (non-occlusive)
- Hydrogel
- Medihoney
selective - enzymatic
topical application that breaks down proteins in necrotic tissue
types of selective debridement
autolytic
biosurgical (maggots)
enzymatic
sharp/surgical
excoriation
Chafing, raw irritated lesion
Linear erosion of the skin by mechanical means
denuded
Loss of epidermis due to exposure to urine, feces, body fluids, exudate, or friction
what wounds would benefit from compression?
venous
arterial
