Wound Care Flashcards
What are the 4 phases of wound healing?
Hemostasis: day 1-3, stop bleeding and fluid loss
Inflammation: day 3-20, new framework for blood vessel growth; swelling, redness, heat
Proliferation or granulation: Week 1-6, pulls the wound closed, looks like sand, tissue regenerates and wound begins to close
Remodeling or maturation: week 6-2 years, final proper tissue
Scarring
Scar occurs if excessive connective tissue is needed
Types of scars
Hypotrophic: doesn’t affect function, flat and smooth
Hypertrophic: stays in the perimeter of the wound, can occur from picking a scab
- keloid: doesn’t stay in the perimeter, skin thickness and race can cause keloid development
- not a lot can be done about keloids: acid injection, surgery
- raised, hard, adhesions
Granulations
Small rounded masses consisting of new blood vessels and a cluster of connective tissue to nourish the blood vessel
Red, sandy appearance
Classification of burns
First degree:
- superficial
- red with mild edema
- don’t scar
- self resolving
Second degree:
- partial thickness
- epidermis and dermis
- blistering
- red to a waxy white
- heals spontaneously
- non scaring if it heals well
- no grafting
- doesn’t matter if you pop it
- MUST pop if it covers a joint, it has become cloudy or bloody, or it impacts function
Third degree:
- full thickness
- destroys the dermis, epidermis, and accessory organs
- dry/leathery - read to black to white
- non blanching (when you poke it, it turns white then red)
- not painful, but the area around it hurts because it is probably a 2nd degree burn
- healing
* margins in only
* grafting if bigger than 50¢
* severe scaring
Fourth degree:
- muscle and bone
Eschar
Crust or drainage and sloughed cells
Non productive scab
Black in color
No sensation
HAs to be debrided
Burn treatment
Sterile for 48-72 hours
Topical treatments
Debridement
- Mechanical
* hydrotherapy
* whirlpool
* tanking
* manual
- Surgical
*usually first 48 hours
* bad apple principle: cut until you get to good skin
* infection
* scar release: not good because it creates more scar tissue, but okay in children because they grow
* enzymatic (chemically)
Burn grafts
Homograft: human skin the comes from someone else, often a cadaver
Autograft: comes from the individual, often their inner thighs
Zenograft: not human skin, often pig skin; currently they are working on creating skin in the lab
Transmission-based precautions
When you know a client has a highly transmissible disease (contact, droplet, or airborne)
- depends on disorder
- gloves, gowns, mask as appropriate
Contact precautions
Clean hands before entering and when leaving the room
Put on gloves and gown before room entry. Discard before room exit.
Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person.
Droplet precautions
Clean hands before entering and when leaving the room.
Make sure their eyes, nose, and mouth are fully covered before room entry and remove before exiting.
Airborne precautions
Clean handing before entering and when leaving the room.
Put on a fit-tested N-95 or higher level respirator before room entry and remove after exiting and closing the door.
Door to room must remain closed.
Stages of wound healing
Inflammation
- vascular and cellular responses
- cannot occur in dead tissue
Proliferation
- healing begins
- as early as 48 hours after injury
Maturation
- strengthening and reorganizing of new tissue
- 6 months to 2 years after an injury
- scar tissue is never more than 80% the tensile strength of normal tissue
What happens in the inflammatory stage?
Body immediately responds to control body loss, prevent infection and fluid loss, signals cells necessary for repair.
- transudate
- Localized blood vessels constrict for several minutes-prevent blood loss.
- Platelets aggregate at the site of injury to create a clot.
After 30 minutes
- Excudate is formed
- Histamine and prostoglandins are released, causing redness, warmth, and swelling.
At the cellular level
- margination (call are attracted to walls)
- phagocytosis (bacteria and debris)
- macrophages (secrete enzymes and growth factors)
- mast cells (secrete inflammatory mediators)
Scab begins to form
Cardinal signs of inflammation
Swelling - tumor
Redness - rubor (erythemal)
Warmth - calor
Pain - dolor
Decreased function - functio laesa
Proliferation phase
Once the cells necessary for repair and regeneration reach the site of injury, the proliferation phase begins.
Can be as quick as 48 hours.
4 phases:
1. Angiogenesis
- The formation of new blood vessels (buds)
- Supply nutrients to the wound
- Tiny red dots
2. Granulation
- Debris and bacteria is removed
- Granular tissue provides temporary lattice - later replaced by scar tissue
- Fibroblasts begin to lay down extracellular matrix
3. Wound contraction
- Myofibroblasts pull the wound margins together
- Degree of contraction is based on shape, depth, and size
4. Epithelialization
- Epithelial cells multiply to fill the wound
Maturation and remodeling phase
Granular tissue laid down in the proliferative phase must be strengthened and reorganized.
- This is called scarring
- This process can take up to 2 years
- Most change occurs in the first 6 months
- A scar that is pink is still remodeling
- A flesh color is finished
Opportunity to affect the scar
Hypertrophy and contracture
Occurs with any wound
- hope to see it soften and flatten after a few weeks
- redness is normal - vascularity decreases by 6 months to 2 years
A scar that is thickening is referred to by many as hypertrophic.
Excessive scaring - raised and outside the boarders of the wound is keloid, some don’t differentiate between hypertrophy and keloid
Grading a burn: Lund Browder Chart
