Wound Care Flashcards
Intrinsic factors of wound healing
- age
- chronic diseases present
- perfusion/oxygenation
- immunosuppresison
- neurologically impaired skin
Extrinsic factors of wound healing
- medications
- nutrition
- irradiation and chemo
- psych stressors
- wound ‘bioburden” and infection
Bioburden
- Whatever is colonized on a wound
- pathogens
Iatrogenic Factors for healing
- local ischemia due to pressure/other forces
- inappropriate wound care
- trauma
- wound extent and duration
Zones of Wound Healing
- zone of hyperemia
- zone of stasis
- zone of coagulation
Zone of coagulation
- area of necrosis
- will not heal
Zone of Hyperemia
- inflammatory response surrounding the wound
- normal tissue going through normal response
- redness of skin
Zone of Stasis
- part that may or may not heal
- important to protect this zone so it can heal
- hanging in the balance
Re-epithelialization
- recreation of a permeable barrier
- skin reinstituted as functional barrier
- epithelial cell migration from nearby tissues begins within hours of injury
Granulation Tissue
- new or budding tissue
- composed of capillaries and collagen
- fills defects of full-thickness wounds
- bleeds easily, relatively fragile
Demarcation
-clear differentiation between viable and non-viable tissue
Excoriated Tissue
- epidermal tissue abrasion
- to chafe, tear or wear off the skin
- often linear
Sinus Tract
- channel or passageway extending into viable tissues with one entrance only
- travels under skin
Tunneling
-narrow channel or passageway with openings on both ends
Abscess
-localized collection of pus
Induration
- palpably hard tissue
- often at edge of wound
- can indicate abscesses (must determine cause)
Drainage
- Exudate or transudate
- indicates inflammatory response
Exudate
- found in inflammatory stage of wound healing
- contains cells, proteins and other solid materials
- 2 kinds: purulent or serous
Purulent
- milky/cloudy appearance but can be any color
- indicate infection
Serous
- thin, clear usually amber color
- mostly contains serum
- (Serosanguinous-thin with some RBC)
Transudate
- thin, cloudy drainage found in the proliferation stage of wound healing
- like exudate but has fewer cellular componenets
Dehiscence
- splitting of open wound
- separation of layers of surgical wound (partial, superficial or complete)
- bad
Risk Factor of Dehiscence
- obesity
- because adipose is less vascularized
Necrosis
- tissue death
- residual dead tissue can impede normal healing
Slough
- Yellow and thin covering of wound
- stringy appearance
Eschar
- more advanced necrosis
- soft or hard (leathery)
- represents full-thickness destruction of tissue
- black/dark colored
Necrotic tissue tends to become more______
-adherent to wound bed as level of damage increases
As necrotic tissue worsens, the color may____
-progress from white-grey to yellow to brown/black
Methods of Wound Closure
- first intent
- secondary intent
- third intent
First Intent Closure
-close the wound and done
Second Intent Closure
-larger wound must fill in on it’s own
Third Intent
-intentionally left open to get rid of infection first
Debridement
- removal of dead tissue
- 4 types
4 Types of Wound Debridement
- Mechanical
- Sharp
- Enzymatic
- Autolytic
Mechanical Debridement
- PT
- Pulsed lavage, whirlpool/flow-over hydrotherapy etc
Sharp Debridement
-with scalpel
Enzymatic Debridement
-put stuff on the wound to break down necrosis
Autolytic Debridement
- scab, body creates temporary roof
- healing under scab and scab falls off
- body does it on it’s own
Ulcer
- loss of epidermis and dermis
- most are preventable
Common Locations of Decubitus Ulcers
- bony prominences
- ischium, sacrum, coccyx, olecranon, heels, occiput, scapulae, lateral malleoli, trochanters, acromion
Decubitus
lying down position
5 Risks/Causative factors for Decubitus Ulcers
- interface pressure (externally)
- Friction (skin on other surface)
- Shearing
- Maceration (softening due to excessive moisture)
- decreased skin resilience (dehydration)
Maceration
-softening due to excessive moisture
Grading decubitus ulcers
- grade I-IV
- IV is the worst
- stage I-skin is still intact
- don’t massage area or use donut cushions
Osteomyelitis
-Bone infection
Signs of Infection
- redness
- fever
- increased temp
- discoloration
- drainage (smelly)
Prevention of Decubitus Ulcers
- MOBILITY
- assessment of surfaces in contact
- vigilance in the presence of incontinence
- multidisciplinary consultation (RN, NA, Family, Physicians)
Other Ulcer Types
- Arterial
- Venous
- Neuropathic
Modalities for Wound Care
- ESTIM
- US (pulsatile)
- SWD
- Whirlpool
Whirlpool
- softens eschar and other necrotic tissue
- turbulence provide mechanical debridement
- flow over therapy is better
Flow-Over Hydrotherapy
- wound cleansing with immediate flushing away of potentially infectious material
- more sanitary than whirlpool
Grade I Pressure Ulcer
- skin intact
- warmer/cooler than other skin
- firm or boggy consistency
- pain/itching sensation
- redness
Grade II Pressure Ulcer
- Partial thickness skin loss of epidermis and/or dermis
- superficial
Grade III Pressure Ulcer
- full thickness damage/necrosis to subq layer to fascia
- deep crater
- with/without undermining of adjacent tissue
Grade IV Pressure Ulcer
- Full thickness with necrosis or damage to muscle, bone or supporting structures (tendon, joint capsule)
- undermining and sinus tracts
Unstageable Pressure Ulcer
- wound covered with eschar
- or more than 50% necrotic tissue
- or filled with granulation tissue
Deep Tissue Injury (grade of pressure ulcer)
-pressure related injury to subq tissues under intact skin
Neuropathic ulcers
- weight bearing surfaces
- well-defined margins
- no undermining
- graunlation tissue present
- no pain
Arterial Ulcers
- deep pale base
- well defined edges
- black necrotic tissue
- dry
- cool leg
- painful
Venous Ulcers
- uneven edges
- ruddy granulation tissue
- warm leg, edema
- wet
- some pain
