Wound Care Flashcards
Epidermis
Superficial Layer (Skin)
Dermis
Deep layer (Skin)
Subcutaneous Layer
Not part of this skin. Connective & adipose tissue.
Two Types Dead Tissue In A Wound
Slough & Eschar. Must be removed before healing can take place.
Slough
Moist, loose, stringy dead cells, appears yellow in color
Eschar
Thick, dry leather-like tissue, black in color.
Primary Pressure Ulcer Risk Factors
Pressure, Shear Forces, Poor Nutrition, Lack of Sensation, Incontinence
Stage 1
Area of redness, epidermis. Skin intact.
Stage 2
Partial thickness skin loss effecting the epidermis, dermis, or both. Appears moist and pink. Abrasion, blister, or shallow crater.
Stage 3
Full thickness skin loss involving damage to or necrosis of subcutaneous. Deep crater. Bigger than appears on surface (undermining). Exudate may be observed.
Stage 4
Destruction of deep tissue such as fascia, joint tissue, and bone. Necrotic tissue is likely to be present. Muscle or bone. Exudate may be observed.
Wound Assessment
Identity the wound stageMeasure the wound size(Length, width,depth, tunneling & undermining)Observe and describe the tissue at the wound edgesObserve and describe the characteristics of any exudate(viscosity, amount, color)
Wound Assessment Factors
Observe and describe the characteristics of any necrotic tissue.Describe wound colorObserve and describe surrounding skinObserve and describe characteristics of wound healing.
Debridement
The removal of necrotic tissue from the wound. Sharp - Scalpel, scissors PTA cannot in most states. Non - sharp dressings.
Sharp Debridement
Most rapid method
Mechanical Debridement
Pressure irrigation, the removal of dressing, hydrotherapy, e-stim, ultrasound.
Enzymes
Autolysis, effective for small areas of necrosis or when unable to tolerate other methods
Semi Permeable Film
Made from transparent polyurethane membranes with H2O adhesives. For Stages I & II.
Lacerations
Go through all layers of the skin and into the fat or deeper tissues.
Puncture Wounds
Caused by sharp pointed objects entering the skin.
Human or Animal Bites
Can be puncture wounds, lacerations, or a combination of both.
Chronic Wounds
Diabetic Sores, Pressure Sores, Vessel Disease Wounds, Surgery Wound Breakdown, Spinal Injury Wounds, Chemical Wounds.
Partial thickness
Superficial Wound.The epidermis and upper portion of the dermis are involved. Wound doesn’t reach subcutaneous tissues. Grade I & II
Full thickness
Deep wound. Epidermis and entire dermis and subcutaneous tissues are involved (fascia, joint tissue, bone). Grade III & IV
Pressure Ulcer Management
Provide relief or reduction. Debridement of necrotic tissue. Wound and skin cleansing. Cleanse ulcer with sterile saline. Dressing changes.
Basic Goals of Wound Care
Protect wound and surrounding area from trauma. Reduce strain on tissues. Protect tissues from stress and movement in the area of the wound. Reduce pathogenic microorganisms. Expedite the healing process. Reduce formation of scar tissue.
Moist Wound Healing
Maintains moisture allows the body to move cells into the entire area of injury. Reduced scar tissue and chance of infection.
Dressing
Protect the wound, assist the healing process, reduce infection & contamination, remove exudates & toxic waste.
Angiogenesis
New blood vessels grow in low oxygen environment
Pain relief
Nerves are soothed
Re-Epithelialization
Coverage of new skin is enhanced
Semi Permeable Film Examples
3M Tegaderm, Polymem, Bioclusive, OpSite
Hydrocolloid
Made up of gelatin, pectin, and/or carbonoxymethylcellulose in a poly isobutylene adhesive base. Dressing of choice for Stage II & III.
Hydrogel
Contains approximately 96% H2O or glycerin. Transparent, comfortable, moisture-retentive, & permeable to O2. Stage II & III.
Wet to Wet Dressing
Use on Stage II partial thickness and Stages III & IV. Changed every 8 hrs to maintain moist wound base.
Wet to Dry Dressing
Stages II and IV wounds for Debridement. Slough and necrotic tissue will adhere to dressing, to be removed.
Calcium Alginates Dressing (CaAl)
Used to absorb heavy drainage but will require secondary dressing to cover the CaAl.
