Wound Care Flashcards
phases of healing (3)
- inflammatory phase2. proliferation phase3. maturation phase*all overlapping
inflammatory phase
begins the moment of injury and lasts 2 days to 2 weeks initial vasoconstriction to control blood lossprotein-based fluid leaks out of vessels and swelling begins along with clean-up cellswithin 30 minutes mast cells release histamine to cause vasodialation
proliferation phase
begins once injured area being clean and free of damaged tissue, foreign matter, and bacteria and last several weeksconsists of granulation, angiogenesis, wound contraction, and epithelialization*moist wound bed desired
maturation phase
“remodeling phase”water and amino acids squeezed out of the granulation tissue matrixcollagen fibers produced, forms scar*can last up to 2 years
scar vs skin strength
scar is 80% as strong as skin at full maturity*scar management is important
factors that affect healing (9)
- circulation2. debris in wound bed3. infection4. chemical stress5. temperature of wound bed6. amount of moisture in/around wound bed7. medications and other medical conditions8. nutrition9. age
debridement
the removal of necrotic tissue from a wound so the healthy tissue is exposed in the wound bed
slough
yellow, white stringy tissuemoist composite of fibrin bacteria, dead cells and exudate*dead tissue
eschar
black, hard tissue, occasionally moist in appearance
autolytic debridement
when the body breaks down the necrotic tissue on its owncan encourage with dressingscomfortable and effective, but slower*watch for macerated skin
enzymatic debridement
use of topical enzymes to break down slough and escharcheck state practice actcollagenase ointment - needs Rx*may cause discomfort
sharp debridement
use of sharp instrument (scissors/scalpel) to selectively remove necrotic tissuecheck state practice actneed to be skilled*fastest and most effective method
mechanical debridement
remove of dead tissue using methods like whirlpool agitation, high pressure fluid irrigation, or wet-to-dry dressings**NOT RECOMMENDED
hypergranulation tissue
looks like shiny, deep-red balls of tissue that grow taller than the wound marginsoft, bleeds easytreat with nitrate sticks (do with dressing changes/turns tissue gray)
wound cleansing frequency
wound should be cleansed every time the dressing is changed
best wound cleansing solutions
normal salinesterile waterdrinkable tap water
wound cleansing solutions to avoid
hydrogen peroxide, Dakin’s solution, povidone iodine/Betadine, soap, bleach*never use anything you would not be willing to put in your eye
hydrogen peroxide and wounds
should only be used in home setting to clean cuts/scrapes immediately after injuryonce wound is free from debris, OH can be toxic to granulation tissues and use can slow wound healing
moisture balance
moist wound will heal much faster than a wound that is too wet or too dry
goals of wound dressing
keep bacteria out, retain some moisture, but still absorb any excess fluid if needed
non-occlusive dressing
allows for free passage of water, vapor, and bacteria
occlusive dressing
will not allow passage of water, vapor, and bacteria
semi-occlusive dressing
falls in the middleallows passage of water vapor, but not water or bacteria
types of dressings (6)
- transparent film2. impregnated low-adherence dressings3. hydrogels 4. gauze 5. foams 6. alginates
transparent film dressings
semi-occlusivethin, see-through films that adhere right to the skin and can be used as primary or secondary dressing*can last up to 7 days
impregnated low-adherence dressings
non-occlusive to semi-occlusivedesigned to make contact with wound and reduce sticking and tearing of wound tissue during dressing changesrequires secondary dressingreduces risk of infection
hydrogel dressings
non-occlusive to semi-occlusivedesigned to hydrate wounds and promote autolytic debridementrequires secondary dressingneeds to be changed every 24-72 hours
gauze dressings
non-occlusivemost widely available and commonly usedcan be used to clean, pack, or cover woundsas primary dressing it cannot easily create moist wound environment and also tends to shed fibersgood secondary to keep other dressings in place
foam dressings
semi-occlusivemosty polyurethane and used to absorb moderate amounts of exudate and provide cushioningcan be primary or secondary depending on branddoesn’t conform well to hand
alginate dressings
non-occlusive to semi-occlusivederived from seaweedhighly absorbent and made for moderate-large amounts of exudateas alginate absorbs fluid, it is converted to a gel that provides moisture to the wound bedrequires secondary dressing
primary intention
wound is closed with sutures or staples*wound heals by fibrous adhesion and little to no granulation tissue
secondary intention
the wound is left open and left to heal through the granulation process*requires close monitoring
tertiary intention
“delayed primary wound closure”wound is left open initially then closed a few days later
patient education on wound care and smoking
educate them that nicotine decreases the delivery of O2 to tissue and can increase the risk for wound healing complications 1 cigarette can reduce blood flow to hand*encourage clients to temporarily stop smoking until wound is healed (or at least cut back)
eval - location of wound
when describing the location of a wound, be precise do so in terms of anatomical positionex. “The wound is on the anterior medial aspect of the distal forearm, 2 cm proximal to the pisiform”
eval - size of wound
length, width, depth recorded in mm or cmclock method or length and width at longest points
eval - wound depth
depth measure by inserting a moistened sterile cotton-tipped applicator into the deepest part of the wound*look for tunneling
tunneling
a narrow and deep hole that runs away from the main part of the woundcreates “dead space” and increases risk of abscess formationrecord depth and location using clock face method
eval - wound margins
note color and condition of edges of the woundhealthy: pink and flat, firmly attached to tissue underneathwatch for undermining
undermining
space under the wound margins *sign that wound is not healing effectivley
eval - periwound skin
note color and condition of skin around the woundshould be skin-colored or maybe a little pinkredness, inflammation or hardening could indicate infectionsmall lesions could indicate damage from adhesive dressingssoft, white indicates skin has absorbed too much fluid
macerated skin
soft, white skin that results from wound exudate not being adequately absorbed by the wound dressing*fragile and easily damaged
denuded skin
when the epidermis around the wound starts to breakdown
eval - wound characteristics
describe wound using “red-yellow-black” system and document with digital photos to record wound healing progression
“red-yellow-black” system
estimate what % of the wound is colored by each colorred: healthyyellow: sloughblack: eschar
photographing wounds
helpful in documentingalways do at same point of treatment, same camera, same settings, same distance, NO FLASH
eval - wound exudate
describe color, consistency, odor and amount of discharge*hydrocolloid dressings produce foul odor; this is normal so assess after cleaning
serous
clear and watery exudate*normal
serosanguinous
thin and pink exudate*normal
sanguinous
thin and bright red exudate*may or may not be normal depending on amount and type of tissue in wound bed
purulent
thick or thin, tan to yellow exudate*sign of possible infection
foul purulent
thick, yellow to green exudate with bad odor*sign of infection
signs of infection (9)
- pain2. foul odor3. pus drainage4. redness5. warm to touch6. hardening around wound7. lymphangitic streaking/red streaks8. malaise9. fever
wound care clinical reasoning (5)
- moist wound healing is best2. create a clean wound bed3. wound bed is fragile4. infection must be identified5. do no harm
