Wound Care Flashcards
Characteristics of the epidermis
outer epithelial layer
protective barrier
avascular
prevents dehydration of underlying tissue
Characteristics of the dermis
highly vascular
strong and elastic due to collagen and elastin
What does the dermis contain
hair follicles
sebaceous glands
nerve endings
receptors for pain, touch, cold, heat
Characteristics of the subcutaneous layer
below dermis
adipose tissue
connective tissue-fascia
What does thhe subcutaneous tissue do
provide insulation, support, cushioning
protects underlying tissue
what is a partial thickness wound
through the epidermis into dermis
What are the phases of normal wound healing
inflammatory
proliferative
maturation/remodeling
what does the inflammatory pahse do
prepares wound for healing and cleans debris
What does the proliferative phase do
rebuilds the damaged structures and provides strength to the wound
what does the maturation/proliferative stage do
modifies the immature scar to a mature scar
What occurs during the inflammation phase
control bleeding and combat infection
signal cells necessary for repair and regeneration
How long does inflammation last
acute: 24-48 hours
subacute: up to 6 days
Cardinal signals of the inflammatory phase
swelling redness warmth pain decreased function
What are the 4 events that occur in the proliferative phase
angiogenesis
granulation tissue formation
wound contraction
epithelialization
what is angiogenesis
formation of new blood vessels
what is granulation tissue formation
temporary connective tissue that goes across and fills the wound
What is wound contraction
edges of wound grow closer together
what is epithelialization
epithelial cells that go across temporary granulation
what is the purpose of the proliferative phase
resurfacing of the wound bed
What does the tissue look like in the proliferative phase
red, beefy, fragile
how long does the proliferative phase last
2-24 days
How long is the maturation/remodeling phase
21 days on
what happens in the maturation/remodeling phase
changes in the bulk, form, and strength of scar
granulation tissue must be strengthened and reorganized to fit surrounding tissue
When does the greatest change occur in the maturation/remodeling phase
6-12 mo
What are the 3 methods of wound closure
primary
secondary
delayed primary
What is primary wound closure
edges touch (what you think of with surgical wound) can use staple glue stitches
What is secondary wound closure
wound edges dont touch
what is delayed primary wound closure
wound edges can be touching but wait to close
What is eschar
dry darker black dead tissue
What is skin
largest organ in the body
interphase b/t body and env.
What is slough
moist, green-yellow, slimy dead tissue
what is desiccation
look dry, including edges
what is maceration
too moist/wet
makes tissue fragile
What is undermining
use q tip to go underneath edges of wound b/c it extends past edges
What is tunneling
stick something under skin b/t 2 wounds
What is exudate
Thicker liquid b/c more protein in it
yellow, cream
what is transudate
generally blister
clear watery fluid
what is periwound
edge of wound
where edge of wound stops and healthy skin begins
Factors affecting wound healing
wound characteristics
local factors
systemic factors
Wound characteristics affecting healing
mechanism of onset time since onset location dimensions wound hydration necrotic tissue or foreign bodies infection
local factors affecting wound healing
circulation (diabetes, cold, fear, pain, peripheral vascular diseases)
sensation (perihperal neuropathy, stroke)
mechanical stress (pressure ulcer)
systemic factors affecting wound healing
Age inadequate nutrition comorbidities meds behavioral risk taking
Types of wounds
Arterial insufficiency Veous insufficiency pressure ulcers neuropathic ulcers burns trauma
What is the pain like in arterial wound insufficiency
severe
increased with elevation (b/c decrease circulation more)
What is the location of arterial insufficiency
Mostly LE (distal toes, dorsum of foot, lat malleous, ant, leg, areas of trauma)
What is an arterial insufficiency wound like
Base pale poor granulation round regular margins little to no bleeding,drainage necrotic tissue
What is the appearance of an arterial insufficiency wound
Thin, shiny, ddry skin, hair loss, cool skin
What are pulses like in arterial insufficiency wounds
decreased or absent pedal pulse
Factors leading to arterial insuffiency ulcers
Smoking diabetes hypertension advanced age trauma hypolymphedma
what is the pain like in venous insufficiency wounds
mild to moderate
decreased w/ elevation/compression
What is the location or venous insifficiency wounds
Medila lower leg, medial malleous, areas of trauma
what is the wound like in venous insufficiency
Red wound bed
good granulation
irregular margins
copious drainage
What is the appearance of a venous insufficiency
edema
normal to warm skin temp
What is the pulse like in venous insufficiency
normal
Where are the most common places for pressure ulcers
bony prominences (sacrum, greater trochanter, heels)
Where are common locations for neuropathic ulcers
heel, ball of foot, big toe
What are burns classified by
Type and depth
What are the goals of wound care
protection reduce strain on nearby tissue protect periwound reduce pathogenic microorganisms in and around wound speed up healing process reduce/decrease scar tissue
What to document and assess in wound care
Location size undermining/tunneling wound bed edges drainage odor surrounding skin wound healing
What are the two methods of debridement
selective
nonselective
What are form of selective debridement
sharps
autolytic
enzymatic
biologic
what is autolytic
use bodys own enzymes to get rid of tissue
What is enzymatic
put topical enzyme on wound
What is biologic debridement
use maggots
What are nonselective forms of debridement
mechanical-scrubbing, whirlpool
Surgical
Universal precautions for wound care
use gloves
use appropriate disposal containers
use a sterile field when debriding a wound
Modalities for wound care
Whirlpool e stim ultrasound hyperbaric o2 pulsatile lavage vac compression
What type of env do wounds heal faster
moist
