Wound Care Flashcards
Identify the purposes of irrigation
- Cleansing exudate/debris using a wound cleansing solution
- Application of warmth or medication
- Cleansing a wound which cannot be reached by forceps
Identify the purposes of packing
- Ensure that that wound heals from the inside to outside to prevent abscess formation
- Absorption of wound drainage
- Maintenance of the contour of the cavity
- Exertion of pressure on traumatized blood vessels
Identify the purpose and basic assessment of a vacuum assisted closure (VAC)
- applies localized negative pressure
- removes fluid from area surrounding the wound
- promotes formation of granulation tissue
- useful for excessive drainage
Describe the wound healing process: 1. inflammatory phase
• Bodies reaction to wound healing • Begins within minutes of injury • Lasts 3-5 days a. Hemostasis • Vasoconstriction o Injured blood vessels • Platelet aggregation • Clot formation o Fibrin matrix layer provides framework for cellular repair • Damaged tissue and mast cells secrete histamine o Results in vasodilation o Exudation of serum and WBC into damaged tissues o Phagocytosis Cleanup to prepare for rebuild • Leukocytes
Describe the wound healing process: 2. Proliferative phase
• Reconstructive/granulation phase
• 3-24 days
• Wound is pink and vascular
• Main activity
o Filling and covering wound bed
o Contraction of wound
o Resurfacing by epithelization
• Epithelial cells migrate from wound edge to form a new surface
• Epithelial cells only migrate across a moist surface
o Need right conditions for wound healing to take place
Describe the wound healing process: 3. Remodeling phase
• Maturation phase
• Final stage
• Begins within 3 weeks
o Can last for more than a year
• New collagen forms to increase wound strength
• Mature scar is formed
o In contrast to granulation tissue, it is avascular and pale
• Would is never as strong as original tissue
Identify factors that enhance would healing
• Nutrition and hydration o Fluids, vitamins, protein, calories o Dietician consult o Fundamental to cellular integrity and tissue repair • Positioning o Turning regime • Medications o Systemic and topical • Clean/sterile environment and technique o Sterile dressing changes To decrease risk of nosocomial wound infections • Activity • Skin care • Good glycemic control
Identify factors that impair wound healing
• Age
o Alters all phases of wound healing
o Vascular changes impair circulation
o Inflammatory response slowed
o Collagen tissue less pliable
• Infection
o Prolongs inflammatory phase
o Prevents epithelization
o Delays collagen synthesis
• Impaired oxygenation
o Alters synthesis of collagen and formation of epithelial cells
o Lack of oxygen = decreased healing
Anemia
• Drugs
o Steroids decrease inflammatory response and slow collagen synthesis
o Anti-inflammatories suppress protein synthesis/epithelization
o Antibiotics increase risk of superinfection
o Chemo drugs depress bone marrow fx and impair inflammatory response
• Radiation
o Tissues become fragile and poorly oxygenated
• Malnutrition
o All phases of healing affected
• Obesity
o Fatty tissue lacks adequate blood supply to resist bacterial infection and deliver nutrients and cellular elements for healing
• Smoking
o Decreases function Hgb in blood, therefore lowering oxygenation in blood
o Increases platelet aggregation and hypercoagulability
• Vascular diseases
o Decreased circulation and impairs tissue perfusion
Diabetes
• Wound stress
o Inhibits formation of endothelial cell and collagen networks
healing by primary intention
• Skin edges are well approximated or closed with sutures or staples
• Healing occurs by connective tissue deposition (epithelialization)
o Surgical wound
healing by secondary intention
• Wound edges are not well approximated • Healing occurs by o Granulation tissue formation o Contraction of wound edges o Epithelization Pressure ulcers, surgical wounds with tissue loss
Complications in wound healing
- hemorrhage
- infection
- dehiscence
- eviseration
- fistulas
hemorrhage
o Internal or external
o Risk greatest 24-48 hours post op
infection
o Usually happens 4-5 days post op
Dehiscence
o Most common 3-11 days Before collagen formation takes place o Partial or total separation of wound layers o More common with abdominal wounds o In pt with risk of poor wound healing Nutrition, infection, obesity o Sudden strain of coughing o Granulation tissue not strong enough to withstand the forces imposed o the wound o Mechanical strain in obese pts Increased pressure on wound healing
evisceration
o Total separation of wound layer
o With visceral organ profusion
o Emergency condition requiring surgical repair
o Place sterile towels soaked in sterile saline onto extruding tissues/organs, NPO, prepare for surgery and signs and symptoms of shock
fistulas
o Abnormal passage between two organs or between an organ and the outside of the body
o Form as a result of poor wound healing or as a complication of a disease
