Wound Care Flashcards
A type of wound results from planned treatment (ex. Self-harm)
Intentional
A type of wound results from unexpected trauma.. accident/ burns / shooting.
Unintentional
A type of wound: skin broken, portal of entry
Open
A type of wound: trauma from force, skin intact, soft tissue damage, internal injury, possible bleeding
Closed
A type of wound: that goes through normal/ timely healing process < 3 mos.
Acute
A type of wound: fails to go through normal stages of healing; no timely progress in healing >3 mos.
Chronic
Four inflammatory responses:
- Vascular
- Cellular
- Formation of e exudate
- Healing (regeneration and repair)
Inflammatory response: 4 cardinal signs and symptoms :
- Pain
- Redness
- Heat
- Edema
Managing inflammation using:
RICE! ▫️Rest ▫️Ice ▫️Compress ▫️Elevation
Heat therapy
▫️24-48hrs post ➡️ heat vasodilation ➡️ promotes healing
What not to do with ice therapy:
◽️ice place directly on skin
▫️ice wrapped tightly to knee with tensor
▫️ice left for 1hr
Phase 1 wound healing: systemic inflammatory response
▫️fever
▫️elevated WBC
▫️Malaise
Phase 2 Wound Healing:
▫️granulation phase (body activates collagen)
▫️thin layer of epithelial cells forms
Phase 3 wound healing
▫️maturation phase (begins as early as 7days after injury)
▫️collagen remodel and reorganizes
▫️scar forms
▫️keloid
Delayed wound healing
▫️local factors
▫️systemic factors
▫️site of injury
A skin 10 cms. Beyond the wound edge
periwound
___is a skin barrier used to place before dressing, to prevent peeling off 1st layer of skin
Cabalone
Maceration can occur if excessive moisture is present. Common problem in ____, _____ and ___
Venous leg ulcers, diabetic ulcers and high draining / exudating wounds
Assessing Drainage:
▫️sanguineous
▫️serosanguineous
▫️serous
▫️purulent
Controlling odour w wound care
Deodorizers
Ventilation
Wound odour is largely due to tissue degradation/tissue death
Klebsiella, pseudonomas
Signs of infection
▫️inflammation ▫️pus ▫️⬆️/change in exudate ▫️fever ▫️pain ▫️delirium in elderly
When doing dressing changes DO NOT:
▫️wrap tape completely around an extremity
▫️pull dressing off a wound
- can cause further tissue damage
- soak to remove
Frequency of wound dressing?
3-7 days
________ healing stimulates cell proliferation and encourages epithelial cells growth
Moist
How does wound heal?
from the bottom up
is the medical removal of dead, damaged, or infected tissue to improve healing potential of the remaining healthy tissue.
Debridement
Methods of wound debridement:
▫️Surgical
▫️mechanical
▫️autolytic
▫️enzymatic
Types of dressing
▫️films ▫️hydrogels ▫️hydrocolloids ▫️alginates ▫️foams
Type of dressing: retains moisture, protect from infection. Minimally absorbent, allow O2,
Tegaderm, opsite
Films
Type of dressing: creates moist environment, not for excessive drainage. Gently eliminate necrotic tissue by autolytic debridement
DouDerm
▫️Hydrogels
A type of dressing: moist environment, promotes autolytic debridement. Occlusive (does not allow atmospheric O2 to enter). Supports debridement.
Tegasorb
Hydrocolloid
A type of dressing: use for moderate drainage.
Mepilex
Foams
A type of dressing: moderate to heavy drainage. Form gel-like substance that facilitate autolytic debridement
Gel fills wound space (e.g. aquacel)
Calcium alginate
Specialty dressings: antimicrobial
▫️silver
▫️cadexomer iodine
▫️broad spectrum Abx
Complications of wound healing:
▫️infection
▫️adhesions
▫️dehiscence
▫️evisceration
Stage of pressure ulcer: intact skin with no Blanchable redness. Often present over bony prominence
Stage 1
Stage of pressure ulcer: partial-thickness skin loss with exposed dermis. Wound bed is PINK/RED. Fat tissue is not visible
Stage 2
Stage of pressure ulcer: full thickness skin loss. Fat tissue involved. Granulation tissue present. No fascia, muscle or tendon exposure
Stage 3
Stage of pressure ulcer: full thickness skin and tissue loss. Exposed fascia, muscle, tendon, ligament, cartilage or bone. Slough and Eschar often visible.
Stage 4
Braden scale key assessment indicators
▫️sensory perception ▫️moisture ▫️activity ▫️mobility ▫️Nutrition ▫️friction and sheer
