Wound Care Flashcards by Lysza Sabanal

A type of wound results from planned treatment (ex. Self-harm)

Intentional

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A type of wound results from unexpected trauma.. accident/ burns / shooting.

Unintentional

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A type of wound: skin broken, portal of entry

Open

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A type of wound: trauma from force, skin intact, soft tissue damage, internal injury, possible bleeding

Closed

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A type of wound: that goes through normal/ timely healing process < 3 mos.

Acute

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A type of wound: fails to go through normal stages of healing; no timely progress in healing >3 mos.

Chronic

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Four inflammatory responses:

Vascular
Cellular
Formation of e exudate
Healing (regeneration and repair)

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Inflammatory response: 4 cardinal signs and symptoms :

Pain
Redness
Heat
Edema

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Managing inflammation using:

RICE!
▫️Rest
▫️Ice
▫️Compress
▫️Elevation

Heat therapy
▫️24-48hrs post ➡️ heat vasodilation ➡️ promotes healing

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What not to do with ice therapy:

◽️ice place directly on skin
▫️ice wrapped tightly to knee with tensor
▫️ice left for 1hr

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Phase 1 wound healing: systemic inflammatory response

▫️fever
▫️elevated WBC
▫️Malaise

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Phase 2 Wound Healing:

▫️granulation phase (body activates collagen)

▫️thin layer of epithelial cells forms

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Phase 3 wound healing

▫️maturation phase (begins as early as 7days after injury)
▫️collagen remodel and reorganizes
▫️scar forms
▫️keloid

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Delayed wound healing

▫️local factors
▫️systemic factors
▫️site of injury

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A skin 10 cms. Beyond the wound edge

periwound

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___is a skin barrier used to place before dressing, to prevent peeling off 1st layer of skin

Cabalone

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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 ```