Wound Care Flashcards
What are the phases of wound healing (in order)
1) Hemostasis: clot formation + vasoconstriction then dilation
2) Inflammation: fibrinolysis, increased capillary permeability –> edema, inflammatory mediators e.g. cytokines attract neutrophils, macrophages
3) Granulation = rebuilding phase: granulation from in–>out***
- fibroblasts + angioblasts lay down new blood vessels and scar tissue, epithelialization, contraction of wound edges
4) Maturation/remodelling: fibroblast remodelling of dermis
Factors that affect wound healing?
Age, overall health of patient
concurrent health challenges that affect tissue perfusion
DM
malnutrition
stress
pressure, friction, shear
medications e.g. corticosteroids and immunosuppressants
DEAAD: Drugs Edema Albumin Anemia Diseases
What are the components of the Braden scale?
Friction/shear Moisture Sensory perception Mobility Activity Nutrition
What stage is an ulcer that is unresolved, non-blanchable erythema of intact skin
stage 1
What stage is an ulcer that is full thickness ulcer with damage to subcutaneous tissues that may extend down to, but not through underlying fascia
stage 3
What stage is an ulcer that is full thickness, with tissue loss with exposed muscle, bone, or tendon
- slough or eschar may be present
stage 4
What stage is an ulcer that is partial thickness ulcer with skin loss that involves epidermis and/or dermis
stage 2
What stage is an ulcer that have thick, dry, black necrotic tissue
eschar
Briefly describe the different types of debridement
Autolytic - moist, interactive dressing provides environment for liquefying slough and promoting granulation
Enzymatic - applying naturally occurring enzymes exogenously to degrade debris
- Collagenase
- most successful in removal of eschar
Mechanical - to physically remove debris from wound
- simplest method e.g. wet to dry saline dressing with wound irrigation
Surgical - fast and effective but costly
- suitable for wounds with large areas of necrosis or high degree of contamination/infection
- converts chronic wound to acute
- only performed by trained individual
Biological - use of living organisms (eg. sterilized maggots) to remove necrotic or dead tissue from a wound
What are the factors that promote “best practice” of wound care?
1) patient-centered
2) holistic
3) interdisciplinary
4) evidenced-based
When assessing a wound, what dimensions should you measure?
Length - longest length
Width - perpendicular to length
Depth - deepest point
Wound assessment should include…?
Measurement dimensions Exudate: quantity, quality appearance of wound bed patient's pain tunnelling/sinuses condition of wound edge
What are the 3 ways to prep the wound bed?
- Debridement
- Bacterial balance: look for subtle clinical signs of infection, heat, redness, pain, increased exudate or pus, foul odor
- Moisture balance - select appropriate dressing for moisture balance to stimulate granulation tissue and re-epithelialization
Dressing products for heavy exudate are called
absorbers e.g. foams, hydrofibers (e.g. Aquacel), crystalline gauze (e.g. Mesalt), alginates
Dressing products for mild to moderate exudate are called
Maintainers:
hydrocolloids - for mild to moderate exudate e.g. tegasorb, duoderm
transparents - minimal drainage e.g. tegaderm
