wound care Flashcards
any wound that lasts longer than 3 months is considered
chronic
what are the phases of wound healing
inflammatory
proliferative
remodeling
what is the inflammatory phase
is a sequential reaction to cell injury. It neutralizes and dilutes the inflammatory agent, removes necrotic materials, and establishes an environment suitable for healing and repair.
what is the vascular response of the inflammatory phase
transient vasoconstriction right after injury
histamine release/ vasodilation
fibrin/platelets
growth factors
goal is to stop the bleeding, “hemostasis”
what is the cellular response of the inflammatory phase
this phase is 6-12 hours later
neutrophils come from bone marrow
monocytes and macrophages come from blood
here we have chemotaxis which is the migration of cell to site of injury
which phase of wound healing creates vasodilation and increase capillary permeability resulting in hemostasis
- redness, swelling, heat at injury
- vascular response
- cellular response
- formation of exudate
2
what is exudate
fluid to site of injury
what is serous
clear
ex. blister
what is serosanguinous
pink
what is fibrinous
sticky
ex. Adhesions, gelatinous ribbons seen in surgical drain tubing
Frequently covers fluid-exuding wounds such as venous ulcers
what is hemorrhagic/sanguinous
red
blood
ex.Hematoma, bleeding after surgery or tissue trauma
what is purulent
pus, dead WBC
ex. Furuncle (boil), abscess, cellulitis (diffuse inflammation in connective tissue
what is catarrhal
mucus
ex. Runny nose associated with upper respiratory tract infection
what are the two phases of the healing process
regeneration
repair
what is the local manifestation of inflammation
redness, heat, pain, swelling, and loss of function
what is the systemic mainfestation of inflammation
increased WBC count with a shift to the left, malaise, nausea and anorexia, increased pulse and respiratory rate, and fever.
what is acute inflammation
the healing occurs in 2 to 3 weeks and usually leaves no residual damage. Neutrophils are the predominant cell type at the site of inflammation.
what is subacute inflammation
has the features of the acute process but lasts longer. For example, infective endocarditis is a smoldering infection with acute inflammation, but it persists for weeks or months
what is chronic inflammation
lasts for weeks, months, or even years. The injurious agent persists or repeatedly injures tissue.
what are the key concept in treating soft tissue injuries and related inflammation.
Rest, ice, compression, and elevation (RICE
what is regeneration of the healing process of inflammatory
Regeneration is the replacement of lost cells and tissues with cells of the same type.
what is repair of the healing process of inflammatory
is healing as a result of lost cells being replaced by connective tissue. Repair is the more common type of healing and usually results in scar formation.
repair has what 3 stages
primary
secondary
tertiary
what is primary intention
healing takes place when wound margins are neatly approximated, as in a surgical incision or a paper cut.
clean dry clean with normal saline
what is secondary intention
leave it open, edges cannot be approximated
cleansing, keeping wound moist
filling dead space
transparent dressing provides moisture and oxygen transfer
ex. from trauma, ulceration, and infection have large amounts of exudate and wide, irregular wound margins with extensive tissue loss.
what is tertiary intention
(delayed primary intention) healing occurs with delayed suturing of a wound in which two layers of granulation tissue are sutured together after infection is controlled
what are the wound classification
superficial partial thickness full thickness skin tear color system: red yellow black
what is a superficial wound
involves only the epidermis
what is a partial thickness wound
extends to the dermis
what is a full thickness wound
wounds have the deepest layer of tissue destruction because they involve the subcutaneous tissue and sometimes even extend into the fascia and underlying structures such as the muscle, tendon, or bone
what is a skin tear
is a wound caused by shear, friction, and/or blunt force resulting in separation of skin layers. A skin tear can be partial thickness or full thickness.
what are complications of wound healing
adhesions contractions dishesnce evisceration fistula excess granulation tissue hypertrohpic scars kelid formation hemorrahge infection
what is an adhesion
Bands of scar tissue that form between or around organs
what is contractions
results in deformity
what is dehisence
Separation and disruption of previously joined wound edges
usually occurs when primary site bursts open
what is evisceration
Occurs when wound edges separate to the extent that intestines protrude through wound
what is excess granulation tissue
Excess granulation tissue may protrude above surface of healing wound
what is a fistula formation
An abnormal passage between organs or a hollow organ and skin
what is hypertrophic scars
Inappropriately large, raised red and hard scars
what is keloid formation
Great protrusion of scar tissue that extends beyond wound edges and may form tumor-like masses of scar tissue
what is the proliferative stage of wound healing
new capillary networks
granulation tissue
epitheliaization
contracture- wound edges being pulled to each other
what are the principles of care
wound hydration
blood supply
infection minimization
when is the wound very fragile
during the proliferative stage
what does moisture promote
epithelization
what is the remodeling phase of the wound healing
cells responsible for the collagen synthesis and anigogensis undergo apoptosis
wound strength increases
wound contraction continues
scar formation
how long could the remodeling phase take
up to 2 years
what is leukocytosis
anything above 10,000
what is a red wound
healthy
very fragile don’t scrub
non adherent dressing- moist techaderm
what is a yellow wound
drainage, exudate needs to be removed to heal
clcium aginate- seaweed it absorbs drainage
what is a black wound
necrosis going on, dead cells need to be removed for healing
gangerous wound, needs to be debrided
what does the color system come from
secondary intention
if a dehiscence happens between 1-3 day who’s fault
technical problem
if a dehiscence happens between 3-10 days who’s fault
nutrtional status
obesity
infection
the surgeon would be charged because something is wrong inside
what are the factors that delay wound healing
nutrtional deficience inadequate blood supply corticosterioid drugs infection mechanical friction advanced age obesity DM anemia poor general health smoking necrotic tissue
what are the types of debridement
surgical
mechanical
autolytic
enzymatic
what is surgical debridement
scapel or scissors
can change chronic wound into acute wound- promote bleeding stimulates platelets
Used when large amounts of nonviable tissue are present
• Prepares wound bed for healing, skin grafting, or flaps
what is mechanic debridement
either wet to dry or wound irrigation
what is wet to dry debridement
open-mesh gauze is moistened with normal saline, lightly packed into wound surface, and outer layer allowed to dry. Wound debris adheres to dressing and then dressing is removed
what is wound irrigation
Make certain bacteria are not accidentally driven into wound with high irrigation pressure
what is autolytic debridement
Semiocclusive or occlusive dressings used to soften dry eschar by autolysis
what is enzymatic/biological debridement
Drugs applied topically to dissolve necrotic tissue and then covered with moist dressing
ex: leaches
what are the stages of pressure ulcers
stage 1 stage ll stage lll stage lV deep tissue injury nonstageable
what is a stage 1 pressure ulcer
non-blancable
redness
intact skin
tender, firm, soft warm or cool
what is stage ll pressure ulcer
partial thickness skin loss
exposure of dermis
no loud nor bruising
serios or serosanguious blister
what is stage lll pressure ulcer
full thickness tissue loss,
stubcutaenous, fat, but bone tendon and muscle not exposed
slough present
undermining and tunneling
what is stage lV pressure ulcer
full thickness tissue elosee bone, tendon, or muscle exposure slough or eschar present underminng and tunneling ostomyelitis and osteitisi
what is slough
stringy,attached to wound bed, could be necrotic
what is a deep tissue injury pressure ulcer
a purple or maroon localized area of discolored intact skin or a blood filled blister due to damage of underlying soft tissue from pressure eo sheet.
painful, firm, mushy, boggy
what is unstageable pressure ulcer
full thickenss tussue loss in which base of ulcer is covered in slough and/or eschar in the wound be
can’t see how deep it is because necrotic tissue on outside
untreated ulcer may lead to
cellulitis
Stage III or IV (full skin–thickness injury) pressure ulcer acquired after admission to a health care setting is considered
serious reportable event
what do we assess with wounds
location size color surrounding skin drainage temperature pain wound closure
what are some diagnostic tests
CBC sedirmentaion rate C reactive protein albumin total lymphocyte count
what is the normal albumin levels
anything over 3.5
what is a marker of sepsis
procalcitonin
what is a negative pressure wound therapy
vaccum/suction
what are additional therapies for wound healing
negative pressure wound
hyperbaric oxygen
positioning
what types of dressings are ther
gauze nonadherent transpaent films hydrocolloids hydrogels calcium alignate foam antimircobials
