Wound Care Flashcards
Functions of skin
Protects Controls body temp Functions as excretory organ Functions as sensory organ Provides identity
Functional components of the skin
Epidermis
Dermis
Subcutaneous tissue
Epidermis
Tough leathery outer skin
Keritinocytes, melanocytes, Merkel cells, Langerhan’s cells
Functions:protection, regulates body fluid, production of vitamin D
Dermis
Highly vascular
Superficial lymphatics
Fibroblasts, macrophages, WBC, mast cells
Functions: nutrition, thermoregulation, sensation
Subcutaneous tissue
Supports the skin
Adipose tissue and fascia
Partial thickness wounds
Loss of epidermis
Can lose part of dermis
Full thickness wounds
Loss of epidermis and dermis
Sequence for tissue healing
Inflammatory phase
Proliferation
Maturation/remodeling
Signs and symptoms of inflammation
Redness
Swelling
Heat
Pain
Proliferation
When cells needed for repair and regeneration reach the injury site
4 crucial events during proliferative phase
Angiogenesis
Granulation tissue formation
Wound contraction
Epithelialization
Maturation/remodeling
The granulation tissue laid down must be strengthened/reorganized
Collagen synthesis continues
Fibers reorient along lines of stress
Internal influence
External influence
Continues up to 2 years
Scar tissue is at most 80% of original tissue strength
3 processes of wound closure
Primary intention
Secondary intention
Tertiary intention
Primary intention
Wounds without tissue loss Edges approximated Low risk for infection Heals quicly Dry dressing or no dressing Surgical incision
Secondary intention
Wounds with tissue loss Edges not approximated High risk for infection Heals slowly Wet to dry dressing Pressure ulcer, burn
Tertiary intention
Wounds in which closure is purposefully delayed Moderate infection risk Moderate scar Heals quickly once closed Moist dressing when dry, dry when closed Contaminated wound, traumatic injury
Signs and symptoms of infection
Temperature Flu symptoms Tachycardia WBC, C-reactive protein test Purulent drainage Edema/erythema Malodorous wound drainage Induration
Factors affecting wound healing
Local: circulation, sensation, mechanical stress
Systemic: age, drugs, lifestyle, diseases
At-risk clients
Immobility COPD, PVD, cardiac disease Immune deficiencies, infection Poor nutrition/hydration Diabetes/obesity Meds Age Severity of wound
Assessment
Inspection, palpation, olfaction
Subjective data
Pain, pruritus, body image
Objective data
ABCDE
Expected findings
Clean pink/red edges Moderate to no edema Temp same as other tissue Minimal drainage Pain decreasing consistently
Complications
Bleeding Dehiscence Fistula formation Infection Excessive pain Loss of mobility or function Anxiety Body image disturbance
Dehiscence
Separation of epidermis and dermis
Fistula formation
Opening between organ and outside or two organs
Types of wound drainage
Sanguineous: bleeding
Serosanguineous: thing watery
Serous: clweawr, thin, watery
Purulent: thick, opaque, tan/yellow/green/brown
Host interventions
Hand washing
Improve nutrition: Vitamins A and V, protein, zinc, iron, calories (>4000/day extra), fluids (2 L/day)
Mobility
Rest
Mode of transmission interventions
Handwashing Clean environment PPE Barrier techniques Cover portals
Agent interventions
Handwashing Isolation precautions Proper disposal of contaminated items Antibiotics Culture and sensitivity of wound
