Wound Care/Healing Flashcards
What are the phases of wound healing?
- hemostasis
and inflammation - proliferation
- maturation and remodeling
What is hemostasis?
Injured blood vessels constrict and platelets gather to stop bleeding
What is the purpose of the scab that forms when the clot dries out?
protect the cut by keeping germs and other stuff out and giving the skin cells underneath a chance to heal
What causes vasodilation?
Damaged tissue and mast cells secrete histamine, leading to vasodilation
What is the role of white blood cells (leukocytes)?
- Neutrophil: ingest bacteria and small debris
- Monocyte = macrophages: clean wound of bacteria, dead cells, and debris by phagocytosis.
What is the role of macrophages?
They release growth factors to attract fibroblasts
What is the role of fibroblasts?
Synthesize collagen (connective tissue), providing matrix for granulation, in turn supporting re-epithelialization
Describe granulation
- Supports re-epithelization as granulation tissue fills the wound
- healing process in which lumpy, pink tissue containing new connective tissue and capillaries forms around the edges of a wound
What is the role of epithelials?
Migrate from wound edges and start to resurface. When surface has been repaired = epithelization
What is angiogenesis?
process by which new blood vessels form, allowing the delivery of oxygen and nutrients to the body’s tissues
Describe primary intention healing
- skin edges are approximated, or closed, and risk of infection is low.
- Healing occurs by epithelization and heals quickly with minimal scar formation, as long as infection and secondary breakdown are prevented
- Caused by surgical incision, wound is sutured or stapled
Describe secondary intention healing
- Wound involving loss of tissue (burn, pressure injury, severe laceration) heals by secondary intention
- Wound is open until filled by scar tissue (not approximated)
- Heals by granulation tissue formation, wound contraction, and epithelization
- Takes longer to heal so risk of infection is greater
- Scarring is severe
- Loss of tissue function is often permanent
Describe tertiary intention healing
- Wound open for several days, then wound edges are approximated
- Caused by wounds that are contaminated and require observation for signs of inflammation
- Closure of wound is delayed until risk of infection is resolved
What does WOUND represent? What do we use it for?
- W: what happened
- O: Oxygen/perfusion
- U: underlying factors
- N: Nutrition
- D: Disease/Drugs
- Whole patient assessment, interviewing patient
What is necrotic tissue?
- dead cells in your body organ due to lack of oxygen and interrupted blood supply. Cannot be reversed
- black or brown necrotic tissue is eschar
What is eschar
black or brown necrotic tissue is eschar
What is slough?
soft yellow or white tissue, stringy substance attached to wound bed
What is granulation tissue?
red, moist tissue composed of new blood vessels
List potential complications of wound healing
- hemorrhage
- Infection
- Dehiscence
- Evisceration
- Fistula formation
- Failure to heal progressing to a chronic wound
What is debridement?
removal of nonviable, necrotic tissue
What is wound dehiscence?
- Partial or total separation of wound layers
- Could be due to failed healing
What is evisceration?
- Protrusion of visceral organs through a wound opening (could be due to total separation of wounder layers)
- Emergent, Requires surgical repair.
What nursing care do you do if you see evisceration?
Quickly place sterile towels soaked in sterile saline over extruding tissues to reduce chance of bacterial invasion and drying of tissues and contact the physician.
What is excoriated?
Linear erosion of skin tissue resulting from mechanical means
What is exudate?
Describes amount, colour, consistency, and odour of wound drainage and part of wound assessment
- fluid leaking from wound
What is a fistula?
- Abnormal passage between two organs or between an organ and the outside of the body
- Formed due to poor wound healing, complication of disease like Crohn’s disease
What is a hematoma?
- Localized collection of blood underneath tissues.
- Appears as a swelling, a change in colour, sensation, warmth, or a mass that takes a bluish discoloration
What is induration?
Increased firmness of the tissue
Define ischemia
Reduction in blood flow
What are the types of drainage?
- purulent
- serous
- sanguineous
- serosanguineous
Describe purulent drainage
- white, yellow, green tan or brown fluid and might be slightly thick in texture
- sign of infection
Describe sanguineous drainage
Bright red, indicates active bleeding
Describe serous drainage
clear, watery plasma
Describe serosanguineous
Pale, red, watery, mixture of clear and red fluid
Why are wound drains inserted?
When a large amount of drainage is anticipated, drain is inserted in or near a surgical wound.
List the parameters that we would assess if patient has wound drainage system
- The number of drains and drain placement
- The security of the drainage apparatus (suture(s), safety pin)
- Character of drainage
- Drainage volume
- Drainage flow through tubing and around (to ensure patency -not obstructed)
- If connected to suction, system needs to be assessed to ensure pressure ordered is exerted
What do you do if there is a sudden decrease in drainage?
Sudden decrease in drainage through tubing may indicated blocked drain which may require surgical revision, contact physician
Define hemorrhage
bleeding from a wound site. Risk of hemorrhage is greatest during first 24-48 hours after surgery or injury
What are primary intention abnormalities?
- Wound’s incision line poorly approximated
- drainage present more than 3 days after closure
- inflammation decreased in first 3-5 days after injury
- no epithelization of wound edges by day 4
- no healing ridge by day 9
What are secondary intention abnormalities?
- pale or fragile granulation tissue, granulation tissue bed is excessively dry or moist
- exudate present
- necrotic or sloughy tissue present in wound base
- epithelization not continuous
- fruity, earthy, or putrid smell
- presence of fistulas, tunnelling, undermining
How does infection impact wound healing?
Prolongs inflammatory phase, delays collagen synthesis, prevents epithelization, and increases production of proinflammatory cytokines, which leads to additional tissue destruction
What is the role of protein in wound healing?
It helps rebuild epidermal tissue. Collagen is a protein formed from amino acids acquired by fibroblasts from protein ingested
What is the role of vitamin C in wound healing?
promotes collagen synthesis, capillary wall integrity, fibroblast function, and immunological function
What is the role of vitamin A in wound healing?
reduces negative effects of steroids on wound healing, epithelization, wound closure, inflammatory response, angiogenesis, collagen formation
What is the role of zinc in wound healing?
collagen formation, protein synthesis, cell membrane and host defenses
List the important vitamins and minerals for wound healing
- protein
- vit C
- vit A
- zinc
- collagen
- water
How does ischemia impact wound healing?
- decreases blood oxygen (O2 fuels cellular functions essential to healing)
- impairs blood flow
Define anemia
condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body’s tissues
How does smoking impact wound healing?
Vasoconstricts and prevents blood flow getting to a wound
How does corticosteroids impact wound healing?
topical corticosteroids can thin the skin and have anti-inflammatory properties that reduce healing
How does anti-inflammatory medications impact wound healing?
reduce inflammatory response in wounds leads to decreased healing responses
How does radiation impact wound healing?
harms cells responsible for cell repair
How does stress on a suture line impact wound healing?
openings forming into the skin and leading to poor scar formation
Define wound
disruption of the integrity and function of the tissues in the body
What are the types of wounds?
- with tissue loss
- without tissue loss
- acute wound
- chronic wound
What is an acute wound?
proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity
What is a chronic wound?
fails to proceed through an orderly and timely process to produce anatomical and functional integrity
What are the three teaching principles to prevent client contamination of procedures?
A) Avoid sudden movements of body parts covered by sterile drapes
B) refrain from touching sterile supplies, drapes, or nurse’s gloves or gown
C) avoid coughing, sneezing, or talking over sterile area
What are some anticipated issues during a prolonged sterile procedure? (4)
- pain
- voiding
- comfort
- need to cough
Nursing interventions for pain during procedure
Ensure that if patient is in pain before the procedure or it is anticipated they will develop pain during the procedure to administer analgesics no more than half an hour before procedure to allow relief from the pain so that they are better able to tolerate long procedures
Nursing intervention for voiding during procedure
Ensure that the patient void’s before the procedure begins to ensure that they will be able to withstand the entire procedure during one sitting both for patient convenience and not needing to set up another sterile field
Nursing intervention for comfort during procedure
Ensure that patient is comfortable enough in the position that they are in to be able to stay still for the entire duration of the sterile procedure
Nursing intervention for needing to cough during procedure
Ensure that if patient needs to cough they do so before the sterile field is set up or if they are excessively coughing provide them with a mask to prevent the contamination of the sterile field with their own microorganisms
Difference between surgical asepsis and medical asepsis
Medical: Reduce the number of microorganisms and their spread
Surgical: Eliminate all microorganisms, including spores, from an object or area.
what is a nosocomial infection
Infection that is transmitted and contracted at the hospital also known as a healthcare associated infection
Define sterilization
Removing of all microorganisms including bacteria spores
Define superinfection
Develops when broad spectrum antibiotics eliminate a wide range of microorganisms and not just those causing infection. Normal bacterial flora is eliminated, reducing body’s defences, and allowing disease-producing microorganisms to multiply
Define disinfection
Cleaning that eliminates all microorganisms but not bacteria spores
What is an invasive procedure?
Body cavity or organ is entered by either puncture or incision
List the 7 purposes for wound dressings
1) protects wound from microorganism contamination
2) aids in homeostasis
3) promotes healing by absorbing drainage and supports autolytic debridement
4) supports or splints wound site
5) protects patient from seeing wound (if unpleasant)
6) promotes thermal insulation of the wound surface
7) provides moist environment for the wound bed
When are wound dressings no longer required?
in a normally healing wound, when wound drainage is minimal, the healing process forms a natural fibrin seal that eliminates the need for a dressing. Wounds that have extensive tissue damage always require a dressing.
What is the purpose of the contact/primary layer of dressing?
thin, non-adherent sheets placed on an open wound bed to protect tissue from direct contact with other agents or dressings applied to the wound.
What is the purpose of an absorbent layer of dressing?
to absorb large quantities of exudate and hold it away from the wound and surrounding skin
What is the purpose of the outer protective/secondary layer of dressing?
an effective tool to protect the primary dressing or provide additional functionality beyond the primary dressing
What are the characteristics of moist dressing/healing?
- Reduced risk of infection
- Reduced healing time
- Faster re-epithelization
- Better cosmetic
What are characteristics for dry dressing/healing?
- Encourages scab formation
- Delays healing
- Increases pain
- May produce scar
How do you prevent dehiscence?
provide support to area using folded thin blanket or pillow placed over abdominal wound when patient is coughing. This splints and supports healing tissue when coughing increases intra-abdominal pressure.
What is an abdominal binder?
Supports large abdominal incisions that are vulnerable to tension or stress as patient moves or coughs. Secured with safety pins, Velcro strips, or metal stays
What are 4 assessment parameters to complete before applying a binder?
- Inspecting skin for abrasions, edema, discolouration, or exposed wound edges
- Covering exposed wounds or open abrasions with sterile dressing
- Assessing condition of underlying dressings and changing them, if soiled
- Assessing skin of underlying areas that will be distal to the bandage for signs of circulatory impairment (coolness, pallor, cyanosis, diminished pulses, swelling, numbness, and tingling) to provide a means for comparing changes in circulation after bandage application
What are the principles of surgical asepsis? (12)
- All objects used in the sterile field must be sterile
- Sterile objects touched by non-sterile objects are not sterile
- Sterile objects out of vision or below waist level are not sterile
- Sterile objects can become non-sterile by prolonged exposure to airborne micro-organisms (just-in-time set-up)
- DO NOT use wet/previously wet packaged sterile items - contaminated
- The edges of a sterile field are considered non-sterile (1” boarder)
- DO NOT reach over the sterile field
- DO NOT open sterile packages directly over the sterile field
- Keep the tips of your forceps pointing downward after wet
- DO NOT sneeze, cough or talk over your sterile field.
- Ask your patient to avoid talking over the open wound
- CHECK EXPIRATION DATES
Under what circumstances does a nurse collect a culture of wound drainage?
When there needs to be tests ran on the drainage, when there is abnormal findings, when there is an order for it
What are intermittent sutures?
surgeon ties each individual suture made in the skin
What are continuous sutures?
series of sutures with only two knots, one at the beginning and one at the end of the suture line
What are retention sutures?
placed more deeply than skin sutures, nurses may or may not remove them depending on agency policy
How does diabetes impact wound healing?
- poor circulation
- delays healing time
