Wound Care Intro Flashcards
Skin function
Metabolism Protection Thermoregulation Sensation Social interaction Skin immune system
Epidermis complete renew
Every 3-4 weeks
Epidermis layers
Stratum consumer Stratum lucidum Stratum granulosum Stratum spinosum Stratum basale
Key cells in epidermis
Keratinocytes
Malnocytes
Langerhans
Basement membrane
Anchors epidermis to dermis
Laminate lucida and lamina densa
Semipermeable filter which regulates transfers of nutrients and cells b/n dermis and epidermis
What layer affected when a blister (bulla) forms
Basement membrane
Dermis
2-4mm
Papillary dermis and reticular dermis
Contains elastin and collagen
Dermis contains
Hair follicles Sweat glands Sebaceous glands Blood vessels Lymph vessels Nerves
Key cells in dermis
Fibroblast
Lymphocytes
Macrophages
Mast cells
Skin pigmentation
Effects the appearance of skin damage
Primary would closure
Immediate
Delayed primary wound closure
Wound is temporarily left open;
Closed in 4-7 days using sutures
Closure delayed to tx local infection or contamination or to allow edema to reduce
Secondary wound closure
Closes by new tissue formation w/ subsequent contraction and/or epithelialization
Phases of healing
Hemostasis (0-3 days)
Inflammation (4-6)
Proliferation (4-24)
Remodeling (3wks to 2 years)
Hemostasis
Vasoconstriction
Platelet aggregation
Fibrin seals lymph vessels
Migration of leukocytes
Inflammation
Release of histamine
Neutrophils early
Macrophages late
Phagocytosis
Proliferative phase
Fibroblast proliferation Fibroplasia Angiogenesis Reorganization of EC matrix Epithelialization
Maturation phase
3wks -2 years
Collagenase breaks down inappropriately oriented collagen molecules
New collagen, initially laid down in a chaotic way, becomes oriented along the lines of controls stress; has more tensile strength
Scar tissue strength
<80% as strong as original tissue
Chronic wound inflammation
“Dirty” Cellulitis Odor Escobar Drainage
Chronic wound proliferation
“Clean” Granulation Epithelialization Contracture Closure
Periwound
Blanchable Callous Cellulitis Dermatitis Edema Erythema Infection Ischemia Macerated
Blanchable
Turns white w/ pressure, then color returns
Callous
Extra layers of skin
Usually due to pressure
Cellulitis
Inflammation of tissue; presents with edema, erythema, pain, and heat, often with induration and a demarcation of the red area; usually signifies spreading infection
Dermatitis
Inflammation of the skin
Edema
Increased fluid in interstitial space
Erythema
Redness; caused by capillary hypermedia
Infection
Invasion and multiplication of microorganism in body tissue resulting in cellular injury
Ischemia
Impair blood supply
Macerated
Softening or sogginess of skin due to retention of excessive moisture; presents as white, moist skin
Wound base
Abscess Autolysis Contraction Dehiscence Demarcation Dermis Desiccated Epithelialization Eschar Ecchymotic Enterocutaneous fistula Friable Granulation Hypergranulation Necrosis Sinus tract Slough Undermining
Abscess
Hole or localized collection of purulent fluid; outside closes off and inside fills w/ purulent fluid
Autolysis
Natural, spontaneous progress of deviatlized tissue being separated from viable tissue
Contraction
Myofibroblast pulls would edges together, occurs in proliferative phase of wound healing
Dehiscence
Bursting open of a surgical incision, usually due to infection
Demarcation
Line b/n viable and non viable tissue
Desiccated
Dry dead tissue
Epithelialization
Part of proliferation phase of wound healing;
Characterized by new pink tissue
Eschar
Necrotic tissue which is tough and leathery or hard
Ecchymotic
Purple, damaged tissue
Enterocutaneous fistula
An abnormal connection b/n the intestines and skin
Friable
Fragile tissue that bleeds easily, used t describe unhealthy granulation tissue
Granulation
Beefy red tissue comprised of new blood vessels and collagen
Hypergranulation
Granulation tissue which forms above the level of the surrounding skin, preventing epithelial cells from growing across the wound
May also describe irregular granulation tissue
Necrosis
Dead tissue
Sinus tract
A vertical or oblique narrow channel or opening that leads away from the base of the wound and may penetrate the fascia; has potential for abscess
Slough
Yellow, gray, or green necrotic tissue; may be
viscous or fibrinous and tough; is often strongly
adherent to wound base
Undermining
Yellow, gray, or green necrotic tissue; may be
viscous or fibrinous and tough; is often strongly
adherent to wound base
Exudate
Serosanguineous
Serous
Sanguineous
Purulent
Serosanguineous exudate
Pink/yellow, thin
Serous exudate
Clear, watery, consistency
Sanguineous exudate
Bloody, red
Purulent exudate
Containing pus, opaque, cloudy
Autolysis debridement
Body’s own enzymes destroy necrotic tissue
Enzymatic debridement
Enzyme breaks down protein in necrotic tissue;
Used primarily for slough
With eschar, score prior to application
Mechanical debridement
Nonselective (whirlpool, pulsating lovage, wet to dry dressing, scrubbing)
Sharp debridement
Use of sharp instruments to debridement
Pairing callous
Shaving down callous at wound edges and periwound
Scoring eschar
Cutting perpendicular lines in necrotic tissue w/ sharp instrument to allow moisture to permeate the tissue
