Wound classification and assessment and wound care management. Flashcards
wound classification
1- partial thickness where all or a portion of the dermis is intact;
2- full thickness where the entire dermis and sweat glands and hair follicles are severed, expose bone, tendon, or muscle
3- unstageable, a full-thickness loss where the true depth cannot be determined; deep tissue injury
intentional wounds
such as surgery, intravenous therapy or lumbar puncture
wounds edges are clean and bleeding is usually controlled
Unintentional wounds
accidental wounds.
such as
unexpected traumas, gunshots, burns, forcible injury.
wounds are jagged bleeding uncontrolled, high risk for infection.
open wounds
Skin surface is broken, providing a portal of entry for microorganisms. Bleeding, tissue damage, increase in infection
Ex; incisions and abrasions
Closed wounds
blow, force or strain caused by trauma. Skin is NOT broken, but tissue is damaged, internal injury and hemorrhage.
Ex; ecchymosis, hematomas.
Acute wounds
Surgical incisions, usually heal within days to weeks.
edges are well approximated and risk of infection is low.
healing process is usually not interrupted
Chronic wounds.
The wound edges are often not approximated, the risk of infection is increased,
healing time is delayed (>30 days).
remain in the inflammatory phase of healing
Wounds healed by primary intention
well approximated (skin edges tightly together).
primary can become secondary if they become infected.
Wounds healed by secondary intention
edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated,
Wounds healed by tertiary intention
wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed
Undernourished patients are at greater risk for developing a wound infection because
they have difficulty mounting their cell-mediated defense system associated with T-lymphocyte activity
inflammatory phase
follows hemostasis and lasts about 2 to 3 days. White blood cells, predominantly leukocytes and macrophages, move to the wound.
macrophages enter wound.
ingest debris, release growth factors which release epithelial cells. Attracks fibroblasts that help fill the wound.
Acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury.
Hemostasis
Hemostasis occurs immediately after the initial injury. Involved blood vessels constrict and blood clotting begins through platelet activation and clustering
causes swelling and pain
platelets simulate other cells to migrate to the injury
proliferation phase
lasts for several weeks, fibroblastic, regenerative, or connective tissue.
new tissue is built to fill the wound space, primarily through the action of fibroblasts
granulation tissue, forms the foundation for scar tissue development
Collagen synthesis and accumulation continue, peaking in 5 to 7 days
maturation (or remodeling) phase
3 weeks after the injury, and can continue for month or years.
scar, an avascular collagen tissue that does not sweat, grow hair, or tan in sunlight, eventually becomes a flat, thin line.
