wound healing Flashcards
what are the four phases of wound healing
-hemostasis
-inflammatory
-proliferative
-maturation
describe hemostasis
-first phase (occurs within 48 hours after wound)
-vasoconstriction
-exudate producation
-platelet activation -> clot formation
desrcibe the inflammatory phase
-vasodilation (increases drainage)
-phagocytosis (wound is flooded with WBCs)
-localized inflammatory response (looks like infection with redness, warmth, swelling, and tenderness)
-lasts 4-6 days
describe proliferative phase
-rebuilding, new tissue fills wound space
-lasts 3-24 days
-fibroblasts ad growth factor create collagen and blood vessels
-granulation tissue formation (not always visible, thin layer, super vascular)
describe maturation phase
-can take up to two years
-collagen matures
-scar tissue is created (less elastic and string than surrounding tissue, avascular with no hair or sweat)
in which phase of the wound healing process is new tissue built to fill the wound space, primarily through the action of fibroblasts?
proliferation phase
name some different types of wound healing
-primary intention (primary union)
-secondary intention (contraction and epithelialization)
-tertiary intention (delayed closure)
describe primary intention (primary union)
-clean incision
-minimal tissue loss
-early suture
-“hairline” or minimal scarring
describe secondary intention (contraction and epithelialization)
-gaping irregular wound
-heals from the bottom up
-epithelium grows over scar
-scarring and infection are more prevalent
-examples may include pressure injuries, deep lacerations, or burns
describe tertiary intention (delayed closure)
-wound is intentially left open for a period of time
-may be unable to close or need to monitor for bleeding
name some systemic factors that affect wound healing
-age (old ppl take long to heal)
-nutrition (protein, vitamins A & C, zinc)
-circulation and oxygenation
-health status (diabetes, shock, immunosupression, obesity, chemotherapy, steroids, antibiotics)
name some local factors that affect wound healing
-moisture (desiccation or maceration)
-trauma **
-edema** (interferes with blood flow)
-infection (increased stress to the body and demand of resources)
-bleeding (clots may need to be evacuated)
-necrosis (no healing with dead tissue)
-biofilm (thick collection of bacteria, can make wound difficult to treat)
what is desiccation
drying, dehydrated, crust
what is maceration
excessive moisture
name some complications of wound healing
-hemorrhage or hematoma
-dehiscence or evisceration
-infection
-fistula
describe hemorrhage
-can see
-low Hgb and Hct
describe hematoma
-collection of blood under intact skin, warm to touch, painful
-form in dependent area
-low Hgb and Hct
describe dehiscence
-wound edges separate
-r/t infection or wound stress
describe evisceration
-emergency
-abdominal organs escaping
describe infection
-occurs 7 dyas after wound
-microorganisms get in there
-sepsis and ostomyolitis
describe fistula
abnormal connection between two adjacent organs/vessels that usually do not connect
what are 5 signs of localized infection
- redness
- heat
- edema
- pain
- altered function
what wound complication is cuased by over hydration related to urinary and fecal incontinence
maceration
what subjective data is included in assessment of skin integrity
-normal skin condition
-hx of skin conditions/wounds
-psychosocial effects of impaired skin integrity (pain, fear, anxiety, impact of ADLs, change in body image)
what objective data is included in the assessment of skin integrity
-visual, tactile, olfactory assessment (wound assessment, presence of tubes or devices, areas of pressure)
-nutritional status
-risk scoring tools
-diagnostic tests (ex. biopsy)
what are some findings of intact skin
-color
-temperature
-moisture
-texture
-odor
-turgor
what are some examples of nurses diagnoses r/t skin integrity
-impaired skin integrity
-impaired tissue integrity
-risk for infection
-imblanced nutrition
-pain
describe outcome identification and planning r/t skin integrity
-patient speicifc and patient focused
-ex. skin will show no signs of breakdown during hospitalization
describe implementation r/t skin integrity
-health promotion (sunscreen, skin checks)
-prevention of pressure injuries (positionaing and skin care, pressure recucing surfaces)
-pateint teaching (hygiene and handwashing, pressure injury prevention, symptoms of infection)
-prevent and manage wounds (remove nonviable tissue and manage wound exudate)
-protect wounds (dressing)
-monitor lab values
-provide nutritional support
-teach patient appropriate wound care
describe evaluation r/t skin integrity
-evaluate pt outcomes r.t goals of the care plan
-evaluate and revise interventions
look at this
the use of sharp tools to remove devitalized tissue is called…
surgical debridement
assessing a wound on a foot, the nurse finds tissue destruction down to the bone. what would the nurse classify this as?
stage 4 pressure injury
which statement best describe the healing process for a surgical wound that was closed with sutures?
A. debridement aids in the surgical healing process
B. new tissue fills sides and base of wound
C. the proliferative stage is longer with surgical wounds
D. the edges of the wound are approximated
D
