Wound Management Flashcards
Causes of wounds
Hypoxia, heat/cold, mechanical trauma
Types of mechanical trauma
Abrasion (scrape)
Laceration (cut)
Contusion (bruise)
Puncture (poke)
Avulsion (tear)
Incision (surgical cut)
Exudate types
Serous (plasma)
Purulent (pus)
Sero-sanguinous (bloody/plasma)
Sanguinous (blood)
The 4 stages of wound healing
- Hemostasis
- Inflammatory
- Proliferative
- Remodeling
Healing types
Primary intention: Edges well approximated with sutures. Leaves fine scar.
Secondary Intention: Irregular large wound, heals by granulation tissue , large scar
Tertiary Intention: Contaminated wound. Heals by granulation tissue, delayed closure with suture
Pressure Injury Stages
Stage I: Reddened area
Stage II: Reddened area, forms blister
Stage III: Into subcutaneous tissue
Stage IV: Into muscle and bone
Complications in wound healing
Infection
Fistula formation
Dehiscence
Evisceration (emergency)
Adhesions
Contractures
Hyper-granulation
Hemorrhage
Formation of hypertrophic scars, keloids
Supporting wound healing
Acute: Observation, RICE
Collaborative care:
Drug therapy, hyperbaric oxygen therapy, nutritional therapy
Nursing Interventions:
Health promotion
Prevention of infection
Minimize inflammation
Adequate nutrition
Wound care
Wound Irrigation
Sterile saline
Sterile water
Tap water
Use enough pressure to clean debris but not do damage (8-15 psi)
Debridement Types
Surgical, mechanical, autolytic, enzymatic, biosurgical (maggots)
Purpose of wound packing
Absorb drainage
Protect the wound
Remove non-viable tissue
Fill dead space
Maintain moisture in wound
Negative pressure wound therapy
Negative pressure that absorbs drainage, fills dead space, keeps a moist environment and pulls on cells so they divide faster
