Wounds Flashcards
Thermoregulation skin?
vasoconstriction
vasodilatation
perspiration
Elimination done by skin?
through sweat
certain byproducts
electrolytes
water
Storage a function of skin?
stores 15% body’s water
stores 1/3 of the body’s blood supply
Synthesis of Vitamin D
when exposed to UV sunlight
Absorption?
of certain drugs
Sensation?
(pain, pressure, temperature)
Definition of wound:
any break in the normal integrity of the skin and tissues
Classifications of wounds?
Intentional vs Unintentional
Closed vs Open
Acute vs Chronic
Pressure injury stages
Intentional wounds: Planned procedures
Surgeries, interventional radiology therapies, paracentesis, etc.
Done under sterile field
Wound edges clean and bleeding usually under control
Infection minimal and healing facilitated
Acute wounds?
Heal within days to a week
Progresses through the normal healing process Ex: surgical inc
Risk of infection < chronic
Chronic wounds?
Healing is delayed >30 days
Healing stalled d/t infection, ischemia, continued pressure, or edema
Ex: diabetes ulcers, PVD, PI
The wound remains in the inflammatory phase of healing
Phases of wound healing?
Hemostasis
Inflammation (2-3 days)
Proliferation (Granulation, fibroblastic, connective tissue)
Maturation (Remodeling)
Hemostasis?
Occurs immediately after tissue injury
Vasoconstriction and blood clotting via platelet and fibrin aggregation
Level of contamination
contamination does not equal infection
Clean wound
Uninfected wound with minimal inflammation
Respiratory, GI, GU tracts not involved
Clean-contaminated wound
Surgical incisions that are madein the respiratory, GI, or GU tract
Higher risk of infection but no obvious infection
Contaminated wound
Open, traumatic wounds or surgical incision in which there is a bridge in asepsis
High risk of infection
Infected wounds
> 100,000 organisms per gram of tissue
Organisms present BEFORE procedure
*Beta-hemolytic strep presence in any number indicates and infected wound
*Beta-hemolytic strep presence
*Beta-hemolytic strep presence in any number indicates and infected wound
*Beta-hemolytic strep presence
When do Signs of Infection appear
Usually occurs 2-7 days after injury or surgery
Contaminated wounds more likely to get infected
PRESSURE INJURY?
“A PRESSURE INJURY is a localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device”
The injury can present as intact skin or an open ulcer.
STAGES OF PRESSURE INJURY?
STAGE 1
STAGE 2
STAGE 3
STAGE 4
SUSPECTED DEEP TISSUE INJURY
UNSTAGEABLE PRESSURE INJURY
DEVICE RELATED PI
Mucosal Membrane Pressure Injury:
Found on mucous membranes with a history of medical device at location of injury
Due to the anatomy of the tissue these injuries cannot be stage
Other Device Related PI That Can Be Staged
Behind ears from nasal cannula
Nasogastric tubes
Endotracheal tubes
PRESSURE INJURY stage 2
Partial thickness skin loss with exposed dermis
Wound bed viable, shallow, pink or red and moist
Intact serum filled or ruptured blister
No adipose tissue, granulation tissue, slough or eschar
May be mistakenly used to describe skin tears, burns, maceration, excoriation, incontinence associated dermatitis or, abrasions
How does infection affect wound healing?
Bacteria invades tissue → systemic response
How does infection affect wound healing?
Bacteria invades tissue → systemic response
What is undermining? Wound Assessment
Erosion under the wound edges, resulting in a large wound with a small opening
May have multiple directions
What is Tunneling? Wound Assessment
Destruction of the fascial planes which results in a narrow passageway
Potential for abscess formation
Usually one direction
*Use the clock face to describe direction of wound
Location. Wound Assessment
Describe location using anatomical terms
Non-healing wounds on feet usually d/t diabetes or PVD (peripheral vascular disease)
Jackson Pratt (JP)
Placed during surgery or interventional radiology to remove fluid collection
Can help in healing process and remove infected pockets of fluid
Flaps?
Blood supply stays attached to flap
Grafts don’t work well over hard structures like bones or very complex wounds
What is Regenerative/Epithelial Healing?
Wound only involves epidermis and dermis
New tissue cannot be distinguished from intact skin
No scar formation
E.g. Partial-thickness wounds
What are Langerhan cells? what are they made of? found ?
They phagocytize foreign material and trigger an immune response. they are on the epidermis
What tissue is the epidermis made of?
Thin, barrier layer
Made of by epithelial cells
What are keratinocytes? what do they provide ?
Found in epidermis. Keratinocytes provide strength and elasticity
What are Melanocytes? what do they provide ? found in ?
Epidermis. Melanocytes give skin pigment
What are Langerhan cells? what do they provide ? found in?
phagocytize foreign material and trigger an immune response
What layer is the dermis? What does it contain?
Second. Contains collagen: elastic connective tissue to provide structural integrity
Blood vessels
Sweat and oil glands, hair follicles, sensory receptor
Does the skin act as a physical barrier ?
YES
What is the ph on the skin?
Low pH (4-6.8), inhibits microbes
Acidic environment.
what does the sebum on the skin contain?
Sebum on the skin contains antimicrobials
How does the skin provide immunity?
Provides immunity
Epidermis: Langerhan cells
Dermis: macrophages and mast cell
Does the skin prevent excess fluid loss?
YES
Does the skin synthesis Vitamin D?
when exposed to UV sunlight
does the skin absorb certain drugs ?
Yes
what sensations are transmitted through the skin ?
pain, pressure, temperature
Another function of the skin is body image?
yes
What are the 4 wound classifications and their subcategories?
Intentional vs Unintentional
Closed vs Open
Acute vs Chronic
Pressure injury stages
What are the characteristics of intentional wounds ?
They are Planned procedures such as :
Surgeries, interventional radiology therapies, paracentesis, etc.
Done under sterile field
Wound edges are clean and bleeding is usually under control
Infection is minimal and healing is facilitated
What are the characteristics of unintentional wounds?
They are accidental such as :
Unexpected trauma (accidental cuts, stabbing, gunshot, burns)
Contamination of wound likely d/t unsterile environment
Bleeding may be uncontrolled
High risk of infection and longer healing time
What are the characteristics of open wounds through intentional or unintentional means?
well: The risk of infection is dependent on the intention.
If intentional = lower risk
If unintentional = higher risk
What are the characteristics of open wounds through intentional or unintentional means?
well: The risk of infection is dependent on the intention.
If intentional = lower risk
If unintentional = higher risk
What are the characteristics of closed wounds, meaning wounds where the skin stays intact?
Blunt force trauma: Falls, internal injury from a car accident, assault
Contusion, hematomas, ecchymosis
What are the characteristics of Acute wounds?
?
Heal within days to weeks
Progresses through the normal healing process Ex: surgical inc
Risk of infection < than chronic
What are the characteristics of chronic wounds?
Healing is delayed >30 days
Healing stalled d/t infection, ischemia, continued pressure, or edema
Ex: diabetes ulcers, PVD, PI
The wound remains in the inflammatory phase of healing
what are the 4 stages of healing?
Hemostasis (Bleeding)
inflammation
proliferative
remodeling
what are the 4 stages of healing?
Hemostasis (Bleeding)
inflammation
proliferative
remodeling
is inflammation a specific reaction ?
No
is inflammation the same as infection ?
Not the same as infection; although infections may trigger inflammation
is inflammation the same as infection ?
Not the same as infection; although infections may trigger inflammation
when does hemostasis occur and what happens during this stage?
Occurs immediately after tissue injury
Vasoconstriction and blood clotting via platelet and fibrin aggregation
What is inflammation intended for? where does it occur? which is the second phase of wound healing
Intended to neutralize, control or eliminate offending agent
Occurs at tissue level on skin : e.g. result of trauma, surgery, insect bites, sore throat
Occurs at cellular level inside body : e.g. stroke, DVT, myocardial infarctions
What is the chemical response during inflammation and what are the local symptoms? which is the second phase of wound healing
Chemicals mediators such as histamine, kinins, prostaglandins released at site of injury also responsible for early stage vasodilation
Kinins attract neutrophils to area
What is the chemical response during inflammation and what are the local symptoms? which is the second phase of wound healing
Chemicals mediators such as histamine, kinins, prostaglandins released at site of injury also responsible for early stage vasodilation
Kinins attract neutrophils to area
What is the systemic response during inflammation ? which is the second phase of wound healing
Fever caused by endogenous pyrogens released by neutrophils and macrophages
Chills occur in fevers d/t resetting of hypothalamic thermostat control
what is contusion?
A contusion is any injury that causes blood to collect under the skin
Echymosis
bruising
what is exudate?
a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation.
Parasentesis
Perforation of a cyst. Intentional wound
echhymosis
bruising
5 cardinal signs of inflammaton
redness
warmth
swelling
pain
loss of function
what provides immunity in the dermis?
macrophages and mast cells
what provides immunity in the dermis?
macrophages and mast cells
Hematoma
blood clot .A pool of mostly clotted blood that forms in an organ, tissue, or body space
chronic healing lasts ?
more than 30 days
kenin and prostaglandins.
Chemical response during innflammation. any of a group of substances formed in body tissue in response to injury. They are polypeptides and cause vasodilation and smooth muscle contraction.
kenins
attract neutrofils to the area of inflammation.
what causes fever during inflammation ?
endogennous pyrogens released by neutrophils and macrophages to rest highpothalamic temp
what causes fever during inflammation ?
endogennous pyrogens released by neutrophils and macrophages to rest highpothalamic temp
histamines and prostaglandins during inflammation ?
they cause vasodilation for wbc etc to come and help
what do fibroblasts do ?
fibro = cell blast= make.
They form collagen and produce growth factors to form BV. all of this results in granulation and tissue formation. it is highly vascular and bleeds easily though
Granulation tissue is
the foundation for scar formation
Granulation tissue is
the foundation for scar formation
Clean wound
Uninfected wound with minimal inflammation
Respiratory, GI, and GU tracts not involved
Clean wound
Uninfected wound with minimal inflammation
Respiratory, GI, and GU tracts not involved
Clean-contaminated
Surgical incisions that enter the respiratory, GI, or GU tract
Higher risk of infection but no obvious infection
Contaminated
Open, traumatic wounds or surgical incisions in which there is a breach in asepsis
High risk of infection
Infected wounds
> 100,000 organisms per gram of tissue
Organisms present BEFORE the procedure
Beta-hemolytic strep presence
*Beta-hemolytic strep presence in any number indicates and infected wound
When do signs of infecction occur in injury
2 to 7 days after
When do signs of infecction occur in injury
2 to 7 days after
ulcer
an open sore on an external or internal surface of the body, caused by a break in the skin or mucous membrane that fails to heal.
wher si the wound bed viable shallow and pink or red ?
stage 2 pressure injury
intact serum or reptured blister
stage 2
what is excoriation ?
excessive skin scratching
contamination does not equal infecction
yes
List 12 areas of bony prominance
Occiput
ear
scapula
elbow
sacrum
ischial tuberosities
greater trochanter
medial condyle of tibia
fibular head
medial mallelous
lateral malleolus
heel
how much is capillary pressure that causes low pressure ?
20mm hg ver low
ischimia
inadecuate blood supply to tissue
especially the heart
isch=to stop/slow
emia=blood
how long can tissue tolerate ischemia ?
2h only
mucosal membrane pi can’t be staged due to their anatomy and location?
true
where does a non blanchable erythema occur?
stage 1 PI
pressure injury is how in color ?
not marron or purpula because that is a feature of deep tissue injury
is stage 1 pressure injury difficult to asses in people with dark skin?
yes
what layer of skin can be seen with stage 2 PI
the dermis because there is a partial loss of skin
can we see adipose tissue, granulation, slough or eschar during a stage 2 pressure injury ?
hell no
what can a stage 2 PI mistake for?
skin tears, burns,maceration , excoriation, incontinence associated dermatitis and abrasions
is the skin intact in a stage 1 PI?
yes
warmth and firmness compared to adjacent tissue ?
stage 1
stage 3 and 4 PI are full thickness tissue loss
true
is adipose and granulation visible in the ulcer during stage 3 ?
yes
Is epibole (center ) visible during stage 3 PI?
yes
Slough and or eschar may be visible during a stage 3 PI
yes
what happens if Slough and or eschar obscure a 3 stage injury ?
the wound can’t be staged
Can undermining and tunneling occur in stage 3 injury ?
yes it may but not 100%
Is facia and bone and tendon visible in stage 3 injury?
no they are not
CERTAIN AREAS: NOSE, EARS, OCCIPUT ARE SHALLOW ULCERS BUT CAN BE STAGE III OR WORSE
?
true
Can we see Exposed bone, tendon, muscle, tendons, ligaments
in a stage 4 injury?
yes
is Epibole, undermining and/or tunneling common
in a stage 4 injury ?
yes
Slough or eschar may be present in a stage 4 pi but does not completely obscure the wound bed
true
can a stage 4 pi cause osteomyelitis?
yes
what is the healing scar tissue of stage 4 pi made of ?
made of protein/collagen tightly woven together
the new ly regenerated tissue from stage 4 pi is always gonna be stage 4 even if it looks like stage 2 because we can’t reverse staging
true
if a stage 4 injury is reopened we call it stage 4 even if it looks like stage 2
true
what is an unstageable pressure injury?
it is when Extent of tissue damage cannot be terminated d/t obscurity from slough or eschar
what happens of we remove eschar or slough from a stage 3 or 4 injury ?
it can be staged
can we remove eschar from a stable wound?
Stable eschar (dry, adherent, intact without erythema) on heel or limb should not be softened or removed. Provides natural barrier to cover wound
what is a deep pressure injury DTPI ? and what color is it ?
Persistent nonblanchable deep red, maroon, or purple discoloration
what is a serum filled blister ?
a stage 2 pi
what is a blister filled with blood ?
DTPI
is DTPI difficult to detect in dark people?
yes
DTPI
can resolve without tissue loss pr it can open and reveal the extent of tissue injury
shear is when?
One layer of tissue slides over another layer of tissue. Ex epidermis over dermis. This causes the 2 layers to separate from each other. due to this separation Blood vessels and capillaries damaged → impaired circulation
what is an example of shearing?
When a patient partially sitting up in bed and person sliding down toward foot of bed; skin sticks to sheet
does an edema and pressure interfere with blood flow ?
yes
do dehydrated cells die
?
yes dissecation kills cells
does moist environment promote epithelialization?
oui
does maceration caused by overhydration cause changes pH of skin and promotes bacterial growth and therefore causing infection?
yes
can epithelization occur over dead tissue ?
Necrosis - Epithelialization cannot occur over dead tissue (slough or eschar); must be debrided
what is a biofilm in a wound? and what does it do ?
A protective matrix of bacterial that ↓ the effectiveness of abx and normal immune response
does a biofilm contain multiple species of bacteria?
Biofilm may contain multiple species of bacteria that shield against the immune system and antimicrobial agents
can a biofilm healing through chronic inflammation, delayed granulation tissue formation, and delayed epithelial migration
yes
can a biofilm healing through chronic inflammation, delayed granulation tissue formation, and delayed epithelial migration
yes
biofilm Impairs migration and proliferation of keratinocytes
?
oui
Is a biofilm a reservoir for infection?
yes
what is the percentage of biofilm in chronic wounds ?
60%
what is the PRIMARY CAUSE OF WOUND CHRONICITY
biofilm
Adequate circulation importanat in wound healing ?
yes , to carry oxygen and nutrients to wound
Nutrition - wound healing requires adequate protein, carbohydrates, fats, vitamins and minerals, fluid intake
yes
does bacteria compete with granulation tissue for nutrition?
oui
Vit…. and …. essential for epithelialization and collagen synthesis
A and C
what does zinc do to cells ?
Zinc promotes proliferation of cells
what does zinc do to cells ?
Zinc promotes proliferation of cells
Is protein essential for cell and tissue growth? What is the recommended amount?
yes . 1-2.5 g/kg/day of protein to prevent tissue catabolism)
Is protein essential for cell and tissue growth? What is the recommended amount?
yes . 1-2.5 g/kg/day of protein to prevent tissue catabolism)
why is it important to make 50% of our diet carbs ?
cellular metabolism; protein sparing
30-45 kcal/kg/day to maintain (+ positive )nitrogen balance
how much fat should we intake for wound healing ?
20 to 30% of what we eat has to come from fat. It provides energy, protein sparing, vit A absorption
does fat help with vit A absorption ?
yes
HOw much fluid should we intake a day ?
- Maintain fluid intake to 1ml/Kcal/day (ex: 2500 Kcal =2500mL/day)
2.5 L
why does fever affect BMR and why is it used during wound healing?
fever regulates your temp and to carry this out you need more energy and therefore more oxygen to meet the BMR
what is diaphoresis? and what does it cause on the skin in excess?
masceration
what is a normal albumin level? what is its half life
3.2g to 5g /dl and its half-life is 20 to 22 days
what is normal prealbumin aka Transthyretin level? what is its half-life
(normal 2—42 g/DL)
Half life 2-4 days
what is a better indicator of current nutrition albumin or prealbumin ?
prealbumin
What is a normal level of transferrin and what does it do?
170 to 370 mg/dl
Transport protein to carry iron
Overly thin and obese people more susceptible to skin irritation and injury
yes
how do Corticosteroids affect wound healing?
decrease the inflammatory process
Anemia?
affects negativly wound healing
what does hypothermia cause in wound healing?
causes vasoconstriction
Impaired immune function and chronic illnes slow wound healing
true
chemotherapy agents, DM, prolonged abx, immunocompromised people have more difficulty healing
yes
Higher risk for dehiscence d/t increased tension on skin
it occurs in obese people
Wound tension in obese people increases tissue pressure-reduces microperfusion and O2 availability in obese people
oui
what does adiponectin do in obese people?
Low adiponectin impairs angiogenesis leading to micro-abnormalities that cause a persistent state of mild inflammation
Impaired keratinocyte proliferation and migration (critical step in re-epithelialization) is common in obese people
yes
Hyperglycemia impairs wound healing and leads to higher risk of infection
yes because it does not let the inmune system work
Stress of wound increases blood sugar level
oui
what do excess sugars do?
Excess sugars increase glycation → inhibit collagen and elastin regeneration
Impaired circulation in diabetes and perfusion lead to hypoxia (foot ulcers, chronic pressure-related wounds)
Free radicals from hypoxia further prolong injury
yes
diabetes causes Impaired immune function-T cells, phagocytosis, bactericidal ability etc.
oui
Vitamin A and C help with epithialization and collagen synthesis
oui
zinc promotes the proliferation of cells
si
dehiscence
In obese people Higher risk for dehiscence d/t increased tension on skin
Wound tension increases tissue pressure-reduces microperfusion and O2 availability in obese people
yes
Low adiponectin in obese people?
impairs angiogenesis leading to micro-abnormalities that causes a persistent state of mild inflammation
Impaired keratinocyte proliferation and migration in obese people causes?
slow re-epithelialization
obese pople are more prone to pressure ulcers
oui
Venous insufficiency and cardiovascular disease in obese people make the healing of a wound harder.
yes
Many obese people are actually malnourished despite their weight
True
Hyperglycemia impairs wound healing and leads to a higher risk of infection
oui
Hyperglycemia impairs wound healing and leads to a higher risk of infection
oui
Stress of wound increases blood sugar level
oui
Excess sugars increase glycation which in turn?
inhibit collagen and elastin regeneration
Impaired circulation and perfusion leads to ?
hypoxia (foot ulcers, chronic pressure related wounds)
Free radicals from hypoxia further prolong injury
diabetes impairs immune function-T cells, phagocytosis, bactericidal ability etc.
oui
Peripheral arterial disease
Limits activity d/t pain and leads to muscle atrophy
Thin tissue that is prone to ischemia and necrosis
Need to restore arterial blood perfusion for wound healing
Chronic venous disease
Results in engorged tissue with high levels of waste products resulting in edema, ulceration, and breakdown
is there a higher risk for dehiscence d/t increased tension on skin with …?
Obese people yes
what is adiponectin and what does it do?
Low adiponectin (protein) impairs angiogenesis leading to micro-abnormalities that cause a persistent state of mild inflammation
what happens to your sugar levels when you are stressed over a wound?
Stress of wound increases blood sugar level
what do free radicals from diabetes do
Impaired circulation and perfusion leads to hypoxia (foot ulcers, chronic pressure related wounds)
Free radicals from hypoxia further prolong injury
Intermittent claudication is a characteristic of which condition?
PAD (peripheral arterial disease)
No edema is a characteristic of which condition PAD or PVD?
PAD (peripheral arterial disease)
no pulse or weak pulse is a characteristic of which condition PAD or PVD?
pad
no drainage is a characteristic of which condition PAD or PVD?
PAD
round smooth sores is a characteristic of which condition PAD or PVD?
PAD
black eschar is a characteristic of which condition PAD or PVD?
PAD
location of sores on toes and feet is a characteristic of which condition PAD or PVD?
PAD
dull achy pain is a characteristic of which condition PAD or PVD?
PVD
lower leg edema is a characteristic of which condition PAD or PVD?
PVD
pulse and drainage present is a characteristic of which condition PAD or PVD?
PVD
sores with irregular borders is a characteristic of which condition PAD or PVD?
PVD
yellow slough or ruddy skin is a characteristic of which condition PAD or PVD?
PVD
location of sores in ankles is a characteristic of which condition PAD or PVD?
PVD
Wounds may get colonized from surrounding skin and local skin organisms but it does not mean that they are infected
yes
Subtle signs of contamination (bacteria has not invaded tissue) include:
new foul odor, ↑drainage, new tunneling of wound, absent or friable granulation tissue, change in color of wound bed
No active infection until critically colonized (>100K)
oui
Infection
causes ?
Bacteria invades tissue → systemic response
Diminished activity of sebaceous and sweat glands→xerosis (itchy, red, dry, cracked, or fissured skin)
age-related skin change
Epidermis and dermis thins and atrophies
age related skin change
Less effective thermoregulation d/t loss of lean body mass and subcutaneous tissue
age-related skin change
Changes in collagen/elastin fibers decreases elasticity and integrity → prone to tearing
Regeneration of healthy skin takes twice as long in an 80 year old vs 30 year old
Impaired tactile sensitivity
Blood vessels thinner and more fragile-bruise easily
Age Related Skin Changes
If wound present: appearance, drainage, size, closed or open, odor
MEASURE
oui
M
Measure size of wound
E
E=Exudate amount
A
A=Appearance of base: necrotic (black), fibrin (firm yellow), slough (soft yellow – viscous and opaque), granulation tissue (beefy and healthy or red and friable-unhealthy), biofilm
S
S=Suffering (Pain)
U
U=Undermining
R
R=Re-evaluate treatment
E
E=Edges
Measure dimensions
L X W X D
Assess for presence of tunneling/undermining using moistened Q-tip
Length-greatest length in cm (measure from head to toes)
Width-greatest width side to side
Depth-mark with Q-tip at deepest point and hold to ruler
Undermining
Erosion under the wound edges, resulting in a large wound with a small opening
May have multiple directions
Tunneling
Destruction of the fascial planes which results in a narrow passageway
Potential for abscess formation
Usually one direction
BLACK APPERANCE OF WOUND ?
necrotic
firm yellow APPERANCE OF WOUND ?
fibrin
soft yellow – viscous and opaque
slough
beefy and healthy or red and friable-unhealthy
granulation tissue
Wound Assessment Edge/perimeter of wound
Approximated, rolled, calloused
Wound open vs closed (sutures, staples, surgical glue)
Periwound skin (indurated, erythematous, macerated, bruised, normal)
Serous Exudate/drainage:
Serous-typical of clean wounds, clear and watery with little cells=straw colored serum
Sanguineous Exudate/drainage:
Sanguineous-bloody; if BRB=bleeding active; if red-brown and darker probably indicates capillary damage
Best practices for wound healing
Suspend heels – pressure off
Keep HOB at <30 degrees if no contraindication
Inspect skin every shift and at every turn
Nutrition and hydration
Apply moisture barrier if incontinent
Vigilant skin care and moisture
Encourage mobility
Reposition at least every 2 hours
Moist environment provide optimal conditions for wound healing →
increases rate of epithelialization and proliferation. healing exudate-vital proteins, cytokines, and growth factors which facilitate autolytic debridement
Inadequate moisture impedes cellular activities and promotes eschar formation → poor healing
yes
Dry dressings may disrupt healing when removed; fresh tissue gets removed during dressing change
yes
Excessive moisture leads to maceration and increases likelihood of skin breakdown
Creates supportive environment for bacterial growth
yes
Excessive moisture leads to maceration and increases likelihood of skin breakdown
Creates supportive environment for bacterial growth
yes
Wound care
Remove wound debris gently with normal saline
Maintain moist (not dry or wet) environment
Soften necrotic tissue with wet to damp dressing (autolytic debridement)
Always fluff gauze before packing wound
Use absorbing dressings to remove excess exudate
Protect peri-wound
Maintain an aseptic technique to reduce the risk of contamination and infection
Manage pain
Medihoney
contains an osmotic agent to draw out moisture from deeper tissue
Helps to lower the pH of the wound
Xeroform-
Xeroform-occlusive bacteriostatic
Hydrogel
Moist environment
Enhances autolytic debridement
Silver-based dressings
Antimicrobial
Mepilex – foam dressing
pad
Jackson Pratt (JP)
Placed during surgery or interventional radiology to remove fluid collection
Can help in healing process and remove infected pockets of fluid
Debridement
Removal of non-viable
Eliminates source of infection
Helps to visualize wound bed
Promotes healthy tissue to regenerate
Types of debridement
Autolytic
Enzymatic
Surgical
Mechanical
Maggot
negative pressure therapy
Applies negative pressure to the wound to remove excessive drainage (blood, exudate and infectious materials)
Provides direct and complete wound bed contact
Reduces edema
Promotes perfusion and granulation tissue formation by facilitating cell migration and proliferation
what is a Skin Graft:
Taking skin from another part of the body to protect/fill in defect
full-thickness skin graft vs split partial skin graft?
full: includs dermis and epidermis
partial: epidermis and some dermis
where are skin grafts usually taken from ?
areas with extra skin like buttocks, groin, thigh
how long for skin graft to heal ?
This “donor site” heals in 7-10 days
Split/Partial thickness skin graft
?
removes skin but leaves deeper structures with sweat glands and hair follicles
Flaps?
The blood supply stays attached to the flap
Grafts don’t work well over hard structures like bones or very complex wounds
Evaluation of wound ?
Assess the effectiveness of treatment at a minimum once per week with measurements/observations
Reevaluate treatment if not healing in timely manner
The expected trajectory/path for wound healing is that the wound should be 20% smaller at week 2 and 40-50% at week 4 to heal in 12 weeks
what is Regenerative/Epithelial Healing?
Wound only involves the epidermis and dermis
New tissue cannot be distinguished from intact skin
No scar formation
E.g. Partial-thickness wounds
Wound involves minimal or no tissue loss
1 intetntion
Edges approximated (sutures, staples, or surgical glue touching/closed)
primary intention
Minimal scarring (However scar tissue is still only 80% as strong as the original tissue)
Eg. Clean surgical incisions
primary intention
Extensive tissue loss that prevents edges from approximating or because wound intentionally left open d/t contaminated/infected tissue/blood clot
Secondary Intention:
Wound debrided or infection resolved then allowed to heal from inner layer to surface with beefy red granulation tissue (a type of connective tissue)
secondary
Heals more slowly and more scarring
secondary
Tertiary Intention aka
Delayed primary closure
Initially wound healed by secondary intention
3
When there is no evidence of edema or infection, granulation tissue pulled together and wound edges sutured
3
Less scarring than secondary intention
3
Requires strict aseptic technique to prevent infection
3
Hypertrophic scar
small bump
Keloid-scar
Keloid-scar outgrows border of injury; acts like a tumor
Adhesions
Adhesions: bands of scar tissue that form between or around organs e.g intestinal adhesions may lead to bowel obstructions
Excessive contraction results in
Excessive contraction results in deformity; shortens muscle or scar tissue, especially over joints, results from excessive fibrous tissue formation
Hemorrhage
Result from ruptured suture, accidental arterial puncture, fistulas, dislodged clot
Monitor surgical wound and drains frequently for bleeding for the first 48hrs
Apply pressure dressing if needed
Report uncontrolled and excessive bleeding
Hematomas:
type of hemmorage Hematomas: localized mass of blood that could cause tissue ischemia
Dehiscence and Evisceration
Most serious post-op complication
Dehiscence
Dehiscence - partial or total separation of a wound
Evisceration
Complication of a dehisced wound with protrusion of viscera (internal organ)
Prevention and nursing intervention:
in Dehiscence and Evisceration
Prevention and nursing intervention:
Splint wound when cough/sneezing, getting out of bed
Use abdominal binder
If evisceration occurs, place patient in low fowler and immediately cover exposed organ with moistened sterile saline gauze
Contact provider immediately and stay with patient
Fistula
Abnormal passage of an organ or vessel to the outside of the body or from an internal organ or vessel to another
Examples:
Carotid-cavernous fistula - an abnormal connection between the carotid artery to a large vein
Rectovaginal fistula - an abnormal connection between the rectum and vaginal
enterocutaneous fistula - an abnormal connection between the intestine and skin
Partial-thickness wounds?
Partial Thickness – A partial thickness wound is confined to the skin layers; damage does not penetrate below the dermis and may be limited to the epidermal layers only.
concussion
A concussion is an injury resulting specifically from brain trauma
Serosanguineous
most commonly seen in new wounds lighter pink, a combination of serous and sanguineous drainage
Purulence
thick, often malodorous (Pus-WBC’s, bacteria, and cellular debris
Purosanguineous
thick red-tinged pus indicating blood in an infected wound
