Wounds Flashcards
Types of wounds?
Graze/abrasion
Bruising/Contusion
Haematoma
Puncture
Incised/Surgical
Laceration
Degloving
Burns/Scolds
Complicated
What are the different wound classifications?
Clean
- no signs of infection or inflammation
- eg made in surgery
Clean-contaminated
- no signs of infection
- but risk of becoming infected due to location
- eg surgical wounds in GI tract
Contaminated
- the outside object has come into contact with skin
- high risk of infection
- eg open wound
Dirty/Infected
- signs of infection
What are the stages of wound healing?
haemostasis
- bleeding is stopped
- vasoconstriction and platelet activation
inflammatory
- chemical signs throughout body
- draw in WBCs
(works simultaneously with haemostasis stage)
debridement
- WBCs migrate wound and breakdown bacteria
- wound stays at this stage if not healing well
Repair/proliferatice
- granulation tissue forms
- epithelial cells grow over epithelial tissue
- wound it shut
remodelling/maturation
- scar tissue is formed - college for strength
factors affecting wound healing
overall health of patient
systemic disorders - eg clotting or anorexia
age
hypoproteinaemia
blood supply
drugs - immunotherapy dampens immune system
infection
movement
excessive granulation tissue
patient interference
client interference
wound position
size, shape and appearance
general wound management?
initial stage
- cleaning and removing any non-viable tissue (debridement)
- if you suspect infection a culture should be taken prior to cleaning
- gently clean and flush the wound at a pressure of 8psi
wounds heal better when maintained in a moist environment
- so ideally bandaged to keep moisture in
frequency of bandage changes varies
- in the early stages, daily is likely due to excessive exudates
what are the types of debridement?
surgical
- using a scalpel and scissors to cut away necrotic tissue
- change surgical kit once all damaged tissue is removed
dressings
- do not leave on for longer than 24hrs
- hydrogels, hydrocolloids or adherent
- adherents can be wet-to-dry or dry-to-dry
what are the types of healing processes?
first intention
- wound formed by clea incision and sutured immediately (primary closure)
- minimal scar formation and edges unite firmly
second intention
- significant tissue loss so unable to close surgically
- the wound is left open to heal via granulation - use dressings
third intention
- contaminated - manage as open until infection/material is removed
- left open for a few days until granulation bed forms and then is sutured (secondary closure)
what are wound drains? what are the benefits?
implants that allow the removal of fluid/gas from a wound
benefits
- remove inflammatory mediators, bacteria, foreign material and necrotic tissue
- relieve pressure
- allow easy sampling of fluid during healing
- eliminate dead space
what are the two types of wound drains?
open/passive
- latex, polypropylene or rubber
- rely on capillary action, gravity, overflow and body movement
- bandage often gets saturated - risk of infection
- 48-72hours
closed/active
- collect fluid into a reservoir
- uses an artificial pressure gradient to pull gas/fluid from the wound
- prevents saturation of bandage material
- decrease risk of infection or contamination to staff
- 3-5+ days
what are the possible drain complications?
higher risk of infection
- introducing bacteria
- foreign body reaction
vascular damage
- if moved can cause pressure on the arterial wall
- causes narcosis
blockage
- clogged
- lose suction
- failure
electrolyte imbalance
- from high fluid production and loss
- causes metabolic derangements and hypoproteinaemia
what are skin grafts? why do we use them? how should we manage them?
small punches of skin taken from areas of loose skin
(eg. lateral thorax wall) and then places onto wound bed
- encourages new skin/hair regrowth through use of capillary action
used when a wound cant be close by pulling and stitching skin edges
- high tension = breakdown
or if it has no skin flap
- eg burn wounds
instead of scar tissue which has limited flexibility so not ideal in high tension areas
management:
- dresses changes - careful not to interrupt uptake
- immobilise area as much as possible
- client education
- high risk of infections - barrier nursing
