Wounds Flashcards
Duration of inflammatory phase
Injury to day 4 post injury
Cardinal signs of inflammation (english)
Redness, swelling, warmth, pain
Cardinal signs of inflammation (Latin)
Rubor, Tumor, Calor, Dolore
Endothelial cells produce?
Blood vessels
Epithelial cells produce?
Skin
Fibroblasts produce?
Collagen
Duration of proliferative phase
Day 4 to day 21
Theory of hypergranulation tissue
Too much oxygen promotes hypergranulation (because synthesis is oxygen dependent). Epithelial cells can’t climb the hump of tissue against gravity and epithelialization is stopped. Skin will start to grow under wound.
Duration of maturation phase
Day 21 to 2 years post injury
Characteristics of an immature scar
Red, raised, rigid
Characteristics of a mature scar
Pale, planar, and pliable
Epibole
Hypergranulation causes skin to start to migrate under wound and cause edges of wound to be rounded
When is angiogenesis complete?
At the end of the inflammatory stage
Formula for percent chnage
(Baseline area - current area)/Baseline area
Crater
Tissue defect extending at least to the subcutaneous layer
Dead space
Any open area produced as a result of undermining, tunneling, or sinus tracking
Dermis
Contains blood vessels, nerve endings, epidermal appendages; composed of collagen and elastin fibers; thickenss depends on site and function
Epidermis
Functions for protection, sensation, temperature control;
Fistula
Abnormal passage between two organs or between an organ and outside of the body
Sinus Tract
A soft cavity or channel without defined edges that involves an area larger than the visible surface of the wound
Subcutaneous tissue
Fatty tissue, not well vascularized
Black wound color
Presence of necrotic tissue
Usually dry
Least healthy of wound types
Needs debridement/cleaning
Yellow wound color
Presence of necrotic tissue, possible infection
Usually heavy exudate
Less healthy than Red wound
Needs debridement/cleaning
Red wound color
Clean
Mild to moderate exudate
Granulating
Healing; healthiest of wound types
Stage 1 pressure ulcer
Nonblanchable erythema of intact skin that persists for more than thirty minutes after the pressure has been removed
In individuals with darker skin, discoloration, warmth, edema, and induration (hardness)
Stage 2 pressure ulcer
Partial thickness skin loss involving epidermis, dermis, or both
Superficial and presents as an abrasion, blister, or shallow crater
Stage 3 pressure ulcer
Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia
Presents clinically as a deep crater with or without undermining of adjacent tissue
Typically over a bony prominence
Stage 4 pressure ulcer
Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures
Undermining and sinus tracts
Eschar
Thick, leathery skin on top of wound that is dead tissue
What does CEAP stand for?
Clinical, etiology, anatomic, pathophysiological
Category I skin tear
Tears in which epidermal tissue can be approximated without loss of coverage
Category II skin tear
Tears show scant (25%) to moderate (75%) loss of epidermal tissue
Category III skin tear
Tears show complete loss of epidermal tissue
Contaminated wound
Containing non-replicating bacteria, other microorganisms, or foreign material
Colonized wound
Contain replicating microorgansims adherent to wound, but with no injury to host
Indications of infection (purulent exudate, foul odor, or inflammation) are absent
Infection
Containing replicating microorganisms within a would with damage to host
Equation for infection
Dose x virulence / Host resistance
Host resistance influenced by
Nutritional status
Disease status
Medication use
Primary cause of necrotizing facitis and how o treat it
Strept A
Treatment: Aggressive surgical debridement and amputation
How many colony forming units indicate infection?
10^5
Symptoms of fungal infections
Pruritis Inflammation Swelling Skin eruptions Scaling of skin
Who is at increased risk for fungal infections?
Compromised immune system
Antibiotic therapy
Diabetes
Examples of fungal infections
Candida (thrush and intertriago)
Ringworm
Athletes foot; jock itch
Aspergilli (mold)
Bacteriostatic
A substance that prevents or arrests the growth of microorganisms by preventing multiplication
Bactericidal
An agent that prevents or arrests the action of microorganisms either by inhibiting their activity or by destroying or killing them
Antiseptic
An agent used on living skin, either bactericidal or bacteriostatic
Risk Assessment Tools
Braden scale
Norton scale (specificity of 0.75)
Risk Assessment Pressure Sore (RAPS)
Categories of Norton Pressure Sore Risk
Physical condition Mental condition Activity Mobility Incontinence
Guidelines for Bed Pressure - High Risk
Dynamic flotation mattress
Low air loss bed system
Air-fluidized bed
Guidelines for Bed Pressure - Medium Risk
Static air-filled mattress overlay
Gel mattress overlay
T-foam mattress overlay
Guidelines for Bed Pressure - Low Risk
Mattress overlay 3”-4” foam
Gel mattress overlay
Water-filled mattress overlay
Guidelines for Bed Pressure - No Immediate Risk
Sheepskin pads - questionable effect
Heel protectors
Convoluted foam mattress tops
Autolysis
Disintegration of liquefaction of tissue or of cells by the body’s own mechanisms, such as leukocytes and enzymes
Crusted
Covered over with dried secretions
Denude
Removal of epidermis
Stripping
Denuding by mechanical means
Eschar
Dry, black or brown leathery materials; result of destruction of cells/blood vessels and desiccation of devitalized tissue
Ischemia
Deficiency of blood supply to a tissue, often leading to tissue necrosis
Macerate
To soften by wetting or soaking; refers to degenerative changes and disintegration of skin when it has been kept too moist
Necrosis
Death of tissue
Pus
Thick fluid indicative of infection containing leukocytes, bacteria and cellular debris
Scab
Dried exudate covering superficial wounds, usually containing hemolytic components
Slough
Moist yellowing or gray substance composed of a mixture of fibrin tissue debris and pus that contains bacteria and leukocytes
Autolytic
Use of synthetic dressing to cover a wound and allow eschar to self-digest by the action of enzymes present in wound fluids
Enzymatic
Topical application of proteolytic substances (enzymes) to breakdown devitalized tissue
Mechanical
Removal of foreign material and devitalized or contaminated tissue from a wound by physical forces rather than by chemical or natural forces
Non-selective debridement
Removes both healthy and non-healthy tissue
Selective debridement
Removes only necrotic tissue
Examples of non-selective debridement
Wet to dry Vigorous whirlpool jet agitation Wound irrigation Dakin's Hydrogen peroxide
Examples of selective debridement
Sharp/surgical
Enzymatic
Autolytic
Collagenase (chemical agent) most effective on what kind of tissue
Yellow-green fibrotic tissue and eschars
Indications for hydrotherapy
Need for hydration and increased circulation
Removal of cellular debris, foreign contaminants, and loosely attached necrotic tissue
Softening of thick, hard necrotic eschar
Ischemic wounds that have decreased pain when dependent
Use of calcium alginates
Moderately to highly exudative full thickness wounds and as fillers for moderately to highly exudative full thickness wound cavities
Use of cadexomer iodine
Chronic venous ulcers
Use of foam dressings
Full thickness wounds with moderate to heavy exudate
Use of hydrocolloid
Wounds with light to moderate exudate
Use of hydrogel
To fill a deep, dry wound
Use of transparent film
Open partial thickness wounds with minimal exudate or on closed wounds
Use of biosynethic dressings
Temporary or extended coverage of skin loss wounds like burns, donor sites, or skin tears
Indications for packing
Dead space impairs wound healing and predisposes abcess formation and infection
Contraindications for packing
Patient at increased risk for bleeding
Damage to tissue
Infection
