Wounds care Flashcards
Skin
Epidermis
Pigment and immune system
Hydration
Producing new skin cells
Protection. UV, pathogens, and chemicals
Skin color
Skin
Dermis
Nerve ending (sensations) Oil and sweat glands (keep moist) Hair production (hair follicles)
Wound healing stage
Hemostasis
What is the goal?
Stop bleeding
Vasocontraction allows for hemostasis
Platelets are activated
Wound healing stage
Inflammatory stage
What is the goal?
Clean wound/neutral body reaction!!
Beginning with the injury and lasts 3 to 6days
Delivering oxygen, WBCs, and nutrients
Macrophages engulf microorganisms
Wound healing stage
Proliferation
What is the goal?
# Fill and cover the wound Lasts the next 3 to 24days
Replacing lost tissue
Developing new blood vessels(angiogenesis)
Wound healing stage
Maturation
What is the goal?
Remodeling of scar tissue
Collagen is replaced by a stronger one
Primary intention
Little or no tissue loss
Wound edge well approximates, heals rapidly
A closed surgical incision with staples, sutures, or liquid glue
Secondary intention
Loss of tissue
Wound edges widely separated, un-approximated, longer healing time
Risk of infection
Tertiary intention
Widely separated
Opening of a previously closed wounds
Extensive drainage and tissue debris
Risk of infection
ex)
The abdominal wound is initially left open until the infection is resolved and then closed
The factors that delay healing
Age/increased age delays healing
Why?
Loss of skin turgor(elastic of the skin)
skin fragility
slower tissue regeneration
impaired immune system function
The factors that delay healing
Other factors (instead of age)
Decrease- circulation and oxygenation, absorption of nutrients, collagen
Obesity- fat tissue lack blood supply
Chronic disease additional stress on the body’s healing mechanisms
Smoking, decreased leukocytes count, malnourished pt, infection
Complication wound healing
Wound infection/clinical sigh 4
Erythema
Increased amount of drainage
Warmth
Evaluated WBCs
WBCs range normally 5,000 to 10,000
Traumatic wound infection generally develops at a______days
Surgical wound infection generally develops at post-op day b______ days
a) 2-3
b) 4 or 5
Complication wound healing
Hemorrhage
a) High risk during first what hours of post-op?
b) Process
a) 24-48
b) First, hemostasis occurs within several minutes (usually bleeding stops)
Pt has poor clotting function, blood vessel damage, hemorrhage occurs
This is an emergency situation!
A pressure dressing should apply!!
Notify the provider!!
Monitor vital sigh!!
Complication wound healing
Dehiscence
Incision fails to heal(a surgical cut)
The layer of the skin and tissue separate. (separation of underlying skin layers)
Complication wound healing
Evisceration
With the total separation of wound layer, emergency condition!!
Require surgical repair!!
Notify the provider immediately!!!
Stay with pt!!!
Cover the wound and any protruding organs with a sterile dressing.
Observe for indication of shock
keep the pt NPO in preparing for returning to surgery
Sanguineous drainage?
Contains serum and red blood cells. reddish.
Active bleeding!
Serosanguineous drainage?
Contains both serum and blood
Serous drainage?
The portion of the blood(serum)
Watery and clear or slightly yellow
Purulent drainage?
Infection!!!
Contains blood cells, tissue debris, and bacteria.
Interventions
Irrigation/deep wound
Irrigation solution-NS or commercial wound cleanser
Wear PPE, gown, sterile gloves, mask, and goggles
Hold the tip of the catheter 1inch(2.5cm) above the wound and the area
Clean until the solution draining into the basin is clear
If obtaining wound culture, perform culture after cleansing the wound
Pressure injury?
Local damage to the skin
Prolonged or intense pressure
Occurs bony prominences
Pressure injury stage 1?
Non-blanching erythema
Changes in sensation,
Temperature or firmness
The pic is branching = not stage 1
Pressure injury stage 2?
Partial-thickness skin
Partial thickness loos of dermis pressure
A shallow open ulcer with a red or pin wound bed
Pressure injury stage 3?
Full-thickness skin loss
Fat tissue is visible
Undermining and tunneling may occur
NO exposed muscle, tendons, bone etc
Pressure injury stage 4?
Full-thickness
Exposed muscle-tendon, bone, etc
