Wounds1 Flashcards
What are the 3 layers of skin?
Epidermis
Dermis
Subcutaneous layer
According to NPIAP what is classified as a pressure injury ?
Localized damage to the skin and underlying soft tissue usually under a body prominence or related to a medical or other device
What are some risk factors for getting a pressure injury ?
Advanced age
Anemia
Contractors
Diabetes
Loc alteration
Impaired mobility
Obesity
Incontinence
What are some prevention interventions for pressure injuries?
Reposition patient
Clean skin properly after incontinence
Pressure reducing mattress
Flat heels off bed
Use lifting devices to prevent dragging
What are the 4 main type of classifications for pressure injuries?
Unstageable
Deep tissue pressure injury
Medical device related pressure injury
Mucosal membrane pressure injury
Deep tissue injury (DTi)
Happens from deep within
- look like a hematoma
What are the stages of pressure injuries?
1-4
Stage 1 pressure injuries
Intact skin with localized area of non blanchable erythema
Stage 2 pressure injury
Partial thickness loss of skin with exposed dermis
- wound bed visible / pink or red / moist
Stage 3 pressure injuries
Full thickness loss of skin
- adipose visible in ulcer and granulation tissue and episode ( rolled wound edge)
Stage 4 pressure injury
Full thickness tissue loss with exposed bone , muscle, or tendon
Epibole is
The rolling of skin inwards towards moisture
What is stable escar
It protects itself making the wound not broken open
What does a “healed stage 4 mean”?
A pressure injury was a stage four but it healed however it is more likely to break open again
Surgical acute wound
Skin graft donor
Surgical chronic wound
Infected incision
Nonsurgical acute wound
Burn/ skin tear
Non surgical chronic wound would be
Pressure injury
Lower leg ulcer
Primary intention in wound healing
Surgical - maintained by suchers / staples/ stitches
Secondary intention
Burn
Pressure ulcers
Severe laceration
Wound repair for a partial thickness
Inflammatory response, epithelial proliferation and migration , reestablishment of epidermal layers
Wound repair for a Full thickness pressure injury requires
Inflammatory response
Proliferation phase
Remodeling (svar)
3 phases part of wound repair
Inflammation
Proliferation/ granulation
Remodeling/ maturation
What are some complications that can happen during wound healing
Hemorrhage shock
Infection
Evisceration
Fistula formation
Adhesions
Dehiscence
Skin layers start to separate due to pressure
- happen 1week -1 1/2 week
Evisceration
Bowel goes out of wound
Fistula formation
Communication b/w two things that should not be happening
- colon & bladder become one
Wound vac purpose
Clean out a wound
What affects wound healing ?
Think: didn’t heal
D iabetes
I nfection
D rugs
N utrition
T issue necrosis
H ypoxia
E xcessive tension
A new wound
Low temp
Biofilm is
A slimy / shinny covering over a wound
- needs to be wiped off
What nutrients are important for wound healing?
Increase of calories
Protein
VitMin c
Vitamin a
Zinc
Serous drainage
Clear/ watery plasma
Purulent drainage
Thick yellow / green pus
Serosanguineous drainage
Pale pink watery mixture to clear and red fluid
Sanguineous drainage
Bright red : actively bleeding
Types of ways to close wounds
Staples
Stitches
Seri strips
What do you include in your assessment of a wound ?
Size : lxwxd
Anatomical markings
Tissue involvement - stage / thickness level
Wound bed characteristics
Is there undermining . Tunneling?
Condition of surrounding skin
Gluteal cleft
The butcrack
When doing measurements of a wound you should
Use it as a clock
12-6 is length
3-9 width
Is a wound a sterile or clean technique
Clean - do not touch or try not to touch as much as possible
Time framework is focusing on
Tissue management
Inflammation/ infection present?
Moisture imbalance
Edge
Wound management includes
Moist wound environment
Prevent / manage infection
Ensure wound bed in clean/ intact
Proper nutritional intake
Pain managed
Education
Types of wound debridement
Sharp - surgical
Mechanical - irrigation/ wet to dry dressings
Chemical - medical maggots
How do you clean a wound? Where to start?
Clean least to most contaminated
- wound to outside
Types of dressings
Gauze
Wet to dry
Telefax
Transparent
Hydrocolloid
Hydrogel
Hen does a patients wound usually get evaluated?
About 2 weeks
What is candidiasis
Fungal / yeast infection
- usually found under skin folds
