Exam 2 Flashcards
What are the 4 stages of wound healing?
1.) Homeostasis
2.) Inflammation
3.) Proliferation
4.) Remodeling
Homeostasis:
- Blood vessels constrict to stop bleeding
- Blood clots form
Inflammation:
- Preventing infection
- Neutrophils and Macrophages work to remove debris
Proliferation:
- Granulation of skin
- Tissue repair
- Wound rebuilds connective tissue for protection
Remodeling:
New epithelial tissue forms (New, Healthy Skin)
What are the four stages of Pressure Ulcers and their Characteristics?
Stage 1: Skin intact, redness
Stage 2: Partial-thickness skin loss/ Epidermis and dermis exposed
Stage 3: Full-thickness skin loss/ Epidermis, Dermis and Adipose Tissue Exposed
Stage 4: Full-thickness skin loss / bone, tendons/ligaments and /or Muscle exposed
Unstageable: “Unseen” full-thickness skin and tissue loss but hidden by sloth or eschar
Deep tissue pressure injury: Intact skin, deep red, maroon or purple color
What is slough?
The yellow/white material in the wound bed.
What is eschar?
A collection of dry, dead tissue within a wound. Think Necrotic Tissue.
What is secondary intention?
A wound will be left open (rather than being stitched together) and left to heal by itself, filling in and closing up naturally.
What is primary intention?
The healing of a wound in which the edges are closely re-approximated. (closed together with Sutures, Staples, Stitches etc)
What are the complications of wound healing?
1.) Infection
2.) Hemorrhaging
3.) Dehiscence
4.) Evisceration
Dehiscence definition:
Wound edges separating. Ex.) Sutures, Stiches ect. Popping open.
Hemorrhaging definition:
Loss of blood
Evisceration definition:
Dehiscence occurs then organs leave the open wound.
What nutrition is vital for wound healing?
Protein
Wound VAC ( vacuum-assisted closure) device is an example of what healing intention?
Secondary intention
What is the biggest difference between granulated tissue and Regular Tissue?
Unlike regular tissue granulated tissue is weak.
Debridement:
Removal of dead or necrotic tissue to expose healthy tissue to provide an environment for better wound healing.
What are the risk factors of Wound healing?
*Moisture: causes skin softening and breakdown
*Shear: sliding movement of skin while muscle and bone are stationary
*Friction: two surfaces being dragged against each other (skin and bed linens)
*Impaired mobility: inability to move causes prolonged pressure
*Pressure: prolonged compression
*Poor nutrition, less protein and calories means slower wound healing
If a patient scores 16 or lower on the Braden scale how at risk are they?
They are at risk
If a patient scores 9 or lower on the Braden scale how at risk are they?
They are at high risk.
What is the highest possible score on the Braden scale?
23
Braden scale: True or False
The higher the score the LESS at risk for skin breakdown
True
