Power Points info. Flashcards
Phases of healing (3)
1) Inflammatory phase
2) Proliferative phase
3) Remodeling
Inflammatory phase (3)
a) hemostasis
b) inflammation
c) cell migration
Proliferative stage (2)
a) regeneration
b) replacement with scar tissue
Epithelialization( constructing of new epidermis) begins. At the same time new granulation tissue is formed. New capillaries (angiogenesis) are created, restoring the delivery of oxygen and nutrients to the wound bed. Collagen is synthesized and begins to provide strength and structural integrity to the wound. Contraction, which occurs in open wounds and reduces the size of the wound.
Remodeling aka (maturation phase)
- Collagen is remodeled to become stronger and provide tensile strength to the wound.
- Outer appearance of an uncomplicated wound that will be that of a well-healed scar.
Hemostasis
- Blood vessels constrict; clotting factors activate coagulation pathways to stop bleeding.
- Clot formation seals the disrupted vessels so blood loss is controlled and acts as temporary bacterial barrier.
- Platelets release growth factors, which attract cells needed to begin the repair process.
Inflammation
- Vasodilation occurs, allowing plasma and blood cells to leak into the wound, noted as edema, erythema, and exudate.
- WBC (leukocytes) arrive in the wound to begin wound cleanup.
- Macrophages, appear and begin to regulate the wound repair.
- The result of the inflammatory phase is a clean wound bed in a patient with a noncomplicated wound
Complications of wound healing (4)
1) Hemorrhage
2) Infection
3) Dehiscence/eviceraiton
4) Fistula
Types of wound drainage (4)
1) Serous (clear watery plasma)
2) Sanguinous (bright red, fresh bleeding)
3) Serosanguinous ( pale, red, more watery)
4) Purulent (thick yellow, green or brown)
Factors Affecting Wound Healing (10)
1) Vasulature
2) Anemia
3) Age
4) Compromised host
5) Nutrition
6) Obesity
7) Drugs
8) Smoking
9) Stress
10) Infection
4 things you assess for wounds
1) Appearance
~Approximated edges?
~color
~wound closures
~presence of drain or tubes
2) Drainage
~amount
~color
~odor
~consistency
3) Pain
4) Other
~vitals, labs (WBC & C&S)Factors affecting wound care (6)
1) Type of wound
2) Size
3) Amount of exudate
4) Open vs closed
5) location
6) Physicians orders
5 goals of wound care
1) Prevent and manage infection
2) cleanse the wound~ do not use cleaners that are cytotoxic
3) remove nonviable tissue
4) manage exudate
5) protect the wound
(4&5) ~ Application of dressing
~purposes
~types
~Changing dressings
~Securing dressings
Debridement methods (4)
1) mechanical
2) Autolytic
3) chemical
4) surgical
Skills page 924
Autolytic debridement
Uses synthetic dressings over a wound to allow eschar to be self-digested by the action of enzymes that are present in wound fluids.
- Can be accomplished by using dressings that support moisture at the wound surface. If the wound base is dry use a dressing that adds moisture; if there is excess moisture use a dressing that absorbs moisture while maintaining moisture at the wound bed.
- Some examples are: transparent film, and hydrocolloid dressings.
Chemical debridement (Enzymatic debridement)
- The only enzyme available in the US is Collagenase which digests the necrotic tissue by dissolving the collagen in the dead tissue.
- The use of a topical enzyme preparation, Dankin’s solution, or sterile maggots.
- Depending on the type of enzyme used they either dissolve or breakdown the necrotic tissue.
- Dankin’s placed on a gauze pad and placed on wound breaks down and loosens dead tissue.
- Sterile maggots eat dead tissue.
Mechanical debridement
- The use of wet-to-dry saline gauze dressings.
- Place moistened gauze into the wound and let dry thoroughly before removing, it adheres to dead and viable tissue (so this method is not used routinely).
- NEVER use this method on clean, granulating wound.
- Other methods of mechanical; are wound irrigation (high-pressure irrigation and pulsatile high-pressure lavage) and whirlpool treatments.
Purpose of dressings (7)
1) Protect wound from contamination
2) promote hemostasis
3) Absorb drainage and debride wound
4) Support and splint the wound site
5) Approximate wounds edges
6) Cover unpleasant wound sites
7) Provide moist environment
Types of Dressings (5)
1) Gauze sponge dressings
2) Nonadherent gauze dressings
3) Self-adhesive transparent films
4) Hydrocolloid dressings
5) Hydrogel dressings
Gauze sponge dressing
- Are the oldest and most common dressing.
- They are absorbent and are especially useful in wounds to wick away the wound exudate.
- Diff. sizes and shapes, most common 4X4.
Nonadheherent gauze
- Such as Tefla over a clean wounds with little or no drainage.
- Tefla gauze has a shiny, nonahherent surface that does not stick to incisions or wound openings but allow drainage to pass through the gauze topper.
