Wound assessments Flashcards
(11 cards)
What is the first phase of wound healing and what occurs during it?
Hemostasis
Thrombin converts fibrinogen to fibrin, leading to coagulation from dilated vessels
Lasts for 0-2 days
What is the second phase of wound healing and what are signs of this?
Inflammatory Phase
Pain, redness, heat, swelling, and loss of function at the injury site.
From 2 to 4 days
What is the third phase of wound healing and what occurs during it?
Proliferative Phase
Rebuilding tissue through granulation, wound contraction, and epithelialization
From 4 to 21 days
What is the fourth phase of wound healing and what happens during it?
Maturation Phase
It strengthens the wound, even after it appears healed.
Can last up to 2 years
What is involved in wound assessments?
*Assessment the Whole Person
*General condition of the patient
*Medical and surgical history (diabetes, poor circulation)
*Contributing factors that may impair healing (age, chronic illnesses, medications, and lifestyle choices etc)
*Pain
*Wound Assessment and Plan (Size, depth, appearance, drainage, and signs of infection)
What does dry eschar and/or black necrosis indicate in a wound?
*May indicate necrosis and typically needs debridement
*Dead tissue that appears black, often indicating a lack of blood supply
What is yellow slough?
A soft, yellow tissue that may be necrotic and is often a sign of infection or tissue breakdown
What is granulation tissue?
New tissue that forms during wound healing, characterised by a pink or red color and a bumpy texture.
What does epithelising tissue indicate in a wound bed?
The process of new skin cells forming over the wound, indicating healing is progressing
What should be the main aim of a wound dressing?
Debride
Donate Moisture
Reduce bacterial burden
Absorb Moisture
Protect New Tissue
What are the principles in wound care to fill dead space?
*Dead space must be filled with dressing
material to ensure that wound closure is
delayed until the space has been replaced with
granulation tissue:
*Cavity
*Undermined tissue
*Tracts
*Make sure you can get it out in one piece!
