Flashcards in Wound Care Deck (60)
Loading flashcards...
1
Intrinsic factors of wound healing
-age
-chronic diseases present
-perfusion/oxygenation
-immunosuppresison
-neurologically impaired skin
2
Extrinsic factors of wound healing
-medications
-nutrition
-irradiation and chemo
-psych stressors
-wound 'bioburden" and infection
3
Bioburden
-Whatever is colonized on a wound
-pathogens
4
Iatrogenic Factors for healing
-local ischemia due to pressure/other forces
-inappropriate wound care
-trauma
-wound extent and duration
5
Zones of Wound Healing
-zone of hyperemia
-zone of stasis
-zone of coagulation
6
Zone of coagulation
-area of necrosis
-will not heal
7
Zone of Hyperemia
-inflammatory response surrounding the wound
-normal tissue going through normal response
-redness of skin
8
Zone of Stasis
-part that may or may not heal
-important to protect this zone so it can heal
-hanging in the balance
9
Re-epithelialization
-recreation of a permeable barrier
-skin reinstituted as functional barrier
-epithelial cell migration from nearby tissues begins within hours of injury
10
Granulation Tissue
-new or budding tissue
-composed of capillaries and collagen
-fills defects of full-thickness wounds
-bleeds easily, relatively fragile
11
Demarcation
-clear differentiation between viable and non-viable tissue
12
Excoriated Tissue
-epidermal tissue abrasion
-to chafe, tear or wear off the skin
-often linear
13
Sinus Tract
-channel or passageway extending into viable tissues with one entrance only
-travels under skin
14
Tunneling
-narrow channel or passageway with openings on both ends
15
Abscess
-localized collection of pus
16
Induration
-palpably hard tissue
-often at edge of wound
-can indicate abscesses (must determine cause)
17
Drainage
-Exudate or transudate
-indicates inflammatory response
18
Exudate
-found in inflammatory stage of wound healing
-contains cells, proteins and other solid materials
-2 kinds: purulent or serous
19
Purulent
-milky/cloudy appearance but can be any color
-indicate infection
20
Serous
-thin, clear usually amber color
-mostly contains serum
-(Serosanguinous-thin with some RBC)
21
Transudate
-thin, cloudy drainage found in the proliferation stage of wound healing
-like exudate but has fewer cellular componenets
22
Dehiscence
-splitting of open wound
-separation of layers of surgical wound (partial, superficial or complete)
-bad
23
Risk Factor of Dehiscence
-obesity
-because adipose is less vascularized
24
Necrosis
-tissue death
-residual dead tissue can impede normal healing
25
Slough
-Yellow and thin covering of wound
-stringy appearance
26
Eschar
-more advanced necrosis
-soft or hard (leathery)
-represents full-thickness destruction of tissue
-black/dark colored
27
Necrotic tissue tends to become more______
-adherent to wound bed as level of damage increases
28
As necrotic tissue worsens, the color may____
-progress from white-grey to yellow to brown/black
29
Methods of Wound Closure
-first intent
-secondary intent
-third intent
30
First Intent Closure
-close the wound and done
31
Second Intent Closure
-larger wound must fill in on it's own
32
Third Intent
-intentionally left open to get rid of infection first
33
Debridement
-removal of dead tissue
-4 types
34
4 Types of Wound Debridement
-Mechanical
-Sharp
-Enzymatic
-Autolytic
35
Mechanical Debridement
-PT
-Pulsed lavage, whirlpool/flow-over hydrotherapy etc
36
Sharp Debridement
-with scalpel
37
Enzymatic Debridement
-put stuff on the wound to break down necrosis
38
Autolytic Debridement
-scab, body creates temporary roof
-healing under scab and scab falls off
-body does it on it's own
39
Ulcer
-loss of epidermis and dermis
-most are preventable
40
Common Locations of Decubitus Ulcers
-bony prominences
-ischium, sacrum, coccyx, olecranon, heels, occiput, scapulae, lateral malleoli, trochanters, acromion
41
Decubitus
lying down position
42
5 Risks/Causative factors for Decubitus Ulcers
-interface pressure (externally)
-Friction (skin on other surface)
-Shearing
-Maceration (softening due to excessive moisture)
-decreased skin resilience (dehydration)
43
Maceration
-softening due to excessive moisture
44
Grading decubitus ulcers
-grade I-IV
-IV is the worst
-stage I-skin is still intact
-don't massage area or use donut cushions
45
Osteomyelitis
-Bone infection
46
Signs of Infection
-redness
-fever
-increased temp
-discoloration
-drainage (smelly)
47
Prevention of Decubitus Ulcers
-MOBILITY
-assessment of surfaces in contact
-vigilance in the presence of incontinence
-multidisciplinary consultation (RN, NA, Family, Physicians)
48
Other Ulcer Types
-Arterial
-Venous
-Neuropathic
49
Modalities for Wound Care
-ESTIM
-US (pulsatile)
-SWD
-Whirlpool
50
Whirlpool
-softens eschar and other necrotic tissue
-turbulence provide mechanical debridement
-flow over therapy is better
51
Flow-Over Hydrotherapy
-wound cleansing with immediate flushing away of potentially infectious material
-more sanitary than whirlpool
52
Grade I Pressure Ulcer
-skin intact
-warmer/cooler than other skin
-firm or boggy consistency
-pain/itching sensation
-redness
53
Grade II Pressure Ulcer
-Partial thickness skin loss of epidermis and/or dermis
-superficial
54
Grade III Pressure Ulcer
-full thickness damage/necrosis to subq layer to fascia
-deep crater
-with/without undermining of adjacent tissue
55
Grade IV Pressure Ulcer
-Full thickness with necrosis or damage to muscle, bone or supporting structures (tendon, joint capsule)
-undermining and sinus tracts
56
Unstageable Pressure Ulcer
-wound covered with eschar
-or more than 50% necrotic tissue
-or filled with granulation tissue
57
Deep Tissue Injury (grade of pressure ulcer)
-pressure related injury to subq tissues under intact skin
58
Neuropathic ulcers
-weight bearing surfaces
-well-defined margins
-no undermining
-graunlation tissue present
-no pain
59
Arterial Ulcers
-deep pale base
-well defined edges
-black necrotic tissue
-dry
-cool leg
-painful
60
