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Med/Surg 1 Exam 3 > Wound Care > Flashcards

Flashcards in Wound Care Deck (50)
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1

What are the three types of healing?

Primary intention
Secondary intention
Tertiary intention

2

What is part of primary intention healing?

Tissue surfaces approximated
Minimal or no tissue loss
Minimal granulation tissue and scar
Surgical incision

3

What is part of secondary intention healing?

Edges cannot or should not be approximated
Repair time longer
More scarring and risk of infection

4

What is part of tertiary intention healing?

Left open for 3-5 days and then closed
Allows edema to resolve exudate to drain
Closed with sutures, staples, or adhesive skin closures
"Delayed primary intention"

5

What are the phases of wound healing?

Hemostasis phase
Inflammatory phase
Proliferative phase
Maturation phase (remodeling)

6

What are some complications of wound healing?

Hemorrhage
Infection
Dehiscence
Evisceration

7

What are some modifiable factors for wound healing?

Nutrition
Lifestyle
Medications

8

What happens in the hemostasis phase?

Cessation of bleeding
Vasoconstriction and formation of clot
- Scab inhibits infection
- Epithelial cells migrate into wound- prevent entry of microorganisms

9

What happens in the inflammatory phase?

Blood supply increases
- Erythema and edema
- Exudate cleanses wound
- Neutrophils first 24 hours
- Replaced by macrophages
- Phagocytosis
- Crucial to healing

10

What happens in the proliferative phase?

Day 3-4 to 21 days
- Fibroblasts synthesize collagen: adds strength to wound
- Capillaries grow across wound, bring fibrin
- Granulation tissue forms
- Light red or pink

11

What happens in the maturation phase?

From day 21 up to 1-2 years
- Fibroblasts continue to synthesize collagen
- Wound site is remodeled and contracted
- Scar becomes stronger
-

12

What happens with a hemorrhage complication?

May bleed uncontrollably: emergency
Apply pressure
Surgery may be needed

Hematoma under wound may obstruct blood flow to area

13

What happens with an infection complication?

- Microbes compete for oxygen and nutrition: impairs wound healing
- Change in wound color, pain, drainage
- May occur during injury, surgery, or post-op
- Confirmed by culture
- May have fever, elevated WBC
- Immunosuppressed increased risk

14

What happens with a dehiscence complication?

- Partial or total rupture of sutured wound
- Cover with sterile saline gauze
- Patient to bed with knees bent
- Notify doctor

15

What happens with an evisceration complication?

- Protrusion of internal viscera through an incision
- Cover with large sterile dressing
- Patient in bed with knees bent
- Notify surgeon immediately

16

What are some risk factors for evisceration?

Obesity
Poor nutrition
Trauma
Failure to suture
Coughing
Vomiting
Straining

17

When does evisceration usually occur?

4-5 days post-op

18

Prevention: Nutrition

Protein
CHO's
Lipids
Vitamins A and C
Iron
Zinc
Copper

19

Prevention: Lifestyle

Regular exercise leads to better circulation
Smokers at risk for delayed healing

20

Prevention: Medications

Anti-inflammatory
Anti-neoplastic
Prolonged antibiotics

21

What is serous exudate?

Clear, thin, watery plasma.
Normal during inflammatory: in small amounts Moderate to heavy amount may indicate a high bioburden.

22

What is sanguineous exudate?

Fresh bleeding
In deep partial-thickness and full-thickness wounds.
Small amount may be normal during the inflammatory stage

23

What is Serosanguineous exudate

Thin, watery, and pale red to pink in color
The pink tinge indicates damage to the capillaries with dressing changes

24

What is a clinical manifestation of wounds?

Exudate

25

What is purulent exudate?

Thick and opaque
Tan, yellow, green, or brown in color
Never normal in a wound bed.

26

What are the different types of exudate?

Serous
Serosanguineous
Sanguineous
Purulent

27

Why are elderly patients at risk for impaired wound healing?

Impaired liver function
Nutritional deficiencies
Chronic illness
Vascular changes
Delayed inflammatory response
Slowed collagen synthesis

28

What is a diagnostic test for wounds?

Wound culture and sensitivity

29

When would there be a need for an emergency surgery for wounds?

Life threatening
Repair tissue or vessels

30

When would there be a non-emergency surgery for wounds?

Ineffective healing