Wounds Flashcards
(293 cards)
1
Q
Thermoregulation skin?
A
vasoconstriction
vasodilatation
perspiration
2
Q
Elimination done by skin?
A
through sweat
certain byproducts
electrolytes
water
3
Q
Storage a function of skin?
A
stores 15% body’s water
stores 1/3 of the body’s blood supply
4
Q
Synthesis of Vitamin D
A
when exposed to UV sunlight
5
Q
Absorption?
A
of certain drugs
6
Q
Sensation?
A
(pain, pressure, temperature)
7
Q
Definition of wound:
A
any break in the normal integrity of the skin and tissues
8
Q
Classifications of wounds?
A
Intentional vs Unintentional
Closed vs Open
Acute vs Chronic
Pressure injury stages
9
Q
Intentional wounds: Planned procedures
A
Surgeries, interventional radiology therapies, paracentesis, etc.
Done under sterile field
Wound edges clean and bleeding usually under control
Infection minimal and healing facilitated
10
Q
Acute wounds?
A
Heal within days to a week
Progresses through the normal healing process Ex: surgical inc
Risk of infection < chronic
10
Q
Chronic wounds?
A
Healing is delayed >30 days
Healing stalled d/t infection, ischemia, continued pressure, or edema
Ex: diabetes ulcers, PVD, PI
The wound remains in the inflammatory phase of healing
10
Q
Phases of wound healing?
A
Hemostasis
Inflammation (2-3 days)
Proliferation (Granulation, fibroblastic, connective tissue)
Maturation (Remodeling)
10
Q
Hemostasis?
A
Occurs immediately after tissue injury
Vasoconstriction and blood clotting via platelet and fibrin aggregation
11
Q
Level of contamination
A
contamination does not equal infection
12
Q
Clean wound
A
Uninfected wound with minimal inflammation
Respiratory, GI, GU tracts not involved
13
Q
Clean-contaminated wound
A
Surgical incisions that are madein the respiratory, GI, or GU tract
Higher risk of infection but no obvious infection
14
Q
Contaminated wound
A
Open, traumatic wounds or surgical incision in which there is a bridge in asepsis
High risk of infection
15
Q
Infected wounds
A
> 100,000 organisms per gram of tissue
Organisms present BEFORE procedure
16
Q
*Beta-hemolytic strep presence in any number indicates and infected wound
A
*Beta-hemolytic strep presence
17
Q
*Beta-hemolytic strep presence in any number indicates and infected wound
A
*Beta-hemolytic strep presence
18
Q
When do Signs of Infection appear
A
Usually occurs 2-7 days after injury or surgery
Contaminated wounds more likely to get infected
19
Q
PRESSURE INJURY?
A
“A PRESSURE INJURY is a localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device”
The injury can present as intact skin or an open ulcer.
21
Q
STAGES OF PRESSURE INJURY?
A
STAGE 1
STAGE 2
STAGE 3
STAGE 4
SUSPECTED DEEP TISSUE INJURY
UNSTAGEABLE PRESSURE INJURY
22
Q
DEVICE RELATED PI
A
Mucosal Membrane Pressure Injury:
Found on mucous membranes with a history of medical device at location of injury
Due to the anatomy of the tissue these injuries cannot be stage
23
Other Device Related PI That Can Be Staged
Behind ears from nasal cannula
Nasogastric tubes
Endotracheal tubes
24
PRESSURE INJURY stage 2
Partial thickness skin loss with exposed dermis
Wound bed viable, shallow, pink or red and moist
Intact serum filled or ruptured blister
No adipose tissue, granulation tissue, slough or eschar
May be mistakenly used to describe skin tears, burns, maceration, excoriation, incontinence associated dermatitis or, abrasions
25
How does infection affect wound healing?
Bacteria invades tissue → systemic response
25
How does infection affect wound healing?
Bacteria invades tissue → systemic response
25
What is undermining? Wound Assessment
Erosion under the wound edges, resulting in a large wound with a small opening
May have multiple directions
26
What is Tunneling? Wound Assessment
Destruction of the fascial planes which results in a narrow passageway
Potential for abscess formation
Usually one direction
*Use the clock face to describe direction of wound
27
Location. Wound Assessment
Describe location using anatomical terms
Non-healing wounds on feet usually d/t diabetes or PVD (peripheral vascular disease)
28
Jackson Pratt (JP)
Placed during surgery or interventional radiology to remove fluid collection
Can help in healing process and remove infected pockets of fluid
29
Flaps?
Blood supply stays attached to flap
Grafts don’t work well over hard structures like bones or very complex wounds
30
What is Regenerative/Epithelial Healing?
Wound only involves epidermis and dermis
New tissue cannot be distinguished from intact skin
No scar formation
E.g. Partial-thickness wounds
31
What are Langerhan cells? what are they made of? found ?
They phagocytize foreign material and trigger an immune response. they are on the epidermis
32
What tissue is the epidermis made of?
Thin, barrier layer
Made of by epithelial cells
33
What are keratinocytes? what do they provide ?
Found in epidermis. Keratinocytes provide strength and elasticity
34
What are Melanocytes? what do they provide ? found in ?
Epidermis. Melanocytes give skin pigment
35
What are Langerhan cells? what do they provide ? found in?
phagocytize foreign material and trigger an immune response
36
What layer is the dermis? What does it contain?
Second. Contains collagen: elastic connective tissue to provide structural integrity
Blood vessels
Sweat and oil glands, hair follicles, sensory receptor
37
Does the skin act as a physical barrier ?
YES
38
What is the ph on the skin?
Low pH (4-6.8), inhibits microbes
Acidic environment.
39
what does the sebum on the skin contain?
Sebum on the skin contains antimicrobials
40
How does the skin provide immunity?
Provides immunity
Epidermis: Langerhan cells
Dermis: macrophages and mast cell
41
Does the skin prevent excess fluid loss?
YES
42
Does the skin synthesis Vitamin D?
when exposed to UV sunlight
43
does the skin absorb certain drugs ?
Yes
44
what sensations are transmitted through the skin ?
pain, pressure, temperature
45
Another function of the skin is body image?
yes
46
What are the 4 wound classifications and their subcategories?
Intentional vs Unintentional
Closed vs Open
Acute vs Chronic
Pressure injury stages
47
What are the characteristics of intentional wounds ?
They are Planned procedures such as :
Surgeries, interventional radiology therapies, paracentesis, etc.
Done under sterile field
Wound edges are clean and bleeding is usually under control
Infection is minimal and healing is facilitated
48
What are the characteristics of unintentional wounds?
They are accidental such as :
Unexpected trauma (accidental cuts, stabbing, gunshot, burns)
Contamination of wound likely d/t unsterile environment
Bleeding may be uncontrolled
High risk of infection and longer healing time
49
What are the characteristics of open wounds through intentional or unintentional means?
well: The risk of infection is dependent on the intention.
If intentional = lower risk
If unintentional = higher risk
49
What are the characteristics of open wounds through intentional or unintentional means?
well: The risk of infection is dependent on the intention.
If intentional = lower risk
If unintentional = higher risk
50
What are the characteristics of closed wounds, meaning wounds where the skin stays intact?
Blunt force trauma: Falls, internal injury from a car accident, assault
Contusion, hematomas, ecchymosis
51
What are the characteristics of Acute wounds?
?
Heal within days to weeks
Progresses through the normal healing process Ex: surgical inc
Risk of infection < than chronic
52
What are the characteristics of chronic wounds?
Healing is delayed >30 days
Healing stalled d/t infection, ischemia, continued pressure, or edema
Ex: diabetes ulcers, PVD, PI
The wound remains in the inflammatory phase of healing
53
what are the 4 stages of healing?
Hemostasis (Bleeding)
inflammation
proliferative
remodeling
53
what are the 4 stages of healing?
Hemostasis (Bleeding)
inflammation
proliferative
remodeling
54
is inflammation a specific reaction ?
No
55
is inflammation the same as infection ?
Not the same as infection; although infections may trigger inflammation
56
is inflammation the same as infection ?
Not the same as infection; although infections may trigger inflammation
57
when does hemostasis occur and what happens during this stage?
Occurs immediately after tissue injury
Vasoconstriction and blood clotting via platelet and fibrin aggregation
58
What is inflammation intended for? where does it occur? which is the second phase of wound healing
Intended to neutralize, control or eliminate offending agent
Occurs at tissue level on skin : e.g. result of trauma, surgery, insect bites, sore throat
Occurs at cellular level inside body : e.g. stroke, DVT, myocardial infarctions
58
What is the chemical response during inflammation and what are the local symptoms? which is the second phase of wound healing
Chemicals mediators such as histamine, kinins, prostaglandins released at site of injury also responsible for early stage vasodilation
Kinins attract neutrophils to area
58
What is the chemical response during inflammation and what are the local symptoms? which is the second phase of wound healing
Chemicals mediators such as histamine, kinins, prostaglandins released at site of injury also responsible for early stage vasodilation
Kinins attract neutrophils to area
58
What is the systemic response during inflammation ? which is the second phase of wound healing
Fever caused by endogenous pyrogens released by neutrophils and macrophages
Chills occur in fevers d/t resetting of hypothalamic thermostat control
59
what is contusion?
A contusion is any injury that causes blood to collect under the skin
60
Echymosis
bruising
61
what is exudate?
a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation.
62
Parasentesis
Perforation of a cyst. Intentional wound
63
echhymosis
bruising
64
5 cardinal signs of inflammaton
redness
warmth
swelling
pain
loss of function
64
what provides immunity in the dermis?
macrophages and mast cells
64
what provides immunity in the dermis?
macrophages and mast cells
65
Hematoma
blood clot .A pool of mostly clotted blood that forms in an organ, tissue, or body space
66
chronic healing lasts ?
more than 30 days
67
kenin and prostaglandins.
Chemical response during innflammation. any of a group of substances formed in body tissue in response to injury. They are polypeptides and cause vasodilation and smooth muscle contraction.
67
kenins
attract neutrofils to the area of inflammation.
68
what causes fever during inflammation ?
endogennous pyrogens released by neutrophils and macrophages to rest highpothalamic temp
68
what causes fever during inflammation ?
endogennous pyrogens released by neutrophils and macrophages to rest highpothalamic temp
69
histamines and prostaglandins during inflammation ?
they cause vasodilation for wbc etc to come and help
70
what do fibroblasts do ?
fibro = cell blast= make.
They form collagen and produce growth factors to form BV. all of this results in granulation and tissue formation. it is highly vascular and bleeds easily though
71
Granulation tissue is
the foundation for scar formation
72
Granulation tissue is
the foundation for scar formation
73
Clean wound
Uninfected wound with minimal inflammation
Respiratory, GI, and GU tracts not involved
73
Clean wound
Uninfected wound with minimal inflammation
Respiratory, GI, and GU tracts not involved
74
Clean-contaminated
Surgical incisions that enter the respiratory, GI, or GU tract
Higher risk of infection but no obvious infection
75
Contaminated
Open, traumatic wounds or surgical incisions in which there is a breach in asepsis
High risk of infection
76
Infected wounds
>100,000 organisms per gram of tissue
Organisms present BEFORE the procedure
77
Beta-hemolytic strep presence
*Beta-hemolytic strep presence in any number indicates and infected wound
78
When do signs of infecction occur in injury
2 to 7 days after
78
When do signs of infecction occur in injury
2 to 7 days after
79
ulcer
an open sore on an external or internal surface of the body, caused by a break in the skin or mucous membrane that fails to heal.
80
wher si the wound bed viable shallow and pink or red ?
stage 2 pressure injury
81
intact serum or reptured blister
stage 2
82
what is excoriation ?
excessive skin scratching
83
contamination does not equal infecction
yes
84
List 12 areas of bony prominance
Occiput
ear
scapula
elbow
sacrum
ischial tuberosities
greater trochanter
medial condyle of tibia
fibular head
medial mallelous
lateral malleolus
heel
85
how much is capillary pressure that causes low pressure ?
20mm hg ver low
86
ischimia
inadecuate blood supply to tissue
especially the heart
isch=to stop/slow
emia=blood
87
how long can tissue tolerate ischemia ?
2h only
88
mucosal membrane pi can't be staged due to their anatomy and location?
true
89
where does a non blanchable erythema occur?
stage 1 PI
90
pressure injury is how in color ?
not marron or purpula because that is a feature of deep tissue injury
91
is stage 1 pressure injury difficult to asses in people with dark skin?
yes
92
what layer of skin can be seen with stage 2 PI
the dermis because there is a partial loss of skin
93
can we see adipose tissue, granulation, slough or eschar during a stage 2 pressure injury ?
hell no
94
what can a stage 2 PI mistake for?
skin tears, burns,maceration , excoriation, incontinence associated dermatitis and abrasions
95
is the skin intact in a stage 1 PI?
yes
96
warmth and firmness compared to adjacent tissue ?
stage 1
97
stage 3 and 4 PI are full thickness tissue loss
true
98
is adipose and granulation visible in the ulcer during stage 3 ?
yes
99
Is epibole (center ) visible during stage 3 PI?
yes
100
Slough and or eschar may be visible during a stage 3 PI
yes
101
what happens if Slough and or eschar obscure a 3 stage injury ?
the wound can't be staged
102
Can undermining and tunneling occur in stage 3 injury ?
yes it may but not 100%
103
Is facia and bone and tendon visible in stage 3 injury?
no they are not
104
CERTAIN AREAS: NOSE, EARS, OCCIPUT ARE SHALLOW ULCERS BUT CAN BE STAGE III OR WORSE
?
true
105
Can we see Exposed bone, tendon, muscle, tendons, ligaments
in a stage 4 injury?
yes
106
is Epibole, undermining and/or tunneling common
in a stage 4 injury ?
yes
107
Slough or eschar may be present in a stage 4 pi but does not completely obscure the wound bed
true
108
can a stage 4 pi cause osteomyelitis?
yes
109
what is the healing scar tissue of stage 4 pi made of ?
made of protein/collagen tightly woven together
110
the new ly regenerated tissue from stage 4 pi is always gonna be stage 4 even if it looks like stage 2 because we can't reverse staging
true
111
if a stage 4 injury is reopened we call it stage 4 even if it looks like stage 2
true
112
what is an unstageable pressure injury?
it is when Extent of tissue damage cannot be terminated d/t obscurity from slough or eschar
113
what happens of we remove eschar or slough from a stage 3 or 4 injury ?
it can be staged
114
can we remove eschar from a stable wound?
Stable eschar (dry, adherent, intact without erythema) on heel or limb should not be softened or removed. Provides natural barrier to cover wound
115
what is a deep pressure injury DTPI ? and what color is it ?
Persistent nonblanchable deep red, maroon, or purple discoloration
116
what is a serum filled blister ?
a stage 2 pi
117
what is a blister filled with blood ?
DTPI
118
is DTPI difficult to detect in dark people?
yes
119
DTPI
can resolve without tissue loss pr it can open and reveal the extent of tissue injury
120
shear is when?
One layer of tissue slides over another layer of tissue. Ex epidermis over dermis. This causes the 2 layers to separate from each other. due to this separation Blood vessels and capillaries damaged → impaired circulation
121
what is an example of shearing?
When a patient partially sitting up in bed and person sliding down toward foot of bed; skin sticks to sheet
122
does an edema and pressure interfere with blood flow ?
yes
123
do dehydrated cells die
?
yes dissecation kills cells
124
does moist environment promote epithelialization?
oui
125
does maceration caused by overhydration cause changes pH of skin and promotes bacterial growth and therefore causing infection?
yes
126
can epithelization occur over dead tissue ?
Necrosis - Epithelialization cannot occur over dead tissue (slough or eschar); must be debrided
127
what is a biofilm in a wound? and what does it do ?
A protective matrix of bacterial that ↓ the effectiveness of abx and normal immune response
128
does a biofilm contain multiple species of bacteria?
Biofilm may contain multiple species of bacteria that shield against the immune system and antimicrobial agents
129
can a biofilm healing through chronic inflammation, delayed granulation tissue formation, and delayed epithelial migration
yes
130
can a biofilm healing through chronic inflammation, delayed granulation tissue formation, and delayed epithelial migration
yes
131
biofilm Impairs migration and proliferation of keratinocytes
?
oui
132
Is a biofilm a reservoir for infection?
yes
133
what is the percentage of biofilm in chronic wounds ?
60%
134
what is the PRIMARY CAUSE OF WOUND CHRONICITY
biofilm
135
Adequate circulation importanat in wound healing ?
yes , to carry oxygen and nutrients to wound
136
Nutrition - wound healing requires adequate protein, carbohydrates, fats, vitamins and minerals, fluid intake
yes
137
does bacteria compete with granulation tissue for nutrition?
oui
138
Vit.... and .... essential for epithelialization and collagen synthesis
A and C
139
what does zinc do to cells ?
Zinc promotes proliferation of cells
139
what does zinc do to cells ?
Zinc promotes proliferation of cells
140
Is protein essential for cell and tissue growth? What is the recommended amount?
yes . 1-2.5 g/kg/day of protein to prevent tissue catabolism)
140
Is protein essential for cell and tissue growth? What is the recommended amount?
yes . 1-2.5 g/kg/day of protein to prevent tissue catabolism)
141
why is it important to make 50% of our diet carbs ?
cellular metabolism; protein sparing
30-45 kcal/kg/day to maintain (+ positive )nitrogen balance
142
how much fat should we intake for wound healing ?
20 to 30% of what we eat has to come from fat. It provides energy, protein sparing, vit A absorption
143
does fat help with vit A absorption ?
yes
144
HOw much fluid should we intake a day ?
- Maintain fluid intake to 1ml/Kcal/day (ex: 2500 Kcal =2500mL/day)
2.5 L
145
why does fever affect BMR and why is it used during wound healing?
fever regulates your temp and to carry this out you need more energy and therefore more oxygen to meet the BMR
146
what is diaphoresis? and what does it cause on the skin in excess?
masceration
147
what is a normal albumin level? what is its half life
3.2g to 5g /dl and its half-life is 20 to 22 days
148
what is normal prealbumin aka Transthyretin level? what is its half-life
(normal 2—42 g/DL)
Half life 2-4 days
149
what is a better indicator of current nutrition albumin or prealbumin ?
prealbumin
150
What is a normal level of transferrin and what does it do?
170 to 370 mg/dl
Transport protein to carry iron
151
Overly thin and obese people more susceptible to skin irritation and injury
yes
152
how do Corticosteroids affect wound healing?
decrease the inflammatory process
153
Anemia?
affects negativly wound healing
154
what does hypothermia cause in wound healing?
causes vasoconstriction
155
Impaired immune function and chronic illnes slow wound healing
true
156
chemotherapy agents, DM, prolonged abx, immunocompromised people have more difficulty healing
yes
157
Higher risk for dehiscence d/t increased tension on skin
it occurs in obese people
158
Wound tension in obese people increases tissue pressure-reduces microperfusion and O2 availability in obese people
oui
159
what does adiponectin do in obese people?
Low adiponectin impairs angiogenesis leading to micro-abnormalities that cause a persistent state of mild inflammation
160
Impaired keratinocyte proliferation and migration (critical step in re-epithelialization) is common in obese people
yes
161
Hyperglycemia impairs wound healing and leads to higher risk of infection
yes because it does not let the inmune system work
162
Stress of wound increases blood sugar level
oui
163
what do excess sugars do?
Excess sugars increase glycation → inhibit collagen and elastin regeneration
164
Impaired circulation in diabetes and perfusion lead to hypoxia (foot ulcers, chronic pressure-related wounds)
Free radicals from hypoxia further prolong injury
yes
165
diabetes causes Impaired immune function-T cells, phagocytosis, bactericidal ability etc.
oui
166
Vitamin A and C help with epithialization and collagen synthesis
oui
167
zinc promotes the proliferation of cells
si
168
dehiscence
In obese people Higher risk for dehiscence d/t increased tension on skin
169
Wound tension increases tissue pressure-reduces microperfusion and O2 availability in obese people
yes
170
Low adiponectin in obese people?
impairs angiogenesis leading to micro-abnormalities that causes a persistent state of mild inflammation
171
Impaired keratinocyte proliferation and migration in obese people causes?
slow re-epithelialization
172
obese pople are more prone to pressure ulcers
oui
173
Venous insufficiency and cardiovascular disease in obese people make the healing of a wound harder.
yes
174
Many obese people are actually malnourished despite their weight
True
175
Hyperglycemia impairs wound healing and leads to a higher risk of infection
oui
176
Hyperglycemia impairs wound healing and leads to a higher risk of infection
oui
177
Stress of wound increases blood sugar level
oui
178
Excess sugars increase glycation which in turn?
inhibit collagen and elastin regeneration
179
Impaired circulation and perfusion leads to ?
hypoxia (foot ulcers, chronic pressure related wounds)
Free radicals from hypoxia further prolong injury
180
diabetes impairs immune function-T cells, phagocytosis, bactericidal ability etc.
oui
181
Peripheral arterial disease
Limits activity d/t pain and leads to muscle atrophy
Thin tissue that is prone to ischemia and necrosis
Need to restore arterial blood perfusion for wound healing
182
Chronic venous disease
Results in engorged tissue with high levels of waste products resulting in edema, ulceration, and breakdown
183
is there a higher risk for dehiscence d/t increased tension on skin with ...?
Obese people yes
184
what is adiponectin and what does it do?
Low adiponectin (protein) impairs angiogenesis leading to micro-abnormalities that cause a persistent state of mild inflammation
185
what happens to your sugar levels when you are stressed over a wound?
Stress of wound increases blood sugar level
186
what do free radicals from diabetes do
Impaired circulation and perfusion leads to hypoxia (foot ulcers, chronic pressure related wounds)
Free radicals from hypoxia further prolong injury
187
Intermittent claudication is a characteristic of which condition?
PAD (peripheral arterial disease)
188
No edema is a characteristic of which condition PAD or PVD?
PAD (peripheral arterial disease)
189
no pulse or weak pulse is a characteristic of which condition PAD or PVD?
pad
190
no drainage is a characteristic of which condition PAD or PVD?
PAD
191
round smooth sores is a characteristic of which condition PAD or PVD?
PAD
192
black eschar is a characteristic of which condition PAD or PVD?
PAD
193
location of sores on toes and feet is a characteristic of which condition PAD or PVD?
PAD
194
dull achy pain is a characteristic of which condition PAD or PVD?
PVD
195
lower leg edema is a characteristic of which condition PAD or PVD?
PVD
196
pulse and drainage present is a characteristic of which condition PAD or PVD?
PVD
197
sores with irregular borders is a characteristic of which condition PAD or PVD?
PVD
198
yellow slough or ruddy skin is a characteristic of which condition PAD or PVD?
PVD
199
location of sores in ankles is a characteristic of which condition PAD or PVD?
PVD
200
Wounds may get colonized from surrounding skin and local skin organisms but it does not mean that they are infected
yes
201
Subtle signs of contamination (bacteria has not invaded tissue) include:
new foul odor, ↑drainage, new tunneling of wound, absent or friable granulation tissue, change in color of wound bed
202
No active infection until critically colonized (>100K)
oui
203
Infection
causes ?
Bacteria invades tissue → systemic response
204
Diminished activity of sebaceous and sweat glands→xerosis (itchy, red, dry, cracked, or fissured skin)
age-related skin change
205
Epidermis and dermis thins and atrophies
age related skin change
206
Less effective thermoregulation d/t loss of lean body mass and subcutaneous tissue
age-related skin change
207
Changes in collagen/elastin fibers decreases elasticity and integrity → prone to tearing
Regeneration of healthy skin takes twice as long in an 80 year old vs 30 year old
Impaired tactile sensitivity
Blood vessels thinner and more fragile-bruise easily
Age Related Skin Changes
208
If wound present: appearance, drainage, size, closed or open, odor
MEASURE
oui
209
M
Measure size of wound
210
E
E=Exudate amount
211
A
A=Appearance of base: necrotic (black), fibrin (firm yellow), slough (soft yellow – viscous and opaque), granulation tissue (beefy and healthy or red and friable-unhealthy), biofilm
212
S
S=Suffering (Pain)
213
U
U=Undermining
214
R
R=Re-evaluate treatment
215
E
E=Edges
216
Measure dimensions
L X W X D
Assess for presence of tunneling/undermining using moistened Q-tip
Length-greatest length in cm (measure from head to toes)
Width-greatest width side to side
Depth-mark with Q-tip at deepest point and hold to ruler
217
Undermining
Erosion under the wound edges, resulting in a large wound with a small opening
May have multiple directions
218
Tunneling
Destruction of the fascial planes which results in a narrow passageway
Potential for abscess formation
Usually one direction
219
BLACK APPERANCE OF WOUND ?
necrotic
220
firm yellow APPERANCE OF WOUND ?
fibrin
221
soft yellow – viscous and opaque
slough
222
beefy and healthy or red and friable-unhealthy
granulation tissue
223
Wound Assessment Edge/perimeter of wound
Approximated, rolled, calloused
Wound open vs closed (sutures, staples, surgical glue)
Periwound skin (indurated, erythematous, macerated, bruised, normal)
224
Serous Exudate/drainage:
Serous-typical of clean wounds, clear and watery with little cells=straw colored serum
225
Sanguineous Exudate/drainage:
Sanguineous-bloody; if BRB=bleeding active; if red-brown and darker probably indicates capillary damage
226
Best practices for wound healing
Suspend heels – pressure off
Keep HOB at <30 degrees if no contraindication
Inspect skin every shift and at every turn
Nutrition and hydration
Apply moisture barrier if incontinent
Vigilant skin care and moisture
Encourage mobility
Reposition at least every 2 hours
227
Moist environment provide optimal conditions for wound healing →
increases rate of epithelialization and proliferation. healing exudate-vital proteins, cytokines, and growth factors which facilitate autolytic debridement
227
Inadequate moisture impedes cellular activities and promotes eschar formation → poor healing
yes
228
Dry dressings may disrupt healing when removed; fresh tissue gets removed during dressing change
yes
229
Excessive moisture leads to maceration and increases likelihood of skin breakdown
Creates supportive environment for bacterial growth
yes
230
Excessive moisture leads to maceration and increases likelihood of skin breakdown
Creates supportive environment for bacterial growth
yes
231
Wound care
Remove wound debris gently with normal saline
Maintain moist (not dry or wet) environment
Soften necrotic tissue with wet to damp dressing (autolytic debridement)
Always fluff gauze before packing wound
Use absorbing dressings to remove excess exudate
Protect peri-wound
Maintain an aseptic technique to reduce the risk of contamination and infection
Manage pain
232
Medihoney
contains an osmotic agent to draw out moisture from deeper tissue
Helps to lower the pH of the wound
233
Xeroform-
Xeroform-occlusive bacteriostatic
234
Hydrogel
Moist environment
Enhances autolytic debridement
235
Silver-based dressings
Antimicrobial
235
Mepilex – foam dressing
pad
236
Jackson Pratt (JP)
Placed during surgery or interventional radiology to remove fluid collection
Can help in healing process and remove infected pockets of fluid
237
Debridement
Removal of non-viable
Eliminates source of infection
Helps to visualize wound bed
Promotes healthy tissue to regenerate
238
Types of debridement
Autolytic
Enzymatic
Surgical
Mechanical
Maggot
239
negative pressure therapy
Applies negative pressure to the wound to remove excessive drainage (blood, exudate and infectious materials)
Provides direct and complete wound bed contact
Reduces edema
Promotes perfusion and granulation tissue formation by facilitating cell migration and proliferation
240
what is a Skin Graft:
Taking skin from another part of the body to protect/fill in defect
241
full-thickness skin graft vs split partial skin graft?
full: includs dermis and epidermis
partial: epidermis and some dermis
242
where are skin grafts usually taken from ?
areas with extra skin like buttocks, groin, thigh
243
how long for skin graft to heal ?
This “donor site” heals in 7-10 days
244
Split/Partial thickness skin graft
?
removes skin but leaves deeper structures with sweat glands and hair follicles
245
Flaps?
The blood supply stays attached to the flap
Grafts don’t work well over hard structures like bones or very complex wounds
246
Evaluation of wound ?
Assess the effectiveness of treatment at a minimum once per week with measurements/observations
Reevaluate treatment if not healing in timely manner
The expected trajectory/path for wound healing is that the wound should be 20% smaller at week 2 and 40-50% at week 4 to heal in 12 weeks
247
what is Regenerative/Epithelial Healing?
Wound only involves the epidermis and dermis
New tissue cannot be distinguished from intact skin
No scar formation
E.g. Partial-thickness wounds
248
Wound involves minimal or no tissue loss
1 intetntion
249
Edges approximated (sutures, staples, or surgical glue touching/closed)
primary intention
250
Minimal scarring (However scar tissue is still only 80% as strong as the original tissue)
Eg. Clean surgical incisions
primary intention
251
Extensive tissue loss that prevents edges from approximating or because wound intentionally left open d/t contaminated/infected tissue/blood clot
Secondary Intention:
252
Wound debrided or infection resolved then allowed to heal from inner layer to surface with beefy red granulation tissue (a type of connective tissue)
secondary
253
Heals more slowly and more scarring
secondary
254
Tertiary Intention aka
Delayed primary closure
255
Initially wound healed by secondary intention
3
256
When there is no evidence of edema or infection, granulation tissue pulled together and wound edges sutured
3
257
Less scarring than secondary intention
3
258
Requires strict aseptic technique to prevent infection
3
259
Hypertrophic scar
small bump
260
Keloid-scar
Keloid-scar outgrows border of injury; acts like a tumor
261
Adhesions
Adhesions: bands of scar tissue that form between or around organs e.g intestinal adhesions may lead to bowel obstructions
262
Excessive contraction results in
Excessive contraction results in deformity; shortens muscle or scar tissue, especially over joints, results from excessive fibrous tissue formation
263
Hemorrhage
Result from ruptured suture, accidental arterial puncture, fistulas, dislodged clot
Monitor surgical wound and drains frequently for bleeding for the first 48hrs
Apply pressure dressing if needed
Report uncontrolled and excessive bleeding
264
Hematomas:
type of hemmorage Hematomas: localized mass of blood that could cause tissue ischemia
265
Dehiscence and Evisceration
Most serious post-op complication
266
Dehiscence
Dehiscence - partial or total separation of a wound
267
Evisceration
Complication of a dehisced wound with protrusion of viscera (internal organ)
268
Prevention and nursing intervention:
in Dehiscence and Evisceration
Prevention and nursing intervention:
Splint wound when cough/sneezing, getting out of bed
Use abdominal binder
If evisceration occurs, place patient in low fowler and immediately cover exposed organ with moistened sterile saline gauze
Contact provider immediately and stay with patient
269
Fistula
Abnormal passage of an organ or vessel to the outside of the body or from an internal organ or vessel to another
Examples:
Carotid-cavernous fistula - an abnormal connection between the carotid artery to a large vein
Rectovaginal fistula - an abnormal connection between the rectum and vaginal
enterocutaneous fistula - an abnormal connection between the intestine and skin
270
Partial-thickness wounds?
Partial Thickness – A partial thickness wound is confined to the skin layers; damage does not penetrate below the dermis and may be limited to the epidermal layers only.
271
concussion
A concussion is an injury resulting specifically from brain trauma
272
Serosanguineous
most commonly seen in new wounds lighter pink, a combination of serous and sanguineous drainage
273
Purulence
thick, often malodorous (Pus-WBC’s, bacteria, and cellular debris
274
Purosanguineous
thick red-tinged pus indicating blood in an infected wound
