Wound Care 2
Terms
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- Clean Wound
- uninfected, minimal inflammation, no entry of respiratory, genitourinary, alimentary systems. Closed wound
- Clean Contaminated Wound
- Surgical wound entering the respiratory, genitourinary, alimentary systems. No evidence of infection
- Contaminated Wound
- Open, fresh, accidental would with major break in sterile technique or large spillage from GI tract, evidence of inflammation
- Dirty or Infected Wound
- contains necrotic tissue, wounds with evidence of clinical infection including, odor, leakage, heat, fever
- Partial Thickness Wound
- confined to skin and dermis
- Full Thickness Wound
- dermis epidermis, muscle and some bone possible.
- Factors affecting susceptibility to pressure ulcers
- Immobility, malnutrition, incontinence, diminshed sensations, excessive body heat, advanced age, chronic medical conditions, obesity
- Pressure ulcer etiology
- pressure, shear, force
- Shear
- skin forced in an opposing direction while it stays stationary and bone moves
- Friction
- appearance of abrasion, two surfaces move against one another
- 6 Types of wound
- Incision, contusion, abrasion, puncture (penetration of skin and underlying tissue), laceration (torn and deep), penetrating (deeper than puncture bullet, knife)
- Stage I wound
- Nonblanchable erythema
- Stage II Wound
- partial thickness skin loss involving epidermis and possibly dermis
- Stage III Wound
- Full thickness skin loss with damage or necrosis of subcutaneous tissue that may extend down to but not thru underlying fascia
- Stage IV Wound
- Full thickness skin loss with tissue necrosis or damage to muscle, bone or supporting structures.
- Undermining in Wound
- Wound extends under skin
- Sinus Tracts
- similar to undermining
- Prevention of Pressure Ulcers
- Skin Care, risk assessment, mechanical loading and support surfaces, education
- Primary Intentions Wound Healing
- wound with little or no tissue loss, skin edges aproximate, risk of infection is slight.
- Secondary Intention Wound Healing
- Loss of tissue, edges do not close, risk of infection and loss of tissue function is greater.
- Delayed Primary Intention Wound Healing
- Leave part of wound open intentionally
- Phases of Wound Healing
- Inflammation, proliferation, and maturation/remodeling
- Inflammation phase of wound healing
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Hemostasis- bleeding controlled platelets coagulate,
Phagocytosis- macrophages engulf debris,
Meds- anti inflammatory and steroids assist - Proliferation phase of wound healing
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about 21 days. Production of new tissue- fibroblasts enter w/in 24 hours to make collagen.
Protraction- wound contracts and gets smaller ridges will be evident on incisions.
Epithelialization-Eschar- epithelial cells cover wound - Maturation/Remodeling fphase of wound healing
- Reorganization of collagen. (watch for Keloid). Strength of scar is increased but only about80% as strong as original tissue.
- Adhesions
- develop if there is too much scar tissue
- Factors affecting wound healing
- age, nutrition, lifestyle, health, medications, tissue perfusion, infection, extent of would, wound environment.
- Complications of wound healing
- Hemorrhage, infection, dehiscence, evisceration, fistula.
- Types of Debridement
- Sharp, mechanical, chemical, autolytic(natural moisture and enzymes debride wound under transparent dressing)
- Therapeutic effects of heat
- good for vasodilation, increases capillary permeability, reduces viscosity of blood, reduces muscle tension. Never apply for longer than 1 hour. 15 minutes on and 15 off.
- Therapeutic effects of cold
- effective in initial treatment of breaks, sprains and bruises within the first 24 hours. Serves as a local anesthetic. reduces blood flow thus reducing edema (do not administer if tissue already edematous)Decreases muscle tension, increases blood viscosity. Reduces cell metabolism thus reducing o2 needs of tissue
- Braden Scale for Wounds
- Composite of six subscales, sensory perception, moisture, activity, mobility, nutrition, friction and shear. Score ranges from 6-23 lower the score the higher risk of pressure ulcer forming.
- Granulation Tissue
- red, moist tissue that is healing
- Yellow tissue
- appearance of slough(yellow stringy tissue) must be removed before wound can heal
- Eschar
- necrotic black or brown tissue that must be removed to stage wound and to promote wound healing.
- dehiscence
- partial or total separation of wound layers
- Norton Scale
- 5 risk factors for pressure ulcers, physical condition, mental condition, activity, mobility, incontinence.
- Abnormal Reactive Hyperemia
- Hyperemia over a pressure site lasting longer than 1 hour after the removal of pressure. Surrounding skin does not blanch.
- Reactive Hyperemia
- An area of blanched skin that is relieved of pressure turns red this is reactive hyperemia caused by vasodilation. This return of redness indicates an attempt to overcome ischemia.
- Risks for Heat/Cold Therapy
- Spinal cord injuries, age due to decreased sensation, open wound, stoma, broken skin, edema/scar formation, PVD, confusion
- Avulsion
- the tearing away forcibly of a part or structure. The complete separation of a tooth from its alveolus.
- Maceration
- the softening of a solid by steeping it in fluid.