Wound Care Fundamentals Chapter 28
Wound Care Fundamentals Chapter 28
Terms in this set (93)
Wound Definition -
Damaged skin or soft tissue Occurs as a result of trauma Cuts, blows, poor circulation, chemicals, excessive hot or cold
Wound OPEN -
surface of skin or mucous membrane is not intact (could be accidental or Intentional)
Wound CLOSED -
no opening of skin or mucous membrane (exp blunt trauma pressure)
a clean separation os skin and tissue with smooth even edges
a separation os skin and tissue in which the edges are torn and separated and irregular
a wound in which the surface layers are scraped away
stripping away of large areas of skin and underlying tissue, leaving cartilage and bone exposed
a shallow crater in which skin or mucous membranes is missing
an opening of skin, underlying tissue, or mucosus membrane caused by a narrow sharp pointed object
Contusion (Closed Wounds)-
injury to soft tissue underlying the skin from the force of contact with a hard object, sometimes called a bruise.
the physiologic defense immediately after tissue injury, last approximately 2-5 days.(its purpose is to 1. Limit the local damage 2. Remove injured cells and debris 3. Prepare the wound for healing,
Wound Repair Inflammation Phase 1 Definition -
physiological defense that occurs immediately after tissue injury Purpose Limits the local damage , Removes injured cells and debris, Prepares wound for healing
Wound Repair Inflammation Phase 1 The inflammatory response Lasts about 2
Lasts about 2-5 days
Wound Repair Inflammatory Response First Stage
Local Response Blood Vessels Constrict,Then dilate, Platelets form loose clot to control bleeding, Damaged cells membranes become more permeable Plasma and chemical substances released
Signs and symptoms of infection of wound include?
Swelling, Redness, Warmth, Pain, Decreased function
Second Wave of Defense
Leukocytes and Macrophages (white blood cells) migrate to site of injury Body produces more to take their place, Leukocytosis confirmed through blood specimen
WBC w/differential, Rise in neutrophils and monocytes suggests inflammatory response or infectious process occurring
Neutrophils and monocytes responsible for ?
phagocytosis of pathogens, coagulated blood cellular debris They clean area of wound injury and prepare site for wound healing
Wound Repair Proliferation Phase 2-
Period during which new cells fill and seal a wound Occurs 2 days to 3 weeks after the inflammatory
Wound Repair Proliferation Phase 2 Characterized by Granulation tissue (new blood vessels, fibroblasts, epithelial cells) bright pink to red due to extensive capillaries, grows from wound edge to center fragile
Granulation tissue (new blood vessels, fibroblasts, epithelial cells) bright pink to red due to extensive capillaries, grows from wound edge to center fragile AND Collagen (protein substance tough and inelastic) adhesive strength of wound increases .Blood vessels begin to shrink, Pink color disappears
@ Main substance you will see during the proliferation stage?
Granulation & collagen
Integrity of skin is restored by?
Resolution, Regeneration and scar formation
process by which damaged cells recovers and re-establishes their normal function
cell duplication Scar formation replacement of damaged cells with fibrous tissue acts as non functioning patch
replacement of damaged cells with a fibrous tissue, act as non functioning patch
Wound Repair Remodeling Phase 3 -
Period during which the wound undergoes changes and maturation (Lasts 6 months to 2 years Wound contracts Scar shrinks)
Wound Healing is affected by?
Type of wound injury, Expanse or depth of wound, Quality of circulation, Amount of wound debris, Presence of infection, Status of the patient's health
Wound Healing Speed Depends on?
of wound repair takes place..... Extent of scar tissue that forms..... Depends on how the wound heals
The key to wound healing is?
Adequate blood flow to the injured tissue
Types of Healing?
First intention, Second intention, Third intention
wound separation with protrusion of organs (these complications most likely within 7-10 days after surgery)
separate of wound edges
a wound caused by prolonged capillary compression that is sufficient to impair circulation to the skin and underlying tissue
First (primary) intention
Reparative process wound edges are directly next to one another, Space between wound narrow, small amount of scar tissue forms (EXAMPLE- surgical wound)
Reparative process wound edges are widely separated , More time consuming and complex Margin of wounds are not in direct contact additional time is needed for granulation tissue to extend across wound, Cautious wound care
Reparative process when the wound edges are widely separated later brought together with some type of closure material Broad deep scar Deep, contains extensive drainage and tissue debris May use drainage device or absorbent gauze
Wound Management Defined
Techniques to promote wound healing
Goals of wound management Surgical wound
reapproximate the tissue to restore its integrity
Goals of wound management Pressure ulcer- primary goal is prevention if not prevented then goal
primary goal is prevention if not prevented then goal reduce the size of the wound ,restore skin and tissue integrity
What is the main goal of wound management of pressure ulcer is?
cover over a wound
are tubes that provide a means for removing blood and drainage from a wound
tubes that terminate in a receptacle (exp hemovac, Jackson -prat (JP)
self adhesive, opaque, air and water- occlusive wound covering, they keeps wounds moist, most wounds heal more quickly because new cells grow rapidly in a wet enviroment.(if dressing remains intact can be left in place up to 1 week)
Wound Management Using a Dressing Purposes-
Keep wound clean, Absorbing drainage, Controlling bleeding, Protecting the wound from injury, Holding medication in place, Maintaining a moist environment
Wound Management Types of Dressings-
Gauze, Transparent Hydrocolloid ,Gauze Dressing
Guaze dressing -
-Absorbent Obscure wound, interfere with assessment Granulation tissue may adhere Secure with tape
exp opsite) allow nurses to assess wound without removing dressing, advantages are less bulky, used to cover IV sites, are not absorbent, and tend to loosen.
strips of tape with eyelets (kind of looks like a gurtle, used in patients who are having skin break down during removal of tape)
Self adhesive, opaque, air and water occlusive helps Keep wounds moist Can be Left in place for 1 week Repels other body substances , make sure to Size generously (exp Duoderm)
When to Do Dressing Changes?\
When the Wound requires assessment, Dressing is loose or saturated, or if Dr wants to assess Reinforce if MD desires to change it
Drains Definition -
tubes that provide a means for removing blood and drainage from a wound
Types of Drains include?
Open drains and closed drains
Flat flexible drains, Take drainage passively toward dressing(Use of safety pin)
Tubes that terminate in a receptacle Hemovac, Jackson Pratt Pull fluid by creating vacuum or negative pressure
Cleansing site of Drain-
Insertion site is cleansed in a circular manner,Precut drain gauze place around the base of the drain
knotted ties that hold incision together Silk or synthetic materials
wide metal clips (In place for 2 days to 2 weeks) After taking out, apply Steri-strips "butterflies"
strip or roll of cloth wrapped around a body part ( exp Ace bandage)
type of bandage (Applied to abdomen or breast, elsewhere)
Reasons for Use Bandages/Binders -
Hold dressing in place - tape not indicated or dressing extremely large ,Supporting area around a wound or injury to reduce pain, Limiting movement in the wound area to promote healing
Bandages/Binders Application procedure-
1. Elevate and support the limb @. Wrap from distal to proximal direction. 3. Avoid gaps between each turn of the bandage 3. Exert equal, but not excessive tension with each turn 4. Keep the bandage free from wrinkles 5. Secure the end of the roller bandage with metal clips. 6. Check the color and sensation of exposed fingers or toes often. 7. Remove the bandage for hygiene and replace at least twice a day
removal of dead tissue
Types of Debridement Sharp -
use of scissors or scalpel
involves the use of a topically applied chemical substance that breaks down and liquefy wound debris
Autolytic debridement -
self dissolution, is a painless, natural physiologic process that allows the body's enzymes to soften, liquefy, and release devitalized tissue. occlusive or semi occlusive dressing
Mechanical Debridement- i
nvolves physical removal of debris from a deep wound. One technique is application of Wet to dry dressings
therapeutic use of water in which the body part of the wound is submerged in a whirlpool tank the agitation of the water which contains an antiseptic, softens the dead tissue. Loose debris that remains is removed afterward by sharp debridement
Technique for flushing debris
Structures commonly irrigated include?
Wounds ,Eye, Ear, Vagina
Heat and Cold Applications-
Ice bag, Chemical pack, Compress, Aqua thermia
Uses for Cold-
Reduces fevers, Prevents swelling, Controls bleeding, Relieves pain, Numbs sensation
Uses for Heat-
Provides warmth, Promotes circulation, Speeds healing, Relieves muscle spasm, Reduces pain
Types of Therapeutic Baths ?
those preformed for other than hygiene purposes , help to reduce high fever or apply medicated substances to the skin to treat skin disorders or discomfort.
Pressure Ulcer (Decubitus)Usually appear ?
over bony prominences Sacrum, Hips, Heels, Elbows, shoulder blades, back of head
What Factors Contribute to Pressure Ulcers?
Infrequent movements of body parts, Pressure in local capillaries to less than 32 mmHg for 1-2 hours without intermittent relief, causes cells die from lack of oxygen and nutrition
Stage I Pressure Ulcers
intact but reddened skin fails to resume normal color when pressure is relieved (skin is not broken)
Stage II Pressure Ulcers-
pressure ulcer is red accompanied by blistering or skin tear
Stage III Pressure Ulcers-
shallow skin crater that extends to the subcutaneous tissue May have serous or purulent drainage
Stage IV Pressure Ulcers-
life threatening deeply ulcerated tissue, exposing muscle and bone, Infection may spread throughout body Sepsis
Preventing Decubitus Ulcer Step 1
Identify Clients at Risk
Things help with preventon of Decubitus ulcers include?
Turning every 2 hours, 45 degree angle
Clients at Risk for Decubitus Ulcer include?
Inactive, Immobile, Malnourished, Emaciation, Diaphoresis, Incontinence, Vascular Disease, Localized Edema, Dehydration, Sedation
Prevention of Pressure Ulcers Step 2 -
Implement measures to reduce conditions under which pressure ulcer is likely to form
Nursing Diagnoses For Decubitus Ulcer?
Acute Pain ,Impaired Skin Integrity, Ineffective Tissue Perfusion, Impaired Tissue Integrity, Risk for Infection
potentially fatal systemic infection
Massage boney prominences only if?
Skin blanches with pressure relief
effect that moves layers of tissue in opposite directions
shallow break in the skin
white greenish fluid caused by would infection
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