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Wounds
Nursing skills test 4
52
Nursing
Undergraduate 3
11/11/2010

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Cards

Term
Healing
Definition
This is reestabilishing integrity to injured tissue
Term
Primary, secondary and tertiary intention
Definition
what are the three types of wound healing?
Term
Primary intention
Definition
edges of wound are approximated, these are typically surgical wounds, or would that have a clean cut to them, little tissue is lost.
Term
Normal wound healing of a surgical incision
Definition

this type of wound healing;

  • incised tissue regain blood supply and begins to bind together
  • slight swelling and pinkness to wound is normal
  • after 3-4 days connective tissue strengthens, wound, pinkness of wound will decrease
Term
inflammation
Definition
this is not an infection, but an infection can have this
Term
yes
Definition
Does inflammation make the tissue warm?
Term
Secondary intention
Definition

this is the process whereby an open would closes by new tissue formation with subsequent wound contraction and reepithelialization

usually from trauma, ulcers, infeciton

larger amount of exudate

greater inflammatory reaction= more debris

Term
secondary intention
Definition
healing and granulations for this takes place from the bottom up, edges inward, more granulation, larger scar
Term
Tertiary intention
Definition

this is a combination of primary and secondary

also called delayed primary intention.

  • this wound needs to heal partially with secondary intention, and then is sutured closed.
  • usually are infected wouns or contaminated wounds that can not be sutured closed due to the risk for infection.
Term
Phases of healing
Definition
includes initial or inflammatory, granulation, maturation (scar phase)
Term
Inflammatory
Definition
  • starts on day of incision, and last for 3-5 days after that. 
  • skin is sutured or stapled, area clots allowing WBCs to move across
  • capillary growth will be established here due to the fibrin meshwork
  • increases blood flow through vasodilation
Term

Inflammatory phase

neutrophils

Definition
these are the first leukocytes to arrive, and accumulate within minutes in the would of injury to help pervent invasive infection. they require oxygen to kill bacteria so they depend on blood flow, and deleivering oxygen to the wound.
Term

inflammatory phase

(macrophages)

Definition

the activation of inflammation sends out chemical messages which attact theses to the wound. these long lived cells (weeks) orchestrate the remaining states of wound healing through the release of a variety of polypeptides known as growth factors

Cleaning the area before healing occurs.

Term
inflammatory phase components
Definition
  • clotting of bleeders(1-5mins)
  • increased blood flow(20-30mins)
  • increse oxygen in wound
  • antibodies released in wound
  • increased neutrophils (bacterial killing)
  • increased macrophages (provides growth factor)

 

Term
Granulation phase (proliferative)
Definition

begins day 2 and last 5 to 3 weeks

  • involves three key processes angiogenesis, fibroblast, prolifertion and epithelial cell proliferation
  • need good kind of moisture
Term
energy, protein synthesis and anabolism
Definition
angiogenesis, fibroblast, proliferation and epithelial cell proliferation all reqiure what?
Term

Granulation phase

(Angiogenesis)

Definition

 this is the formation of new blood vessels. can occur easier if the tissues are approximated

secreted by macrophage

Term
Fibroblast proliferation
Definition
migrate to the wound from connective tissue. dependent on oxygen and nutritional status of pt.
Term
epithelial cell proliferation
Definition
this is epidermal cells divide and migrate across the wound. can travel up to 3cm. dependent on moisture. if exudate or dead tissue is present, cells cannot migrate and proliferate. need to keep wound clean of debris
Term
Maturation/scar phase/remodeling
Definition
  • this happens about 3 weeks after initial injury
  • lasts up to one year or more
  • increase in collagen and proliferation of layers of the skin
  • strength of wound is increased during this phase
  • scar is formed, pale and avascular
Term
factor that delay wound healing
Definition

these factors do what?

  • age, malnutrition, poor circulation, infection, anemia, obesity, stress on wound keeps granulation form occuring, diabetes, smoking
Term
complications during wound healing
Definition
hemorrhage- external ro internal, swelling, hematoma, increase size of anatomical part, infection, dehiscence and evisceration
Term
infection of wound
Definition
what is the 2nd most common nosocomial infection
Term
infection
Definition

sugical- usually 4-5 days post op

contaminated or trauma wound- within 2-3 days

Term
to prevent infection
Definition
why do we give prophlactic antibiotics for some surgical procedures?
Term
becuase oxygen is a factor in healing
Definition
why are we checking SATs on our patient with wounds?
Term
increases circulation, prevents DVTs
Definition
why is ambulation so important post-op?
Term
not a lot of blood and oxygen supply in obese people
Definition
how and why does obesity impact healing?
Term
wound dehiscence
Definition

this is partial or complete separation of the outer layer of the wound

possible causes: poor suturing, distention, excessive vomiting, coughing, dehydration, infeciton

treat: reclosure in the OR or leave open and treat wound so it heals by secondary intention, possibly third

Term
Evisceration
Definition

total separationof the layers and protrusino of the internal organs or viscera through the open wound

cause: same as dehiscence

treat: call for help, cover with sterile gauze/towel saturated in normal saline, keep organs moist, do not attempt to reinsert, keep in supine position, VS every 5 mins

Term
Skin tears
Definition
a traumatic wound occurring principally on the extremities of older adults as a result of friction alone or shearing and friction forces which separate the epidermis from the dermis  or both from underlying structure
Term
treatment for skin tear
Definition
  • cleanse skin gently with NS if needed
  • approximate edges of torn skin
  • use steri strips if needed
  • vaseline gauze
  • secure with stretch webbing
  • no tape to skin
Term
pressure ulcer
Definition
localized areas of tissue necrosis that develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time, must be pressure!
Term
cause of PU
Definition
  • pressure
  • decreased blood flow to the tissue
  • interferes with cellular metabolism
  • tissue ischemia results
  • ischemia results in tissue death
Term
Stage 1
Definition

intact skin with non-blanchable redness of a localized area usually over a bony prominence. redness in lightly pigmented skin.

temp- warm or cool

tissue consistency- firm or boggy feeling

sensation- pain, itching

Term
Stage 2
Definition

partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough

  • present as a shiny or dry shallow ulcer, blister or shallow crater
Term
stage 3
Definition
full thickness tissue loss, subcutaneous fat may be visible, but not bone, tendon or muscle, may be undermining and tunneling
Term
stage 4
Definition
full thickness tissue loss with exposed bone, tendon or muscle. slough or eschar may be present on some parts of the owund bed. often undermining and tunneling
Term
unstageable
Definition
full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray green or brown) in the wound bed. until enough slough or eschar is removed to expose the base
Term
look at document for prevention points! to much to fit on flash card! :)
Definition
Term
Braden scale or norton scale
Definition
  • used to assess risk for PU development
  • nursing care is aimed at maintaing tissue integrity-obviously best if we can pervent skin breakdown
  • prevention is less costly than treatment
  • not to mention the psychological toll on patient
Term
pressure ulcer assessment
Definition

assess:

  • site, stage, tunneling undermining, slough, exudate, pain, epithelialization, necrotic tissue type, color, edema, maceration
Term
Red PU
Definition
pink to dark red tissue, usually with granulation tissue
Term
yellow PU
Definition
 slough or soft tissue necrosis, exudate whitish to yellowish to greenish, needs to be cleaned needs method for facilitating exudate out of wound as it is a great medium for bacterial growth
Term
Black PU
Definition
tissue necrosis-= eschar, needs debridement, high risk of infection
Term

Debridement types

(mechanical)

Definition
wet to dry/moist dressing changes; frictino by rubbing, wound irrigation, whirlpool
Term

Debridement type

Chemical

Definition
solution into the wound to remove exudate/tissue
Term

debridgement type

autolytic

Definition
a dressing that facilitates the enzmes in the body to debride the eschar
Term

debridement type

enzymatic

Definition
drugs applied topically
Term

debridement

 

surgical

Definition
surgically cutting or scraping away
Term

Debridement type

(sterile maggots)

Definition
poor them in to the wound and let them eat away and a couple hours later you take them out
Term
healing of a PU
Definition
  • maintain a healthy enviroment for healing to occur
  • prevent or manage infeciton
  • clean the wound
  • remove tissue that is dead
  • facilitate exudate remove
  • protect the PU
  • prevention of further skin breakdown
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