N1213 > Wound Healing > Flashcards

Wound Healing Flashcards

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1
Q

What 2 processes are simultaneous?

A

hemostasis and inflammation

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2
Q

Hemostasis/Inflammation

A
  • injured blood vessels constrict and platelets form to stop bleeding
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3
Q

Inflammation

A
  • histamine
  • vasodilation
  • normal rxn = redness/edema and throbbing
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4
Q

Proliferation

A
  • new blood vessels appear, reconstruction, 3 days to 3 weeks
  • filling with granulation tissue
  • contraction
  • resurfacing
  • fibroblasts
  • angiogenesis
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5
Q

Maturation/Remodelling

A
  • 2 years, depending on wound and collagen scar
  • fewer pigments
  • little redder
  • not same consistency
  • healed wounds = inc. risk for pressure injuries
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6
Q

Primary intention

A
  • non infected
  • wound edges well approximated
  • little scaring
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7
Q

Secondary intention

A
  • wound edges unable to approximate = extensive tissue loss
  • heals from inside out
  • granulation tissue forms to fill spaces
    ex: replaces fibrin clot, pressure ulcer
  • heals by any size
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8
Q

Tertiary intention

A
  • closing granulated ends together after initial healing
  • surgical closure
  • left open for several days, then wound edges are approximated
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9
Q

WOUND

A 
What happened
Oxygen/perfusion
Underlying factors (age, psychosocial, mobility, incontinence, sleep
Nutrition
Disease/drugs
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10
Q

Patient centered concerns

A 
pain
money
isolation
mobility
sleep
stress
depression
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11
Q

Local wound assessment

A
  • location
  • size: length, width, depth
  • characteristics: undermining, tunneling, presence of necrotic tissue or exudate
  • document
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12
Q

Parameters to assess regarding drainage systems

A
  • # of drains
  • placement
  • character of drainage
  • condition of collecting equipment
  • type and # of dressings
  • monitoring of self suction devices
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13
Q

exert a constant low pressure as long as the suction device is completely compressed.

A

Hemovac and Jackson Pratt

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14
Q

Describe the responsibility of a student nurse who identifies wound abnormalities and complications?

A
  • identify abnormalities
  • inform primary nurse
  • document
  • perform wound care, MPR, basic dressing
  • support patient
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15
Q

c) angiogensis

A

c) growth of new capillary blood vessels

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16
Q

c) why are scars lighter in colour?

A

c) contain fewer pigmented cells (melanocytes)

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17
Q

The skin edges are closed by approximation of wound margins. The risk of infection is low. Healing occurs quickly with minimal scar formation, as long as infection and secondary breakdown is prevented. Healing occurs by epithelialization (The formation of granulation tissue in an open wound allows the re-epithelialization phase to take place, as epithelial cells migrate across the new tissue to form a barrier between the wound and the environment).

A

Primary wound intention

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18
Q

Wound edges are not approximated and the wound is left open until it becomes filled with scar tissue. Wounds being healed by secondary intention can be caused by pressure ulcers and surgical wounds that have tissue loss. It takes longer to heal by secondary intention thus the chance of infection is greater. If scaring is severe enough loss of tissue function can occur.

A

Secondary wound intention

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19
Q

Also referred to as: “delayed primary closure”. In some situations, wounds are not closed due to infection. Instead, these wounds are irrigated and dressings applied until the infection is cleared and the wound is closed, surgically, at a later date.

A

Tertiary wound intention

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20
Q

When a wound fails to heal properly the layers of skin and tissue separate.

A

Wound dehiscence

- Dehiscence is the partial or total separation of wound layers.

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21
Q

Evisceration

A

With total separation of wound layers, evisceration (protrusion of visceral organs through a wound opening) sometimes occur

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22
Q

Evisceration - Nursing Care

A

Quickly place sterile towels soaked in sterile saline over the extruding tissues to reduce the chance of bacterial invasion and drying of tissues

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23
Q

approximated wound edges

A

When a wound is well approximated, it means that both sides of the cut fit together really well, nice and tight together. Hopefully the scar from a well-approximated cut will be almost none existent.

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24
Q

An abrasion of the skin or of the surface of other organs by scratching, traumatic injury, chemical burns, or other causes

25
Exudate
Describes the amount, colour, consistency, and odour of wound drainage. Excessive exudates usually indicates the presence of an infection
26
An abnormal passage between 2 organs or between an organ and outside of the body. Most form as a result of poor wound healing.
fistula
27
hematoma
A localized collection of blood underneath the tissues. It appears as a swelling, change in colour, sensation, or warmth, or a mass
28
dermal thickening causing the cutaneous surface to feel thicker and firmer
induration
29
loss (marked reduction) of blood flow to an area
ishemia
30
purulent drainage
Drainage that appears thick, yellow, green, tan or brown. | - infection is suspected
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Sanguineous
drainage that is bright red | - indicates active bleeding
32
serous
Drainage that is a clear, watery plasma.
33
Serosanguineous
Drainage that appears pale, red watery: mixture of clear and red fluid.
34
Why are wound drains inserted?
If a large amount of drainage is anticipated than a drain is often inserted.
35
Review the following steps to empty a drainage system (no dressing change):
A) Preparation 1. Checked physician's orders & institutional policy 2. Gather supplies: clean gloves, measuring device, blue pad 3. Identify client and explain procedure 4. Provide for comfort and privacy. 5. Wash hands and don clean gloves. 6. Elevated bed to workable height.
36
B) Procedure
1. Examined drain & tubing for patency, seal, and stability. 2. Open drainage plug 3. Poured drainage into specimen cup, measure and note characteristics. 4. Compress the Hemovac by pushing top and bottom together OR squeezing ball of Jackson-Pratt (JP) Drain (see Figure 1.1, 1.2 below) 5. Position suction device on bed & attach safety pin if required. 6. Lower bed, ensure client comfort and safety (side rails if required) 7. Discard drainage, remove gloves & wash hands 8. Recorded amount of drainage. 8. Record color, consistency, and odour of drainage (exudates).
37
JP DRAIN
The JP drain should remain concave (somewhat flat). It should not be fully inflated. If the drain is not flat, suction has not been properly established or the system has an air leak.
38
Hemovac system
The Hemovac system is spring loaded. When suction is properly established, it should remain sandwiched together. If the drain is not flat and fills with air, check to see if there is an air leak.
39
Hemmorhage
Loss of large amount of blood externally or internally in a short period of time - hypovolemic shock, distention and swelling
40
Symptoms of hemorrhage
- internal bleeding = distention or swelling of affected body part - swelling, change in colour, sensation, warmth, or a mass - external haemorrhaging is obvious - hypotension - week and rapid pulse - cool clammy skin - rapid breathing - restlessness - reduced urine output
41
List primary intention abnormalities (5).
1) Incision line poorly approximated 2) Drainage presence more than three days after closure 3) Inflammation decreased in first 3-5 days after injury 4) No epithelialization of wound edges by four days 5) No healing ridge by day 9
42
List secondary intention abnormalities (6)
1) Pale of fragile granulation tissue; granulation tissue bed is excessively dry or moist 2) Exudate present 3) Necrotic or slough tissue (Necrotic tissue contains dead cells and debris that are a consequence of the fragmentation of dying cells) present in wound base 4) Epithelialization not continuous 5) Fruity, earthy, or putrid odour present 6) presence of fistulas, tunneling, undermining
43
Secondary prevention
- educate, monitor site for early signs of infection
44
Tertiary prevention
wound care, changing of dressing, addressing associated symptoms
45
Malnutrition
- protein - vitamin C - vitamin A - Zinc - Dehydration
46
List components of documentation of a wound.
``` Periwound skin Undermining or tunnelling Location Stage Edges Measurement Exudate Type of tissue Odour Epithelialisation ``` Documentation: Wound is 3.5-4 cm. Purulent exudate present on 4X4 gauze and surrounding wound. Epithelialization is non continuous. Presence of fistula(s), tunnelling and undermining.
47
Signs of infection for wound healing?
- pain and tenderness - erythema (inc. blood flow to skin - redness) - edema - purulent discharge - warmth - fever/chills - foul odour - elevated white blood cell count - delayed healing
48
List some factors of malnutrition?
* Protein: formation of wound remodelling and immune function. Fibroplasia, angiogenesis, and collagen. * Vitamin C: Collagen synthesis, capillary wall integrity, fibroblast function, immunological function, antioxidant. * Vitamin A: Epithelialization, wound closure, inflammatory response, angiogenesis, and collagen formation. * Zinc: Collagen formation, protein synthesis cell membrane and host defenses * Dehydration: There is an essential fluid volume for all cell function.
49
Risk factors for age?
* Vascular changes: decreased circulation * Liver Function: * Collagen: decreases needed for cell repair * Inflammatory response: Slow with age * Immune Response: Slow with age
50
Risk factors for obesity?
• Constant strain is placed on wounds, as well as the poor healing quality of fat tissue.
51
Impaired oxygenation?
* low blood oxygen * Impaired blood flow * Anemia
52
Risk factors for smoking?
Nicotine is a vasoconstrictor that reduces nutritional blood flow to the skin - resulting in tissue ischemia and impaired healing of injured tissue - carbon monoxide diminishes oxygen transport and metabolism - whereas hydrogen cyanide inhibits the enzyme systems necessary for oxidative metabolism and oxygen transport at the cellular level.
53
Other risk factors?
- corticosteroids - anti-inflammatory medication - radiation - stress of suture line
54
You are caring for a client with a large incision on her left leg. Assuming there are not contraindications to her mobilizing, why would encouraging your client to ambulate, a tertiary prevention strategy, promote wound healing?
- ambulating and moving takes pressure off of bony predominance's on the body and protects the body from pressure sores. It also encourages blood flow, bringing nutrients and taking away waists from the wound
55
For some clients, the psychological manifestation of their wound may be frightening and may even trigger a grieving process over anticipated loss of body function or alteration of body/self image. Write down some interventions?
* Promote self image and esteem * SES help or rehab for work * Psychologist if needed * Support groups * Utilize support systems
56
Health promotion for immobility?
- get patient up and moving, or if not possible reposition patient in bed to reduce pressure ulcers. Practice ROM activities. Use heat therapy to increase circulation
57
Health promotion for obesity?
By promoting proper diet and activity as tolerated, you can increase blood circulation to the wound. Also by decreasing amount of fat tissue you increase healing quality to the wound.
58
Drains should be ____ everyday
measured
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