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36 Cards in this Set
- Front
- Back
Developmental considerations |
-less than 2 yrs: skin thinner & weaker -infant- membranes easily injured & increase infection, over time becomes more resistant - Aged adult- maturation of epidermal skins prolonged=thin, easy damaged skin, circulation and collagen formation impaired=decrease elasticity and increase tissue damage risk |
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Types of Wounds |
*Intentional- therapy or treatment or surgery: sterile infection decreased, healing increased *Unintentional- trauma, stabbing, burns, gunshot: infection increased, bleeding uncontrolled *Open- trauma(intentional or unintentional): increase risk for infection delayed healing *closed- blow force or strain (fall, assault) skin not broken-> ecchymosis and hematoma |
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Acute |
Surgical incision, heal quickly, risk infection low |
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Chronic |
healing process not normal, risk infection high, healing time delayed remain in inflammatory phase of healing: - wound that doest heal in normal time: arterial or venous insufficiency |
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Contusion |
caused by blunt instrument that may result in bruising or hematoma |
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Abrasion |
rubbing or scraping of epidermal layers of skin |
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laceration |
tearing of skin and tissue w/ blunt or irregular instrument |
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Avulsion |
tearing of structure from normal anatomic position |
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phases of wound healing |
hemostasis- involved blood vessels constrict and blood clotting begins inflammatory- white blood cells move to wound proliferation- granulation tissue is formed to fill the wound maturation-collagen is remodeled forming scar |
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hemostasis |
occurs as first response to injury - blood vessels constrict=clotting - Blood vessels dilate, increase permeability - exudate= liquid that forms from plasma and blood components to leak out into the area=swelling and pain -increased perfusion= heat and redness -platelet stim other cells to migrate to injury to help in healing |
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Inflammatory |
after hemostasis 4-6 days - WBC leukocytes and macrophages go to wound - ingest debris release growth factors attract fibroblast to fill wound -mild temp and malaise |
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Proliferation |
- begin 2-3 days within injury last 2-3 weeks - new tissue built to fill wound from action of fibroblast( connective tissue cells secrete collagen induces blood vessel formation and endothelial cells--> which form across wound -granulation tissue forms scar tissue |
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Maturation Phase |
Final stage of healing - 3 wks- 6 months after injury - collagen remodeled, wound stronger - scar is flat, thin white line |
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Local factors affecting wound healing |
*pressure- blood supply disturbed delay healing *desiccation (dehydration) delay heal *WOUNDS KEPT MOIST NOT WET AND HYDRATED= enhanced epidermal cell migration, supporting epithelialization *trauma- inability to heal or delay *Edema- interfere with blood supply to area * infection- increase stress on body *excessive bleeding= large clots, increase amount of space needed to be filled for healing, decrease o2 diffusion to tissues ("o's to the toes") *necrosis- death of tissue must remove ] * biofilm- thick grouping of micro bacteria, decreased effectiveness of antibiotics, chromic wound inflammation, slimy barrier of sugars and proteins |
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Systemic factors affecting wound healing |
*factors not related to wound location but can prolong healing -Age- children and healthy adults heal quicker -Circulation and Oxygenation- adequate blood flow needed - nutritional status- adequate nutrition needed - wound condition - specific condition of wound affects healing - health status- steroid drugs and postoperative radiation delay heal - Immunosuppression- AIDS, lupus - Meds- chemo |
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Wound complications |
- infection -hemorrhage - dehiscence- partial or total separation of wound layers: Evisceration- wound completely separates protrusion of viscera(obese, smokers , malnourished, straining -fistula formation: abnormal passage from internal vessel to outside of body or to another organ |
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Maceration |
caused by over hydration related to incontinence that causes impaired skin integrity |
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Necrosis |
dead tissue in wound delays healing |
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Edema |
swelling at wound interferes with blood supply to the area |
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Desiccation |
process where cells dehydrate and die |
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Factors affecting pressure ulcer |
wound w/ localized area of injury to skin or tissue -aging skin -chronic illness -immobility -malnutrition -fecal and urinary incontinence - altered level of consciousness -spinal cord and brain injuries -neuromuscular disorders |
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Mechanisms in pressure ulcer development |
- external pressure compressing blood vessels: bony prominences -Friction: 2 surfaces rub against each other - shearing: one layer of skin slides over another layer( pt being pulled rather than lifted) |
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Stages of pressure ulcers |
1- intact skin, blanching( pale and white 'ischemia) 2- partial thickness tissue and skin loss, shallow open ulcer 3- full thickness tissue loss, fat may be seen, NO bone tendon or muscle visible 4- full thickness loss, EXPOSED bone tendon or muscle 5- UNSTAGEABLE- covered by slough or eschar in wound bed must be removed to determine stage |
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undermining |
erosion under wound edges |
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tunneling |
destruction of fascial planes=narrow passageway |
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sinus tract |
blind ended tract extends from skin surface to abscess cavity or area |
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Assessment of wound drainage |
-serous- clear, watery - sanguineous- large # of RBCs and looks like blood. Bright red=fresh blood, Dark=older blood -serosanguineous- mix of serum and RBC, light pink - Purulent- WBS liquefied dead tissue debris, thick must foul odor, vary color |
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Wound Assessment |
-Inspect sight and smell - palpation for appearance, drain, pain, different drainages - sutures, drains or tubes, complications - penrose- after abdominal surgery - t-tube- bile drain - hemovac- ortho, abdominal - gauze |
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types of wound dressings |
Telfa- nonadherent Gauze transparent dressings- op site |
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Cleaning wounds- edges |
Approximated edges- work outward from incision Unapproximated edges- clean in full or half circles, begin in center work toward outside clean 1 inch beyond |
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types of bandages |
-roller - circular-anchors bandage -spiral-wrist,fingers, trunk -figure of 8 turn-effective for around joints - recurrent stump bandage- risidual limb, head fingers |
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Types of binders |
- straight- chest and abdomen - T-binder- rectum, perineum, groin -Sling- arm |
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Drainage systems |
open- penrose closed- sutured in skin, low continuous suction: jackson prat- bulb, hemovac- round |
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Color class of open wounds |
R- red- protect Y- yellow- cleanse B- black- debride Mixed wound- has both RY &B wounds
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Effects applying heat |
-dilates blood vessels - increase tissue metabolism - reduce blood viscosity and increase capillary permeability - reduce muscle tension and spasm - relieve pain - treat infections, surgical wounds, inflamed tissue, arthritis, joint, muscle pain, dysmenorrhea, chronic pain |
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Applying Cold |
-constrict blood vessels - reduce muscle spasm - reduce blood flow and release of pain producing histamine, serotonin and bradykinin, reduce edema and inflammation - after direct trauma, dental pain, sprains, chronic pain |