Dehiscence
separation of outer wound layers
Evisceration
rupturing of a wound
Eschar
hard, dry, leathery daed tissue
graunlation tissue
new tissue developing between two cavities in a wound
Surgical incision
- sharply defined edges
- under sterile conditions
- well-approximated-close together-touching
Abrasions
superficial open wound
- scrapes or rub type wound
- superficial
- heals well when kept clean
Lacerations
open wound made by accidental cutting or tearing of tissue
- common-knives, pieces of glass or metal
- jagged edges
Puncture wound
open wound when a sharp item pierces the skin
- round hold that penetrates into deeper tissue
- dependent on the length and diameter of the sharp item
Penetrating wounds
similar to a puncture wound
- object remains embedded in tissue
Pressure ulcers
wound resulting from pressure
- skin maybe intact and erythemic or skin may be broken
Deep tissue injury
area over a bony prominence that differs from surrounding tissue; may be blister- like or a discoloration
stages of pressure ulcers
- stage 1- erythema
- stage 2- partial-thickness of dermis
- stage 3- full thickness loss; damage to epidermis, dermis, and subcutaneous tissue
- stage 4-full thickness loss; damage to deep tissue, muscle, fascia, tendon, joint capsule, and or bone
unstageable
eschar covers the wound, making it impossible to tell the depth
Slough
avascular, devitalized tissue
-necrotic
-can be white, yellow,tan, gray
risk factors for pressure ulcer development
- being elderly
- being emaciated or malnourished
- being incontinent of bowel or bladder
- being immobile or decreased mobility
venous stasis ulcer
develop when venous blood flow is sluggish
- usually in lower extremities
Arterial ulcer
distal portion of the lower extremity, over ankle or bony areas of foot (top of the foot or toe, outside edge of the foot)
-deep with "diff" edges
Diabetic Ulcer
on the foot- at mid foot- ball of the foot, over the metatarsal heads, or on top of toes with Charcot deformity
-often very small
-dry (necrotic)
hemostasis
immediate- minutes to hours
goal is to stop bleeding and form a stable clot.
inflammatory phase
hours-3 days; sometimes up to 5-7 days
goal: clean up invaders and debris; cal in repair crew
proliferation phase
aka- reconstruction
goal: fill the defect and over it
maturation phase
aka: remodeling phase
starts when wound is closed, strengthens the scar
types of wound closures for healing
- primary intention- wound is clean with little tissue loss, edges are approximated, and wound is sutured closed
- secondary intention- there is greater tissue loss, wound edges are irregular, and wound is left open
- tertiary intention- wound is left open for some time to form granulation tissue and then sutured closed
factors affecting wound healing
- age
- chronic illness
- diabetes mellitus
- hypoxemia
- lifestyle choices
- lymphedema
chronic illness
illness affecting major body systems (heart,lung,kidney,neuro)
diabetes mellitus
causes decreased circulation due to narrowed peripheral blood vessels.
hypoxemia
decreased oxygen delivered to the wound via the bloodstream caused impaired healing
lymphedema
area around the wound is edematous
radiation exposure
causes breakdown of underlying connective tissue
wound tension
extra tension placed on the wound edges can lead to ischemia and necrosis
sangulneous
red, bloody
serous
clear to pale yellow
serosanguineous
blood and serous fluid-light red to pink
purulent
thick drainage-various colors
billous
dark greenish-often after gallbladder surgery
hemovac
active drain uses suction
Jackson-pratt
active drain uses suction
T-tube
passive drain uses gravity
penrose
open drain; not commonly used because can provide pathway for pathogens
hydrophilic foam dressing
super absorbent-moderate to heavy exudating wounds
hyrdofiber dressing
for wounds with large amount of drainage
medihoney dressing
provides a most environment conductive to wound healing and is indicated for lightly to moderately exuding wounds
hydrogel dressing
provides moisture to wound
-soothing and cooling
-use for wounds with minimal drainage
polyvinyl dressing
sem-permable- allow oxygen in, keep bacteria out
negative pressure wound therapy
uses gentle. negative pressure to remove drainage and contaminants, a canister collects drainage
pico dressing
negative pressure dressing-less negative pressure
wet to damp/ wet to dry
must fill entire wound including tunneling and or undermining
squeeze out excess liquid before starting to pack-do not want it dripping wet
-pack wound loosely-light ad fluffy
cold therapy
best the first 24 to 48 hours after an acute injury
heat therapy
when the goal is comfort
cryotherapy (cold therapy)
decreases pain and swelling by slowing blood flow
-checking the skin often
heat therapy (themotherapy)
used for sub-q or chronic problems muscle or joint pain
-not appropriate for new injury-can worsen the injury
what should you document for hot cold therapy?
what, where, when, settings, response, safety, policy