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