NURSING PRAC - wound assessment

Define an acute wound

heals in timely manner, usually 6 weeks

define a chronic wound

wound that has evolved into a non-healing state. Takes longer than 6 weeks to heal

Define a surgical wound

a deliberate wound formed by a cut through the skin, muscle or fat

classification of incision

made me a sharp instrument. Can be shallow or deep

classification of contusion

skin is closed by takes on a bruised appearance due to damaged blood vessels

classification of abrasion

surface scrape of skin - painful due to exposed dermal nerve ending

skin tear

traumatic injury to the skin as a result of friction

puncture

penetration of the skin by a sharp instrument

laceration

tissues torn apart, edges jagged

penetrating wound

wound caused by an object that penetrates the skin and underlying tissues

what is a pressure injury

formed by a period of localised ischemia as a result of pressure being applied to the area for a extended amount of time

what happens when blood supply returns (pressure injury)

Reactive hyperaemia is evident as a result of vasodilation

Stage 1 of a pressure injury includes

non-blanching erythema with intact epidermis

stage 2 pressure ulcer includes

partial thickness ulcer involving epidermis and dermis

stage 3 pressure ulcer includes

full-thickness ulcer, extending through the dermis to the subcutaneous tissue

stage four pressure ulcer includes

deep tissue deconstruction extending through fascia and may involve muscles, bones and tendons

occurrence and process of Haemostasis (wound healing)

immediate: vasoconstriction, formation of platelet plug, formation and degradation of blood clot

occurrence and process of inflammatory (wound healing)

0.5 days - Vasodilation manifests as redness, heat, swelling and pain

occurrence and process of Proliferation

3-14 days, fibroblasts produce collagen and new capillaries form

occurrence and process of Maturation

14 days to 2 years - collagen fibres reorganise and strengthen

What should be administered prior to wound care if the patient is in pain

analgesics

What does the TIME acronym stand for

tissue, prevent and treat infection, provide moisture balance, protect edges

Epithelialisation - pink

protect and promote new growth

granulation - red

encourage angiogenesis and promote granulation tissue

sloughy - yellow

Debride slough, manage exudate levels

Necrotic - black

needs rehydration and debridement

infected - green

Reduce bacterial load in the wound. Monitor for systemic infection

Angiogenesis

development of new capillaries from pre-existing blood vessels

Debridement

removal of dead, damaged or infected tissue to improve healing

Dehiscence

a partial or complete separation of the approximated wound edge

Epithelialization

The process by which new epithelial cells form over a wound

Maceration

breaking down of skin due to excessive moisture

Necrosis

death of body tissue

Slough

non viable subcutaneous tissue and by-products