Wound Care and Treating Pressure Ulcers

Flashcards on wound care and pressure ulcers

Wounds

Occur due to trauma, surgery, pressure or burns. May be open or closed.

Hematoma

A type of closed wound.

Sprain

A type of closed wound

Contusion

A type of closed wound.

Abrasion

A type of open wound.

Laceration

A type of open wound.

Avulsion

A type of open wound.

Incision

A type of open wound.

Puncture

A type of open wound.

Amputation

A type of open wound.

Penetrating wound

A type of open wound.

Ulceration

A type of open wound.

Superficial wound

Heals quickly by producing new skin cells; a fibrin clot forms framework for growing new cells.

Partial-thickness wounds

No dermal layer present except at margins of wounds. All necrotic tissue must be removed. Wound heals by contraction.

Full-thickness wounds

Wound contraction and repair.

Braden Scale

Assessment tool to screen for pressure ulcers

Reactive Hyperemia

Excess blood in vessels

Stage 1 Pressure Ulcer

A defined area of persistent redness in lightly pigmented skin

Stage 2 Pressure Ulcer

Partial thickness skin loss involving epidermis, dermis, or both.

Stage 3 Pressure Ulcer

Full thickness skin loss involving damage or necrosis of subcutaneous tissue.

Stage 4 Pressure Ulcer

Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures.

Unstageable Ulcer

Full thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar.

Suspected Deep Tissue Injury

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

Pressure Ulcer Risk Factors

Immobility, Incontinence, Inadequate nutrition, Lowered mental awareness, Excessive diaphoresis, Extreme age, Edema

Prevention of pressure ulcers

Reposition q2h, Float heels, Use trapeze or lift sheet, Use pressure-reducing devices, Shift weight at least once an hour, preferably every 15 minutes

Do NOT massage

Reddened skin or over a bony prominence

Partial or Full thickness wound

Determined by the layers of skin involved.

Inflammation Phase

Begins immediately and lasts 1 to 4 days, includes edema, erythema, heat, and pain.

Proliferation Phase

Begins on third or fourth day and lasts 2 to 3 weeks. Includes macrophage activity, new capillary formation and tissue formation.

Maturation Phase

Final phase begins about 3 weeks after injury and may take up to 2 years. Collagen is lysed and resynthesized producing strong scar tissue.

First intention wound closure

Wound edges are approximated with sutures or staples.

Second intention wound closure

Wound is left open and heals by granulation.

Third intention wound closure

Delayed primary closure, wound is left open for a period of time and then closed with sutures or staples.

Factors Affecting Wound Healing

Age, Peripheral vascular disease (PVD), Decreased immune system function, Decreased lung function, Nutrition, Medications, Lifestyle, Infection, Chronic illnesses

Hemorrhage

A wound complication

Infection

A wound complication

Cellulitis

A wound complication

Fistula

A wound complication

Sinus

A wound complication

Dehiscence

A wound complication

Evisceration

A wound complication

Sutures and staples

Wound closures

Steri-Strips

Wound closures

Dermabond

Wound closures

Serous drainage

Clear, watery plasma

Sanguineous drainage

Fresh bleeding

Serosanguineous drainage

Pale, red, watery: mixture of clear and red fluid

Purulent Draiange

Thick, yellow, green, tan or brown

Jackson-Pratt drain

Drain used to remove excess fluid

Penrose drain

Drain used to remove excess fluid

Hemovac drain

Drain used to remove excess fluid

Dressings Purpose

Prevent microorganisms, Absorb drainage, Control bleeding, Support and stabilize tissues and Reduce discomfort

Wound Cleansing

Water, saline, wound cleanser (as ordered); irrigations, room temperature

Vacuum Assisted Closure (VAC)

Negative pressure, applies suction to wound; draws edges together; removes fluid from wound bed, but keeps wound moist; increases blood flow

Debridement

Removal of necrotic tissue

Sharp debridement

use of sharp instruments to remove necrotic tissue

Enzymatic debridement

use of topical enzymes to remove necrotic tissue

Mechanical debridement

use of physical means to remove necrotic tissue

Heat Application

Causes vasodilation, speeds healing

Cold Application

Causes vasoconstriction; often applied immediately after injury.