Wound and LDA Assesment

Wound

any disruption of skin integrity

Phases of Wound Healing

1. Hemostasis

2. Inflammation

3. Proliferation

4. Maturation/Remodeling

Hemostasis Phase

Bleeding stops through vasoconstriction and clot formation.

Inflammation Phase

White blood cells clean the wound, removing bacteria and damaged tissue.

Edema, erythema, and exudate occur

Proliferation Phase

New tissue, collagen, and blood vessels form, and the wound begins closing.

Granulation and epithelization occur

Maturation/Remodeling Phase

Collagen reorganizes and strengthens, forming a stronger scar.

Types of Wound Closures

1. Primary Intention

2. Secondary Intention

3. Tertiary intention

Primary intention

Wound edges are sutured, stapled, or glued. Edges are approximated.

What does approximated edges mean?

They are closed/brought together

Secondary intention

Wound is left open and heals from the bottom up by forming granulation tissue. Takes longer and usually causes more scarring.

Tertiary intention

Wound is left open at first, usually because of contamination or infection risk, then closed later once it is cleaner.

Expected Finding in wound dressing

Clean, Dry, and Intact

Labeled with date, time, and initals of the person who performed the dressing

Unexpected findings for wound dressing

Soiled, saturated, or not intact

Dressing is overdue to be changed or unlabled

Exudate definiton

(Drainage) Fluid produced by the body in response to tissue damage

What does serous exudate look like?

it is clear or pale yellow, thin & watery

When can serous exudate be expected?

A small amount during early healing is expected

When should you be considered about serous exudate?

When there is a large/increasing amount that is persistent

What does serosanguineous exudate look like?

Light red or pink, thin and watery

When can you expect serosanguineous exudate?

a small amount during early healing can be expected

When should you be concered about serosanguineous exudate?

When it is in a large/increasing amount that is persistent

What does sanguinous exudate look like?

Bright red, fresh blood

When is sanguineous exudate expected?

A small amount immediately after surgery or trauma is expected

When is sanguineous exudate concerning?

When there is a large/increasing amount that is persistent

Describe purulent exudate

Pus — Dark yellow, tan, or green, Thick, opaque and often odorous

When is purulent exudate expected in a wound

NEVER

When should you be concerned about purulent exudate

When it is present, it suggests infection or a high bacterial load in a wound

Scant Drainage

The wound is moist but there is no measurable amount of exudate on the dressing

Small amount of drainage

exudate covers less than 25% of the size of the bandage

Moderate amount of drainage

wound tissue is wet and drainage covers 25% to 75% of the size of the bandage

Copious amount of drainage

wound tissue is filled with fluid and exudate covers more than 75% of the bandage

Superficial wound

loss of epidermis only

Partial Thickness wound

Dermis is exposed

Full-Thickness wound

Loss of epidermis and dermis, and possibly deeper tissue layers

How do you measure the length of a wound?

From 12 o clock to 6 o clock

What is granulation?

Pink or red bumpy tissue that is moist that forms during the proliferation phase of wound healing.

It is composed of new blood vessels, fibroblasts, ecm and collagen

What is epithelialization?

Pink new epithelial tissue that grow in from the edges of the wound

What is Slough?

dead tissue that is the byproduct of the inflammatory phase of wound healing.

Well-hydrated, soft yellow or white tissue

Eschar

black or brown, dry, leathery tissue, caused by cell death from a tissue injury

Maceration

Soft and wrinkly appearance with a whiteish hue caused by the softening and breakdown od skin

Indurartion

hardening and thickening of skin and tissue around a wound caused by edema

Dehiscence

partial or total separation of previously approximated edges

Evisceration

abdominal organs protruding from incision

Undermining

tissue under the wound edge becomes eroded creating an overhang/lip

Epibole

rolling/curling of the wounds edges

What is a pressure injury?

a localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of intense and prolonged pressure in combination with shearing and friction

Stage 1 Pressure injury

intact skin with a visible change in skin color.

Changes in sensation, temperature, pain, and firmness may be seen

Light skin - Medium skin tones : does not blanch

Stage 2 Pressure Injury

Open wound with partial thickness skin loss and visable dermis

Stage 3 Pressure injury

Full thickness loss where adipose tissue is visible. Appears as a open crater

Stage 4 Pressure injury

Full-thickness loss with exposure of deeper stuctures

Why might a pressure injury be unstageable?

The wound base is covered by slough or eschar

Deep tissue pressure injury

Intact area of skin that is deep red, maroon, or purple that has underlying deep tissue damage. May feel boggy

Why is maintaining a moist wound healing environment important?

It facilitates the development if granulation tissue and epithelization reducing healing time, pain, and scaring

Signs a wound is too wet

The dressing is saturated between changes

Maceration or excoriation of the periwound area

Dressings to use for heavily exudating wounds

specialty absorptive, alginate, foam

Signs a wound is too dry

The dressing sticks to the wound base

The wound base is desiccated (dried out/dead)

Epibole (rolled in)

Dressings for dry or minimally exudating wounds

Hydrogel, Hydrocolloid, Occlusive

What does LDA stand for?

Line, Drain, Airway — Any tube that extends from the body