Wounds-final review guide

Risk factors of patients developing hospital-associated wounds

Prolonged immobility, malnutrition, moisture, and inadequate blood flow

Stage I wounds

Non-blanching erythema to the skin. No breakdown

Stage II wounds

Breakdown of epidermis

Stage III wounds

Tissue loss extending through the dermis to the subcutaneous tissue 

-Creates a shallow crater

Stage IV wounds

Ulcer extends beyond the skin and subcutaneous tissue

-Exposes underlying structures like muscle, tendon or bone

Unstageable wounds

Full thickness tissue loss with unspecified depth due to slough or eschar

Wound tunneling

Creating of a narrow channel or tract extending deeper into the tissue

Undermining wound

Larger area of tissue separation under the wound edges, a “pocket”

Slough

Soft, moist dead tissue that is usually yellow or tan in color and found in wounds

-Causes the depth of the tissue to be unstable able because base is obscured

Eschar

a dry, necrotic tissue that is usually black, brown, or tan in color and found in wounds, often requiring removal for healing

-Causes the depth of the tissue to be unstable able because base is obscured

Signs and symptoms of wound infections

Erythema, increased tenderness, warmth, exudate

Exudate

Fluid that leaks from blood vessels into tissues, often containing cells and proteins, observed in wounds

Primary wound healing

Edges of the wound approximated (sutures, staples, glue)

-Usually minimizes scarring

Secondary wound healing

Wound is left to heal naturally 

-Granulation tissues and scarring

Tertiary wound healing

Purposely delayed closure of the wound 

-Often used to allow for infection or edema to drain

Hemostasis

Stage 1 of wound healing

-Focus is on stopping the bleeding process

-Blood vessels constrict, clot forms, coagulation factors reinforce the clot with fibrin

Inflammatory

Stage 2 of wound healing

-Sets in to clean the wound and prepare it for regeneration

-Damages cells and pathogens are removed by neutrophils and macrophages

-S/sx of this phase include swelling, redness, heat and pain

Proliferation

Stage 3 of wound healing

-New tissue is formed close to the wound, Blood vessels grow into the wound and epithelial cells begin to cover the surface forming a new layer of skin

-Granulation tissues can look beefy red

Wound remodeling

Stage 4 of wound healing 

-Reorganization and strengthening of the new tissue, Scar strengthened

Nursing interventions

-Incontinence pads

-Foam dressings

-Purewick/external catheter

-Triad hydrophilic dressing