Nursing 320 Chronic Wound Management

Front 1

Epidermis:
where
made of
function

Back 1

- outermost
- epithelial cells and melanocytes; no blood supply
- protection
regenerates

Front 2

Dermis:
Where
function
contains

Back 2

- below epidermis
- blood supply to nourish epi
- fibroblasts, macrophages, mast, nerve cells
- epidermal appendages (hair follicles, sweat glands, sebaceous glands)

Front 3

SubQ
- where
- made of
- function

Back 3

- below dermis
- adipose, connective, bl vessels, lymph, nerve endings
- protection from pressure and padding against shear

Front 4

Fascia/ muscle
- where
- sensitive to

Back 4

- under subQ
- ischemia (pressure damage) due to being highly vascularised

Front 5

What is the function of skin (6)?

Back 5

Protection
heat regulation
sensory perception
excretion
VD
expression and body image

Hint 5

SHEEPS

Front 6

How is infant skin different?

Back 6

thinner skin and nails

Front 7

How is skin different in older adults?

Back 7

- epi thin
- decreased collagen
- reduced sebaceous and sweat activity
- loss of subQ
- reduced blood flow
- increased capillary fragility
-

Front 8

what is senile pupura

Back 8

caused by increased capillary fragility
purple coloured ecchymoses resolving to brown discolouration

Front 9

What does healthy skin look like compared to at risk?

Back 9

Healthy - supple, dry, acidic
At risk - flakey and dry, or moist

Front 10

How do you prevent skin breakdown?

Back 10

H2T Ax
braden scale
manage nutrition/hydration
maintain perineal skin integrity
mobilize frequently
multidisciplinary

Front 11

What are the classification systems for wounds?

Back 11

Acute vs chronic
partical thickness vs full thickness
pressure ulcer staging system

Front 12

What is an acute wound?

Back 12

Occurs in a sudden manner
follow orderly and predictable healing

Front 13

What is a chronic wound (2 ways to get)?

Back 13

Acute wounds that fail to heal
Wounds that result from loss of perfusion or some other brkdwn in tissue integrity

Front 14

What is a partial thickness wound?

Back 14

involves epi and part of dermis
superficial and painful
heals by regeneration

Front 15

What is a full thickness wound?

Back 15

Epi and dermis completely gone
heals by granulation
results in loss of normal function

Front 16

What is a stage 1 ulcer?

Back 16

reddened and non-blancheable

Front 17

What is a stage 2 ulcer?

Back 17

through epi and into dermis

Front 18

What is a stage 3 ulcer?

Back 18

into SubQ

Front 19

What is a stage 4 ulcer?

Back 19

into fascia

Front 20

What is a DTI?

Back 20

Deep tissue injury
purple/maroon discoloured INTACT skin

Front 21

What is an unstageable ulcer?

Back 21

Base of ulcer is covered by slough and/or eschar, don't know how deep it goes

Front 22

What is primary intention?

Back 22

surgical incision
wound edges approximated
small granulation and epi regen to heal

Front 23

What is secondary intention?

Back 23

Left open to heal through
granulation
contraction
epithelialization

Front 24

What is tertiary intention?

Back 24

delay between injury and surgical closure

Front 25

How does the epidermis heal?

Back 25

regeneration

Front 26

How does the dermis heal?

Back 26

most regenerate
appendages lost
scar formation - granulation

Front 27

how does subQ and fascia/muscle heal

Back 27

Scar formation

Front 28

What are the 3 phases of wound healing?

Back 28

1) inflammatory - hemostasis
2) proliferation - angiogenesis, granulation, epithelialization
3) maturation - remodeling

Front 29

What is the defensive phase of healing?

Back 29

- immediate
- hemostasis and inflammation
- 1-4 days for acute
- chronic wound remains in this phase

Front 30

What is hemostasis?

Back 30

platelet in contact with collagen in tissue - activates response to form platelet plug (fibrin)
- stop bleeding

Front 31

What happens during inflammation?

Back 31

- vasodilation - incr bl flow to area and leaky capillaries
- GF released by plug attracts WBCs to deal with necrotic and bacteria
- short in acute, long in chronic

Front 32

What are S&S of inflammation (3)

Back 32

1. erythema
2. warmth
3. induration (hardened)

Front 33

What are 3 events of proliferation?

Back 33

1. granulation
2. contraction (open wounds only)
3. epithelialization

Front 34

What happens during granulation?

Back 34

wound filled with granulation tissue
- capillaries (neoangiogenesis)
- collagen (fibroblasts)
acute = 5-15 days
chronic = variable

Front 35

What is contraction?

Back 35

- open wounds only
mobilization of wound edges by myofibroblasts to reduce size

Front 36

What happens with epithelialization?

Back 36

Resurface wound by growth of epi from edges
incisional - 3 days
chronic - longer

Front 37

What (2) happens during maturation phase of healing?

Back 37

1. lysis of established collagen
2. synthesis of new collagen to improve tensile strength of scar (to 80%)
takes 1-2 years

Front 38

What factors affect wound healing?

Back 38

1. perfusion - so conditions that affect perfusion, affect healing! (edema, anemia, PVD, DM, cardiac probs...)
2. Nutrition - sp need protein, VC, Zinc
3. Infection - delays collagen, prevents epithelialization, cytotoxic
4. DM - reduced collagen, leukocyte, perfusion
5. steroids - suppress inflammatory
6. Age
7. Stress
8. Immunosupporession
9. other diseases

Front 39

What do you look for (8) in Ax a wound

Back 39

- location
- size (LWD)
- base
- undermining/sinus tract
- edges
- exudate
- periwound
- pain

Front 40

What does the anatomical location of a wound tell you?

Back 40

- ID cause
- healing potential

Front 41

What does the size of a wound tell you?

Back 41

- measure weekly to get healing indication
- debridement changes size

Front 42

What does wound base colour tell you?

Back 42

healthy is red/pink
necrotic is yellow, tan, black

document in percentage of each colour

look for tendon, muscle, bone...

Front 43

What is undermining?

Back 43

tissue destruction underlying intact skin along wound margins
Product of shearing forces

Front 44

What is a sinus tract?

Back 44

pathway that extends in any direction from wound surface - probe to assess

Front 45

What do you look for in exudate?

Back 45

Colour
Odor
Consistency
Amount

Front 46

What (2) do you look for in edges of open wound?

Back 46

1. presence/absence of new tissue
2. contributing factors - nutrition, necrotic, maceration, infection...)

Front 47

What do you look for in periwound area?

Back 47

- erythema
- maceration
- induration
- hematoma
- denuadation

Front 48

What is a critical colonization?

Back 48

When the load o microorganisms prevents wound from healing - may not look infected

Front 49

What is an infection?

Back 49

when host has a response against invading microorganisms

Front 50

What are S&S of infection?

Back 50

Acute - erythema, inducation, fever, pain, elevated WBC, purulent drainage, + CnS

Front 51

What are S&S of chronic wound infection?

Back 51

- wound brkdwn
- delayed healing
- increased pain
- friable granulation tissue
- foul odor

Front 52

What is the most important thing in wound management?

Back 52

Determine and address cause of wound

Front 53

What are 4 principles of wound healing?

Back 53

1. determine and address cause
2. provide systemic support
3. determine patient desired outcome
4. apply appropriate topical therapy

Front 54

What are the principles in topical therapy?

Back 54

IDIPAMOP
ID infection, Debride, insulate, pack, absorb, Moist, open edges, protect

Front 55

What are some methods of debridement?

Back 55

1. autolytic - moist wound envt
2. mechanical - wet to dry
3. biological - maggots
4. enzymatic - santyl

Front 56

How do you select a dressing?

Back 56

manage moisture
consider form of dressing, and function

Front 57

what is hydrogel used for?

Back 57

dry wounds

Front 58

What is transparent film used for?

Back 58

minor abrasions and friction

Front 59

What is hydrocolloid used for?

Back 59

Stage I and II
Minimal exudate
not on heals

Front 60

What is hypertonic gauze used for?

Back 60

yellow, sloughy wounds

Front 61

What is non-adherent dressing used for?

Back 61

fragile wound bases

Front 62

What is hydrofiber used for?

Back 62

heavy exudate wounds

Front 63

What is foam used for?

Back 63

moderate draining
mepilex, allevyn

Front 64

what is antimicrobial used for?

Back 64

iodosorb, when animicrobial effect required

Front 65

What are silvers used for?

Back 65

When heavily colonized

Front 66

How do you treat heals?

Back 66

- off load pressure at all times
- prevent ulceration
- no tegasorb

Front 67

How do you treat skin tears?

Back 67

- treat immediately
- cleanse NS
- approximate
- mepitel/ dry dressing, change Q3-7d