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36 Cards in this Set

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Developmental considerations

-less than 2 yrs: skin thinner & weaker

-infant- membranes easily injured & increase infection, over time becomes more resistant

- Aged adult- maturation of epidermal skins prolonged=thin, easy damaged skin, circulation and collagen formation impaired=decrease elasticity and increase tissue damage risk

Types of Wounds

*Intentional- therapy or treatment or surgery: sterile infection decreased, healing increased

*Unintentional- trauma, stabbing, burns, gunshot: infection increased, bleeding uncontrolled

*Open- trauma(intentional or unintentional): increase risk for infection delayed healing

*closed- blow force or strain (fall, assault) skin not broken-> ecchymosis and hematoma


Surgical incision, heal quickly, risk infection low


healing process not normal, risk infection high, healing time delayed remain in inflammatory phase of healing:

- wound that doest heal in normal time: arterial or venous insufficiency


caused by blunt instrument that may result in bruising or hematoma


rubbing or scraping of epidermal layers of skin


tearing of skin and tissue w/ blunt or irregular instrument


tearing of structure from normal anatomic position

phases of wound healing

hemostasis- involved blood vessels constrict and blood clotting begins

inflammatory- white blood cells move to wound

proliferation- granulation tissue is formed to fill the wound

maturation-collagen is remodeled forming scar


occurs as first response to injury

- blood vessels constrict=clotting

- Blood vessels dilate, increase permeability

- exudate= liquid that forms from plasma and blood components to leak out into the area=swelling and pain

-increased perfusion= heat and redness

-platelet stim other cells to migrate to injury to help in healing


after hemostasis 4-6 days

- WBC leukocytes and macrophages go to wound

- ingest debris release growth factors attract fibroblast to fill wound

-mild temp and malaise


- begin 2-3 days within injury last 2-3 weeks

- new tissue built to fill wound from action of fibroblast( connective tissue cells secrete collagen induces blood vessel formation and endothelial cells--> which form across wound

-granulation tissue forms scar tissue

Maturation Phase

Final stage of healing

- 3 wks- 6 months after injury

- collagen remodeled, wound stronger

- scar is flat, thin white line

Local factors affecting wound healing

*pressure- blood supply disturbed delay healing

*desiccation (dehydration) delay heal

*WOUNDS KEPT MOIST NOT WET AND HYDRATED= enhanced epidermal cell migration, supporting epithelialization

*trauma- inability to heal or delay

*Edema- interfere with blood supply to area

* infection- increase stress on body

*excessive bleeding= large clots, increase amount of space needed to be filled for healing, decrease o2 diffusion to tissues ("o's to the toes")

*necrosis- death of tissue must remove ]

* biofilm- thick grouping of micro bacteria, decreased effectiveness of antibiotics, chromic wound inflammation, slimy barrier of sugars and proteins

Systemic factors affecting wound healing

*factors not related to wound location but can prolong healing

-Age- children and healthy adults heal quicker

-Circulation and Oxygenation- adequate blood flow needed

- nutritional status- adequate nutrition needed

- wound condition - specific condition of wound affects healing

- health status- steroid drugs and postoperative radiation delay heal

- Immunosuppression- AIDS, lupus

- Meds- chemo

Wound complications

- infection


- dehiscence- partial or total separation of wound layers: Evisceration- wound completely separates protrusion of viscera(obese, smokers , malnourished, straining

-fistula formation: abnormal passage from internal vessel to outside of body or to another organ


caused by over hydration related to incontinence that causes impaired skin integrity


dead tissue in wound delays healing


swelling at wound interferes with blood supply to the area


process where cells dehydrate and die

Factors affecting pressure ulcer

wound w/ localized area of injury to skin or tissue

-aging skin

-chronic illness



-fecal and urinary incontinence

- altered level of consciousness

-spinal cord and brain injuries

-neuromuscular disorders

Mechanisms in pressure ulcer development

- external pressure compressing blood vessels: bony prominences

-Friction: 2 surfaces rub against each other

- shearing: one layer of skin slides over another layer( pt being pulled rather than lifted)

Stages of pressure ulcers

1- intact skin, blanching( pale and white 'ischemia)

2- partial thickness tissue and skin loss, shallow open ulcer

3- full thickness tissue loss, fat may be seen, NO bone tendon or muscle visible

4- full thickness loss, EXPOSED bone tendon or muscle

5- UNSTAGEABLE- covered by slough or eschar in wound bed must be removed to determine stage


erosion under wound edges


destruction of fascial planes=narrow passageway

sinus tract

blind ended tract extends from skin surface to abscess cavity or area

Assessment of wound drainage

-serous- clear, watery

- sanguineous- large # of RBCs and looks like blood. Bright red=fresh blood, Dark=older blood

-serosanguineous- mix of serum and RBC, light pink

- Purulent- WBS liquefied dead tissue debris, thick must foul odor, vary color

Wound Assessment

-Inspect sight and smell

- palpation for appearance, drain, pain, different drainages

- sutures, drains or tubes, complications

- penrose- after abdominal surgery

- t-tube- bile drain

- hemovac- ortho, abdominal

- gauze

types of wound dressings

Telfa- nonadherent


transparent dressings- op site

Cleaning wounds- edges

Approximated edges- work outward from incision

Unapproximated edges- clean in full or half circles, begin in center work toward outside clean 1 inch beyond

types of bandages


- circular-anchors bandage

-spiral-wrist,fingers, trunk

-figure of 8 turn-effective for around joints

- recurrent stump bandage- risidual limb, head fingers

Types of binders

- straight- chest and abdomen

- T-binder- rectum, perineum, groin

-Sling- arm

Drainage systems

open- penrose

closed- sutured in skin, low continuous suction: jackson prat- bulb, hemovac- round

Color class of open wounds

R- red- protect

Y- yellow- cleanse

B- black- debride

Mixed wound- has both RY &B wounds

Effects applying heat

-dilates blood vessels

- increase tissue metabolism

- reduce blood viscosity and increase capillary permeability

- reduce muscle tension and spasm

- relieve pain

- treat infections, surgical wounds, inflamed tissue, arthritis, joint, muscle pain, dysmenorrhea, chronic pain

Applying Cold

-constrict blood vessels

- reduce muscle spasm

- reduce blood flow and release of pain producing histamine, serotonin and bradykinin, reduce edema and inflammation

- after direct trauma, dental pain, sprains, chronic pain