Question | Answer |
Phases of wound healing
Inflammatory Response | >Vascular response
>Cellular response
> Formation of Exudate
> Healing |
Inflammatory phase
Vascular Response | Transient Vasoconstriction-> Histamine Release ->
Vasodilation (Increased blood flow which raises filtration pressure) --> Increased capillary permeability (facilitate movement from capillaries into tissue spaces)->
Fibrin->
Growth Factors |
What is Fibrin | fibrous, non-glabular protein involved in clotting of blood |
Vasodilation and Increased capillary permeability responsible for: | redness, heat, and swelling |
What is Exudates | any fluid that filters from the circulatory system into lesions or areas of inflammation |
Cellular Response | >Neutrophils
>Monocytes and Macrophages
>Lymphocytes and other WBCs |
Neutrophils in Cellular Response | >First to arrive (6-12 hours)--> Engulf bacteria, other foreign material & damaged cells
--> short life span (24-48 hours) --> dead neutrophils accumulate w/digested bacteria & other cell debris = creamy substance (pus) |
Monocytes and Macrophages in Cellular Response | second to migrate from circulating blood. >arrive (3-7 days) after onset of inflammation
>on entering tissue space monocytes transform int macrophages --> engulf inflammatory debris
>the role--> cleaning area before healing can occur
> long life span |
Lymphocytes and other WBCs in Cellular Response | arrive later at injury |
Types of inflammatory exudate
Serous | Results from outpouring of fluid; seen in early stages of inflammation or when injury is mild. Examples: skin blisters, pleural effusion |
Types of inflammatory exudate
Serosanguineous | Found during the midpoint in healing after surgery or tissue injury.
Composed of RBCs and serous fluid. This fluid is semiclear pink and may have red streaks. Examples: Surgical drain fluid |
Types of inflammatory exudate
Fibrinous | Occurs with increasing vascular permeability and fibrinogen leakage into interstitial spaces.
Excessive amounts of fibrin that coats tissue surfaces may cause them to adhere. Examples: Adhesions, gelatinous ribbons seen in surgical drain tubing |
Types of inflammatory exudate
Hemorrhagic | Results from rupture or necrosis of blood vessel walls
Examples: Hematoma, bleeding after surgery or tissue trauma |
Types of inflammatory exudate
Purulent (pus) | Consists of WBCs, microorganisms (dead and alive) liquefied dead cells, and other debris. Examples: Furuncle (boil), abscess, cellulitis (diffuse inflammation in connective tissue). |
Types of inflammatory exudate
Catarrhal | Found in tissues where cells produce mucus.
Mucus production is accelerated by inflammatory response.
Examples: runny nose associated with upper respiratory tract infection |
Healing Process
Regeneration | replacement of lost cells and tissues with cells of same type |
Healing process
Repair | healing as a result of lost cells being replaced by connective tissue
(most common results in scar formation) |
Healing process
Regeneration
Labile Cells | >Labile cells->divide constantly -> rapid regeneration (ex: skin, mucous membranes of GI, bone marrow) |
Healing process
Regeneration
Stable Cells | >Stable cells (retain their ability to regenerate but do so only if organ is injured) (ex: liver, pancreas, kidney) |
Healing process
Regeneration
Permanent Cells | Permanent Cells (do not divide) (ex: CNS, Cardiac, and skeletal muscle cells) -permanent loss if damaged - CNS neurons destroyed replaced by glial cells -Cardiac & skeletal replace by scar tissue |
Healing process
Repair
Primary Intention | Surgical incision or papercut
1. Initial
2. Granulation
3. Scar Contracture |
Healing process
Repair
Primary Intention
Initial Phase | 1. Initial: (3-5 days) approximation of incision edges; migration of epithelial cells; clot serving as meshwork for starting capillary growth |
Healing process
Repair
Primary Intention
Granulation Phase | 2. Granulation (5 days to 4 weeks) Migration of fibroblasts; secretion of collagen; abundance of capillary buds, fragility of wounds |
Healing process
Repair
Primary Intention
Scar Contracture | 7 days to several months. Remodeling of collagen; strengthening of scar |
Healing Process
Repair
Secondary Intention | wounds that occur from trauma, ulceration, or infection have large amounts of exudate & wide irregular wound margins with tissue loss
-edges that can be brought together
-clean debris before healing |
Healing process
Repair
Tertiary Intention | Delayed primary intention
-contaminated wound is left open & sutured closed after infection is controlled
-larger scar than primary and secondary |
Clinical Manifestations of Wounds | Local reactions
-Redness
-Heat
-Pain
-Swelling
-Loss of Function
Systemic
-Leukocytosis
-Fever |
Clinical Manifestation
Redness | hyperemia from vasodilation |
Clinical Manifestation
Heat | increased metabolism at inflammatory site |
Clinical Manifestation
Pain | Change in pH, nerve stimulation by chemicals (histamine, prostaglandins) pressure from fluid exudate |
Clinical Manifestation
Swelling | Fluid shifts to interstitial spaces, fluid exudation accumulation |
Clinical Manifestation
Loss of function | Caused by pain and swelling |
Clinical Manifestation
Leukocytosis | increase release of leukocytes from bone marrow (nausea, malaise, anorexia, fatigue) |
Phases of healing | >New capillary networks
>Granulation Tissue
>Epithelialization
>Action of fibroblasts |
Description/Characteristics of Red Wound | -superficial or deep if clean and pink in appearance
-serosanguineous drainage
-pink to bright/dark red healing, or granulating tissue |
Examples of red wound | Skin tears, pressure ulcers (stage II), partial thickness, or second degree burns |
Purpose of treatment for red wound | protection and gentle atraumatic cleaning |
Dressings and therapy of red wound | Transparent film dressing (ex: tegaderm, opsite, duoderm, hydrogels (tegagel), gauze dressing with antimicrobial ointment or solution, telfa dressing with antibiotic ointment |
Description/Characteristics of Yellow wound | -slough or soft necrotic tissue
-liquid to semiliquid slough with exudate ranging from creamy ivory to yellow green |
Example of Yellow Wound | Wounds with nonviable necrotic tissue, which creates an ideal situation for bacterial growth and therefore must be removed |
Purpose of treatment for Yellow Wound | Wound cleansing to remove nonviable tissue and absorb excess drainage |
Dressing and therapy for Yellow Wound | Absorptive dressing, hydrocolloidal dressing, hydrogel covered with gauze, wound irrigations, hydrotherapy, moist gauze dressing with or without antibiotic or antimicrobial agent |
Description/Characteristics of Black Wound | -Black, gray, or brown adherent necrotic tissue called eschar, possible presence of purulent drainage
-risk of wound infection increases in proportion to amount of necrotic tissue present |
Example of Black Wound | Full-thickness or third-degree burns, pressure ulcers (stage III and IV) and gangrenous ulcers |
Purpose of treatment of Black Wound | Debridement of eschar and nonviable tissue |
Dressing and therapy For Black Wound | Topical debridement (enzyme, surgical, chemical) hydrotherapy, moist gauze dressing, hydrogel covered with gauze, absorptive dressing covered with gauze |
What factors delay wound healing | -Nutritional Deficiencies
-Inadequate blood supply
-Corticosteroid drugs
-Infection
-Mechanical friction
-Advanced age
-Obesity
-Diabetes Mellitus
-Anemia
-Poor general health |
delay wound healing
-Nutritional deficiency | -Vit. C (delays formation of collagen fibers and capillary development)
-Protein (Decreases supply of amino acids for tissue repair)
-Zinc (impairs epithelialization) |
Delay Wound Healing
-Inadequate blood supply | -Decreases supply of nutrients to injured area
-decreases removal of exudative debris
-inhibits inflammatory response |
Delay Wound Healing
-Corticosteroid Drugs | -Impair phagocytosis by WBCs
-Inhibit fibroblast proliferation and function
-Depress formation of granulation tissue
-Inhibit wound contraction |
Delay Wound Healing
-Infection | Increases inflammatory response and tissue destruction |
Delay Wound Healing
-Smoking | Nicotine is a potent vasoconstrictor and impedes blood flow to healing area |
Delay Wound Healing
-Mechanical Friction | -Destroys granulation tissue
-Prevents apposition of wound edges |
Delay Wound Healing
-Advanced age | -Slows collagen synthesis by fibroblast
-Impairs Circulation
-requires longer time for epithelialization of skin
-alters phagocytic and immune responses |
Delay Wound Healing
-Obesity | Decreases bloody supply in fatty tissue |
Delay Wound Healing
-Diabetes Mellitus | -Decreases collagen synthesis
-Retards early capillary growth
-impairs phagocytosis (result of hyperglycemia)
-reduces supply of O2 and nutrients secondary to vascular disease |
Delay Wound Healing
-Poor general health | Causes generalized absence of factors necessary to promote wound healing |
Delay Wound Healing
-Anemia | Supplies less oxygen at tissue level |
Complication of Healing | -Hypertrophic Scars
-Contracture
-Dehiscence
-Evisceration
-Excess granulation tissue
-Adhesions |
Complication of Healing
-Adhesions | -Bands of scar tissue that form between or around organs
-Adhesions may occur in abdominal cavity or between lungs and pleura
-Adhesions in abdomen may cause an intestinal obstruction |
Complication of Healing
-Hypertrophic Scars | -Occur when an overabundance of collagen is produced during healing
-Forms an inappropriately large, raised red and hard scar that is non-life threatening |
Complication of Healing
-Contracture | -Wound contraction is a normal part of healing
-Complications occur when there is excessive contraction resulting in deformity
-muscle or scar tissue shortening; esp. over joints, from fibrous tissue formation |
Complication of Healing
-Dehiscence | -separation/disruption of previously joined wound edges
-Occurs when healing site burst open
-Caused by- infection causing inflammation-granulation tissue weak-obesity bc less blood supply in adipose
fluid develop preventing wound edges coming together |
Complication of Healing
-Evisceration | Occurs when wound edges separate & intestines protrude thru wound |
Complication of Healing
-Excess Granulation tissue (proud flesh) | -protrudes above healing wound surface
-if cauterized/cut off healing in normal manner |
What are pressure ulcers? | localized injury to the skin and/or underlying tissue->bony area result of pressure or pressure in combo with shear or friction |
What are contributors to pressure ulcers? | -Shearing force->pressure on skin when adheres to bed & skin slide in direct of body movement
-Friction -> 2 surfaces rubbing
- excessive moisture |
Characteristics of Stage I pressure ulcer? | intact skin w/ nonblanchable redness. |
Characteristics of Stage II pressure ulcer? | Partial thickness loss of dermis ->shallow open ulcer w/ red-pink wound bed or blister |
Characteristics of Stage III pressure ulcer? | full thickness tissue loss->subcutaneous fat may be visible->no bone, tendon, muscle visible |
Characteristics of Stage IV pressure ulcer? | Full thickness tissue loss w/ exposed bone, tendon, muscle |
What are the focused assessment of pressure ulcers? | >location
>Size
>Color
>Surrounding skin
>Drainage
>Temperature
>Pain
>Wound Closures |
Characteristics of unstageable pressure ulcer? | full thickness tissue loss->base of ulcer covered by slough (yellow, tan, gray, green, brown) &/or eschar (tan, brown, black) in wound bed |
Diagnostic test for pressure ulcers | >CBC
-Leukocytosis
-hemoglobin
>Sedimentation rate
>C reactive protein
>Albumin |
What are nursing interventions? | >Fever
>Rest and immobilization
>elevation
>heat/cold
>oxygenation |
Wound management for secondary intention? | >cleansing
>keeping the wound moist
>filling dead space |
Sharp Debridement | -quick method of debridement to prevent, control, remove infection
-Used when large amounts of nonviable tissue are present
-prepares wound bed for healing, skin grafting, or flaps |
Mechanical debridement
3 methods | 1. wet to dry dressing-open mesh gauze moistening w/saline->pack on or in wound, and drys. Removing dressing removes debris.
2. Wound irrigation-make sure bacteria is not driven in wound with high pressure
3. Whirlpool-used-minimal debris present |
Autolytic debridement | -Semiocclusive or occlusive dressing used to soften dry eschar by autolysis.
-Area around wound must be assessed for maceration when these dressings are used |
Enzymatic debridement | -Drugs applied topically to dissolve necrotic tissue and then covered with moist dressing (ex: saline moistened gauzed)
-Ex. of drugs include collagenase, papain, urea
-Process can be slow and thick eschar may need to be scored with scalpel |
Dressings: Gauzes and nonwovens | -Exudate absorption
-Debridement if applied and kept moist
-Maintain moist wound surface
-Cleansing, packing, covering wound variety
ex: Curity, Kling, kerlix |
Dressings: Nonadherent | -woven or nonwoven
-impregnated with saline, petrolatum, anitmicrobials
-minimally absorbent
-Mainly used on minor wounds or second dressing
ex: adaptic, vaseline gauze, xeroform |
Dressings: Transparent films | -semipermeable membrane permits gaseous exchange between wound & environment
-allows wound visualization
-minimally absorbent
-Used for dry non infected wounds or wounds with minimal drainage
ex:tegaderm, bioclusive, blisterfilm, carrafilm, omniderm |
Dressings: Hydrocolloids | -Wafers, powders, pastes made of gelatin, pectin, or carboxymethylcellulose.
-occlusive dressing not allow O2 to wound
-supports debridement & secondary infection prevention
-Superficial & partial thickness wounds/infected wounds
ex: Duoderm, Exuderm |
Dressings: Foams | -Sheets & other shapes of foamed polymer solutions with small, open cells capable of holding fluids
-Absorbing of moderate to heavy amounts of exudate
-Easy removal
-Partial/full-thickness wounds
ex: allevyn, curafoam, flexzan, hydrasorb, lyofoam |
Dressings: Absorptive dressing | -Absorbing exudates
-Maintain moist surface
-Place in wounds to destroy dead space
-Partial/full-thickness wounds
ex: ABD combine pads, Covaderm, Curity abdominal pads, multipad |
Dressings: Hydrogel | -Sheet, gel, gauze designed to donate moisture to a dry wound and maintain moist healing environment
-Rehydrate wound tissue ->debridement
partial or full thickness wounds, deep wounds w/minimal drainage, necrotic wounds
ex: Aquasite, carrasyn gel |
Dressings: Alginates | -nonwoven, nonadhesive pads and ribbons made of polysaccharide fibers or xerogel derived from seaweed.
-Contact with exudate, form a moist gel
-Easy over irregular shape
-Moderate to heavy exudates (pressure ulcer)
ex: Algicell, Algisite, Carrasorb, |
Dressings: Antimicrobials | -Deliver iodine, silver, polyheamethylene biguanide->antibacterial properties
-No resistance
-Partial/Full thickness wounds (surgical incisions)
ex: Acticoat, Biopatch, Curity AMD, Island wound dressing with microban |
Additional therapies | -Negative pressure wound therapy
-Hyperbaric oxygen therapy
-Positioning
>HOB as low as tolerated
>Support surfaces-pressure reduction
> Turn q 2 hours |