Chapter 13
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
|
|
||||
|---|---|---|---|---|---|
| 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
🗑
|
Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Created by:
ygwallace
Popular Nursing sets