restoration process in interrupted , venous stasis ulcers, diabetic foot ulcers, pressure ulcers.
What are the three phases of wound healing
when is the inflammatory phase initiated
after injury and last 2-6days. it is needed for wound healing to occur.
examples of cellular atrophy
Cell shrinkage, cast, menopause, denervation
what is hypertrophy
the cell enlarges.
what is metaplasia
Cell changes type. I.e Ger. response is compensatory
Abnormal cells. Cervical dysplasia leading to cervical cancer. potentially reversible
What initiates the wound healing process
What are the cardinal signs of inflammation
Redness, heat, swelling, loss of function, pain, purulent exudate
What is the cellular phase of inflammation
when neutrophils and monocytes move from circulation to the site of injury.
In what phase is collagen being layed down in the wound healing process
who is at risk for wound dehiscense
What is contamination
Organisms are present
what is colonization
organisms are multiplying and competing for nutrients and oxygen but have not yet invaded into tissues.
what is infection
invasion into tissue to the extent the wound will not heal, a severe infection may make the host sick
Second phase of wound healing
proliferative phase last 3 to 21 days after inuury. Collagen is laid down to strengthen wound. Caps grow accross the wound increaing blood supply. This is where granulation tissue is seen. it is translucent
final phase of wound healing
Remodeling phase- begins about day 21 and lasts up to 2 years. collagen fibers are now the dominant features. scar is seen.
explain primary intention
characterized by prompt wound closure. surgical scar or clean laceration are examples. results in very little granulation tissue, minimal scarring and contracture
a hypertrophic scar that is due to an excessive amount of collage
change that occurs in scar
What is contact inhibition
When basal cells migrate across a wound and stopping when they come in contact with each other
what is the goal in wound management
Protect wound from
what are the nurse managing option in wound care
maintain initial post op dressing for a minimum 24 hours
keep wound dry
splint when moving or coughing
watch for healing ridge.
wounds left open and have greater tissue damage. has more scar and granulation tissue and contraction seen.
Has a higher risk of infection
greater need for nutritional support
the puckering the body does to close a wound
Closure delayed to treat local infection or contamination. i.e appendectomy.
my goal in wound management
establish a healing environment
remove dead tissue
fill dead space
Nursing interventions for wounds
look at the whole patient and other disease conditiond impsvyinh healing (diabetes and vascular insufficiency)
asses for pain
identify s/Sx of infection
treat from the patient out to the wound
Identify the diference between contamination and infection