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exudate
amount, color, consistency, and odor of wound drainage and is part of wound assessment.
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wound
disruption of the integrity and function of tissues in the body
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primary intention
- wound that is closed
- surgical incision, wound that is sutured or stapled
- healing occurs by epithelialization, heals quickly with minimal scar formation
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secondary intention
- wound edges not approximated
- pressure ulcers, surgical wounds that have tissue loss
- wound that heals by granulation tissue formation, wound contraction, and epithelialization
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tertiary intention
- wound left open for several days, then wound edges are approximated
- wounds that are contaminated and require observation for signs of inflammation
- closure of wound is delayed until risk of infection is resolved
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partial-thickness wound repair
- -inflammatory response
- -epithelial proliferation (reproduction)
- -migration and reestablishment of epidermal layers
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hemostasis
injured blood vessels constrict, and platelets gather to stop bleeding
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fibrin
- what clots form.
- later provides a framework for cellular repair.
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inflammatory phase
- damage cells and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and exudation of serum and white blood cells into damaged tissues.
- results in redness, edema, redness and throbbing.
- WBC's reach area within a few hours.
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2nd most important WBC
monocyte which transforms into macrophages
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what do macrophages secrete
growth factor
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what does growth factor attract
fibroblasts
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fibroblasts
synthesize collagen (connective tissue)
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proliferative phase
the filling of the wound with granulation tissue, contraction of the wound, providing matrix for granulation.
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remodeling
- maturation, the final stage
- scare tissue forms
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hemorrhage
bleeding from a wound site
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hematoma
localized collection of blood underneath the tissues
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serous
clear, watery plasma
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purulent
- thick, yellow, green, tan, or brown
- infection
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serosanguineous
pale, pink watery, mixture of clear and red fluid
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sanguinous
bright red, indicates active bleeding.
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dehiscence
partial or total separation of wound layers
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evisceration
protrusion of visceral organs through a wound opening.
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braden scale
sensory perception, moisture, activity, mobility, nutrition, friction and shear
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vitamins needed for healing
calories, protein, vit. c, vit. a, vit. e, zinc, fluid
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abrasion
superficial with little bleeding and is considered a partial thickness wound
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laceration
bleeds more profusely
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puncture
bleed according to depth and size
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normal reactive hyperemia
blanching
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debridement
removeal or nonviable, necrotic tissue
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types of dressing
wet or dry
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vacuum assisted closure
devise that assists in wound closure by applying localized negative pressure to draw the edges of a wound together
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sutures
threads or metal used to sew body tissues together
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drainage evacuators
convenient portable units that connect to tubular drains lying within a wound bed and exert a safe, constant, low pressure vacuum to remove and collect drainage
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