WOUND CARE

amount, color, consistency, and odor of wound drainage and is part of wound assessment.

disruption of the integrity and function of tissues in the body

• wound that is closed
• surgical incision, wound that is sutured or stapled
• healing occurs by epithelialization, heals quickly with minimal scar formation

closed

• wound edges not approximated
• pressure ulcers, surgical wounds that have tissue loss
• wound that heals by granulation tissue formation, wound contraction, and epithelialization

• 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

• -inflammatory response
• -epithelial proliferation (reproduction)
• -migration and reestablishment of epidermal layers

injured blood vessels constrict, and platelets gather to stop bleeding

• what clots form.
• later provides a framework for cellular repair.

• 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.

neutrophil

monocyte which transforms into macrophages

growth factor

fibroblasts

synthesize collagen (connective tissue)

the filling of the wound with granulation tissue, contraction of the wound, providing matrix for granulation.

• maturation, the final stage
• scare tissue forms

bleeding from a wound site

localized collection of blood underneath the tissues

clear, watery plasma

• thick, yellow, green, tan, or brown
• infection

pale, pink watery, mixture of clear and red fluid

bright red, indicates active bleeding.

partial or total separation of wound layers

protrusion of visceral organs through a wound opening.

sensory perception, moisture, activity, mobility, nutrition, friction and shear

calories, protein, vit. c, vit. a, vit. e, zinc, fluid

superficial with little bleeding and is considered a partial thickness wound

bleeds more profusely

bleed according to depth and size

blanching

removeal or nonviable, necrotic tissue

wet or dry

devise that assists in wound closure by applying localized negative pressure to draw the edges of a wound together

threads or metal used to sew body tissues together

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