Functions of The Skin and Wound Healing

HideShow resource information
What are the functions of the skin?
Protection, sensation, elimination, thermoregulation. Metabolic syntheses: melanin & keratin. Communication: colour & odour. Cosmesis: body image
1 of 26
What are the 3 phases of wound healing?
1. Inflammation, 2. Proliferation/reconstruction, 3. Maturation/remodeling
2 of 26
Describe the 1st stage of wound healing
1. Inflammation: 0-3 days. Redness, heat, swelling. Heamostasis: vasoconstriction & platelet response to restrict bleeding. Leukocytes (polymorphs) protect, macrophages clear wound of infection
3 of 26
Describe the 2nd stage of wound healing
2. Proliferation/reconstruction: 2-24 days. Phagocytosis continues, Angiogenesis: new blood vessels = new vascular network = energy for wound. Epithelial cells from outside move in to cover, mitosis thickens. Wound contraction.
4 of 26
Describe the 3rd stage of wound healing
3. Maturation/remodeling: 24 days - 1 yr. Tensile strength increases, vascularity and scar size decrease
5 of 26
What are the 3 modes of wound healing?
1. Primary Intention, 2. Secondary Intention, 3. Tertiary Intention
6 of 26
Explain the first mode of wound healing
1. Primary Intention: min or no tissue loss, min tissue destruction, granulation and min scarring
7 of 26
Explain the second mode of wound healing
2. Secondary Intention: more tissue loss, non approximated edges, granulation can occur if infected, some scar fills w. red soft tissue
8 of 26
Explain the third mode of wound healing
3. Tertiary Intention: Deep wound infected, infected tissue must be removed then at 3-5 days re suture it = deeper scar
9 of 26
What are some factors that could affect wound healing?
Age, meds, nutrition, lifestyle, comorbidities, hydration of wound, wound management practices, wound temp (37), pressure & friction
10 of 26
What are some complications of wound healing?
Infection, hypergranulation, hypertrophic/keloid scars (overgrowth dense fibrous tissue) but keloid expand beyond edge and x resolve well, contractures( short muscles) haemorrhage, haematoma (blood beneath tissue) Evisceration (protrusion of organ)
11 of 26
What is dehiscence?
Ruptured wound, increases discharge from wound 3-4 days after op
12 of 26
Discuss ARTERIAL ulcers
Due to blood x reaching extremities, toes, feet. When legs elevated blood flow reduced even more, lowered = pain relieved. Decreased or absent leg pulses, deep wound, slow cap refill, can = gangrene
13 of 26
Discuss VENOUS ulcers
Has enough blood but excess fluid means it x travel back up leg, elevated = pain relieved, normal leg pulses ruddy granulation, uneven edges, oedema, tissue breakdown
14 of 26
What are some risk factors for Pressure Ulcers?
Prolonged pressure, age, health, mobility, friction & trauma, altered skin moisture, poor skin perfusion
15 of 26
What info should be included in a Wound Assessment?
wound history, size, edge, location, exudate, surrounding skin, pain, psychological impact, documentation on wound chart.
16 of 26
What is debridement?
The removal of necrotic tissue
17 of 26
What are the different methods for Debridement?
Sharp: Removal w. sterile sharp instruments no blood or pain - competent practioner. Surgical: " aseptic envi - med practitioner. Mechanical: damp to dry dressing or irrigation under pressure. Biological: maggots. Enzymatic/chem: debriding enzymes
18 of 26
What does a score of 9 or less mean on Braden Scale
Very high risk
19 of 26
What does score of 13 - 14 mean on Braden Scale?
Mod risk
20 of 26
What does score of 10 - 12 mean on Braden Scale?
High risk
21 of 26
What does score of 15 - 18 mean on Braden Scale?
At risk
22 of 26
What does score of 19 - 23 mean on Braden Scale?
Generally not at risk
23 of 26
What does ISOBAR stand for?
I: Identification, S: Situation, O: Observations, B: Background, A: Assessment, R: Readback
24 of 26
What are the 'Intrinsic' factors in wound management?
Decreases blood supply, age, underlying diseases, malnutrition, obesity, skin perfusion
25 of 26
What are the 'Extrinsic' factors in wound management?
Smoking, certain meds, pts undergoing radiotherapy
26 of 26

Other cards in this set

Card 2

Front

What are the 3 phases of wound healing?

Back

1. Inflammation, 2. Proliferation/reconstruction, 3. Maturation/remodeling

Card 3

Front

Describe the 1st stage of wound healing

Back

Preview of the front of card 3

Card 4

Front

Describe the 2nd stage of wound healing

Back

Preview of the front of card 4

Card 5

Front

Describe the 3rd stage of wound healing

Back

Preview of the front of card 5
View more cards

Comments

No comments have yet been made

Similar Nursing resources:

See all Nursing resources »See all Functions of the Skin and Wound Healing resources »