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Autolysis
Disintegration of tissue or cells by the body's own mechanism (leukocytes, enzymes)
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Debridement
- Removal of necrotic tissue
- sharp
- mechanical
- chemical
- autolysis
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Epithelialization
regeneration of epidermis across a wound surface
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Epiboly
Rolling over of wound margins
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Erythema
redness of skin caused by congestion of capillaries
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Eschar
dry thick necrotic skin
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Gangrene
death of tissue, associated with a decrease of absence of blood supply and bacterial infection
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Granulation tissue
small blood vessels (neovascularization) and immature collagen
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Induration
due to edema, the hard feeling of wound edges
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Maceration
softening of tissue due to moisture or excess fluid
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Necrosis
morphological changes indicative of cell death
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Sinus tract
pathway extending from the wound
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Slough
mass of death tissue or cells
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Undermining
rim under wound margin
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wound margin
rim or border of the wound
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How can pressure ulcers be caused
occlusion of capillaries or friction and shear
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What are 7 types of wound classifications
- burns
- pressure ulcers
- arterial insufficiency
- venous insufficiency
- mixed (arterial & venous insufficiency)
- diabetic wounds
- cellulitis
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What are the two stages of wound healing
primary and second intention
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What is primary intention
- approximation of wound edges via sutures, staples steri-strips
- tends to be much faster and therefore the preffered method in many instances
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What is secondary intention
- this involves the filling of wounds via granulation and epithelialization
- slower, increase risk of infection and scar tissue
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How are wounds measured
- they are measured in centimeters W/D/L
- typically use a clock system if applicable
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What must be documented for wound care
- location
- classification
- width, depth, length
- presence of tunnels, undermining
- wound appearance in percentage
- periwound area: signs of edema, induration, inflammation, infection
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What are the different types of mechanical debridement
- whirlpool
- irrigation
- pulse lavage
- mist
- dressing removal
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What are the three types of sharp debridement
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What are some Physical Therapy interventions for wound care
- prevention and ongoing pressure relief
- wound debridement
- dressing changes/wound management
- modalities (E-Stem/Ultrasound)
- wound cleaning (hydrotherapy/pulsed lavage)
- vacuum assisted closure devices
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When examining a wound what are some of your objectives
- type
- size
- stage
- type and amount of drainage
- tissue
- presence of edema, odor and skin integrity in adjacent area
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