Wound Care Day one

• a wound that has failed to proceed orderly through the healing process
• Ex: dm wound, venus ulcer, pressure ulcer

a disruption in the integrity of the skin and underlying tissues that progress through the healing cascade in a timely and uncomplicated manner

• "recalcitrant" wound is one which fails to respond to interventions. 
• After multiple interventions, the wound fails to progress 
• stubborn, resistant

healthy pt and healthy wound bed

non-adherence

• is a lipid-rich oily substance produced by sebaceous glands in skin
• when mixed with sweat, makes the acid mantle which gives skin it's pH
• helps protect skin

• external skin surface
• 5 layers:
• Stratum corneum
• stratum lucidum
• stratum granulosum
• stratum spimosum
• stratum germinativum
• "Corny Luck Granted, Spi Jerm's (Germ)"

• also called horny layer
• is superficial layer of dead skin cells, is shed daily
• like bark of tree

• also called clear layer
• only present in thick skin

• granular layer
• multilayer (1-5 cells thick)
• cells become compressed, aids in keratin formation

Spiny layer

• Several layers thick
• cells of this layer begin to produce keratin
• cells begin to flatten

• granular layer - only one cell thick
• only layer in which cells undergo mitosis to form new cells

• Keratinocytes
• Desmosomes
• Melanocytes
• Langerhans cells
• "Kinky Destany Melted Lucifer"

• manufacture keratin which is a protein responsible for the toughness of the epidermis
• takes them 4-6 weeks to migrate from stratum germinativum to corneum

specialized structures which bind adjacent keratinocytes to one another and give cohesion to each layer during it's upward progression

• cells which produce melanin, the brown pigment of skin
• purpose is to protect your skin by absorbing harmful UV rays

• Cells which are active in the capture, uptake and processing of antigens (substances that stimulates immune response
• first line of defense against enviro antigens

• forms junction between dermis and epidermis
• As we age, it flattens out and is subject to shearing forces that tend to separate the layers

• barrier against toxic substances/microorganisms
• prevents water loss
• repels water

• supports & nourishes epidermis
• contains nerves, sweat glands, sebaceous glands, and hair follicles

• largest component of dermis
• gel-like matrix made up of sugars and proteins
• functions as structural support for cells, regulates cellular function, lubricates and provides transport system for nutrients and waste products

• macrophages
• mast cells
• fibroblast
• nerves
• langerhans cells

*produced in bone marrow

scavenger cells that ingest dead tissues, repair injured tissue, and act as defense

• contain heparin and histamine
• provides defense such as blood clotting after injury or infection

• cells from which connective tissue is developed
• also produce collagen and elastin

protien which gives skin tensile strength

protein which provides skin with elastic recoil

• nourish
• protect against mechanical injury and microorganisms
• sense environment
• thermoregulation

• loose connective tissue which binds skin loosely to subjacent tissues
• contains lyphatics and deep vessel blood supply
• channels nutrients and O2 to dermis

• white shinny sheaths covering for muscle, nerves and blood vessles
• give support to muscle fibers, keeping tight bundles
• non-viable fascia is grayish in color

connects two or more bones together

attaches muscle to bone

min of 4 cm

• generally occurs with wounds that have undermining
• is due to lack of SQ support around wound & combined with gravity, edges droop and sag

• dry, desiccated (no moisture) necrotic tissue
• firm dry, leathery
• if moistened, slowly turns to slough
• is remnant of collagen matrix

• hydrated necrotic tissue
• color varies including: yellow, gray, tan, brown
• is soft and thin, fibrinous, stringy or mucinous
• is remnant of collagen matrix

• outermost layer of skin is composed of epithelial cells. as wounds heal, they regenerate across wound
• deep pink to pearly pink
• light purple from edges in full thickness wounds
• may form islands in superficial
• can have islands or bridging

• also known as connective tissue or scar tissue
• beefy deep red irregular surface
• replaces the dead tissue 
• *if its regular and smooth, not granulation

• thin clear watery plasma (seen in partial thick wounds/venous ulcers)
• moderate to heavy amount may indicate heavy bio-burden to sub-clinical infection

bloody (fresh bleeding)

thin, watery, pale red to pink, plasma with rbc's

• thin, watery, cloudy, yellow to tan
• could mean infection

• thick, opaque, tan yellow, green or brown
• never normal

• rolled/curled under edges
• migrates down sides of wound instead of across
• body thinks wound is closed

a discharging blind-ended track that extends from surface of skin to underlying area or abcess cavity

• hardened, fibrotic, non pitting edema
• maybe dusky in color
• indicated lymphodema

• process of skin "becoming hard"
• *red flag for undermining, tunneling, sinus tract of infection

• movable compressible, 
• palpable fluid filled cavity

excessive thickening of skin caused by chronic shearing

white wrinkles from excessive moisture

non-blanchable discoloration of variable size may be caused by vascular wall damage, trauma, or vasculitis

• circular, free fluid filled
• up to 1cm

• circular, free fluid filled,
• greater than 1cm

• change in color of skin
• ,circular, flat discoloration
• less than 1 cm
• ex: freckle

same as macule, except larger than 1cm

• superficial, solid elevated mass
• less than 1 cm

• circular, elevated, solid mass greater than 1 cm
• may be seen in epidermis, dermis, or subcutaneous tissue

• circular, collection of leukocytes
• free fluid filled
• varies in size

• firm, edematous plaque, infiltration of dermis
• may last a few hours
• ex: hives, tb test

• superficial, elevated, solid, flat topped lesion
• greater than 1 cm
• ex: psoriasis

crack or split in skin

• refers to thickening of epidermis
• usually due to chronic rubbing or scratching of area

• linear erosion
• destruction of skin my mechanical means
• ex: scratching

loss of epidermis, caused by exposure to urine, feces, body fluids, exudate or friction

• 1. is there viable tissue present? 
• No - 100% necrotic, unstageable
• Yes - see #2

• 2. what viable tissue is present?
• *muscle, tendon, bone... stage 4
• *dermis, SQ.... unstageable because necrotic could areas could be deeper than dermis

• 7 day rule
• once seen, it probably occurred 7 days ago

pressure ulcers found on mucous membranes caused by medical device

• acute pain
• localized, constant, noncyclic or cyclic
• limited and will stop

• results from damaged or malfunctioning nerve fibers
• described as "burning" or "electric shock" feeling