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This type of drainage is bright red and indicates active bleeding.
Sanguineous
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This type of drainage appears thick yellow, green, or brown.
Purulent
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This drainage appears clear and watery like plasma.
Serous
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Abnormal passage between two organs or between an organ and the outside of the body.
Fistula
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This type of drainage is a mixture between red and clear fluids.
Serousanguineous
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This complication occures when visceral organs protrude through a wound opening. Requires immediate emergency surgey.
Evisceration
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This happens when a wound fails to heal properly and the skin and tissue seperate.
-Holding a pillow when coughing helps support the abdomen and healing tissue
Dehiscence
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5 Complication of wound healing
- Hemorrage
- Infection
- Dihescence
- Evisceration
- Fistulas
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Three Phases of Full Thickness Wound Healing
- Inflammatory Phase
- Proliferative Phase
- Remodeling
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Three Phass of Partial Thickenss Wound Repair
- Inflammatory Phase
- Epitheliat Proliferation and Migration
- Reestablishment of Epidermal Layers
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Description of Full Thickness Wounds
Extends into dermis
Heals by scar formation because deeper tissues do not regenerate
example-pressure ulcer
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Description of Partial Thickness Wounds
- Shallow
- Loss of Epidermis
- Heals by regenration
example- surgical wounds
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Primary Intenetion Wounds
Wound is closed
Healing occurs by epithelialization
examples- surgery, sutured skin
-
Tertiary Intention Wounds
Wounds left open for several days, then wound edges approximated.
Wounds that are contaminated require observation.
Closure of wound in delayed because of risk of infection.
-
Chronic Wound
Wound fails to proceed through timely process and produces anatomical and functional integrity issues.
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Factors of Skin Surrounding the Wound Indicative of Wound Deterioration
- Redness
- Warmth
- Maceration
- Edema
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Eschar
Black or brown necrotic tissue that needs to be removed for wounds to heal.
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Slough
Stringy, soft yellow or white tissue attached to wound bed.
-
Granulation Tissue
Red and moist tissue composed of new blood vessels.
Presence indicate progression towards healing.
-
Unstageable ulcer
Full Thickness tissue loss
Base of ulcer covered by slough and/or eschar
Cannot be staged until slough/eschar is removed
-
Stage IV
Full Thickness
Exposed bone, tendon or muscle
Often tunneling included
-
Stage III
Full Thickness
Subcut fat visible
Slough may be present but does not obscure the depth
May include tunneling
-
Stage II
Partial Thickness
Superficial
Looks like a blister, abrasion, or shallow crater
-
Stage I
Intact skin
Nonblanchable redness
Localized
Usually over bony prominence
-
Facts About Staging System
Cannot stage when ulcer is covered with necrotic tissue
Do not progress from Stage IV to Stage III.. Simply classified as Healing Stage IV
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Assessment of Pressure Ulcer
Depth of tissue involvement
Type and % of tissue in wound bed
Wound dimensions
Exudated description
Condition of Surrounding skin
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What is Shear?
Skin and subcut tissue adhere to surface, while muscle and bone slide with direction of body movement.
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Risk Factors for P. Ulcer Development
Impaired sensory perception
Impaired mobility
Level of consciousness
Shear
Friction
Moisture
-
Factors that impair tissue intolerance
Poor Nutrition
Age
Low Blood Pressure
-
Tissue Tolerance
Ability of underlying skin structures to assist in redistributing pressure
-
Characteristics of Dark Skin at Risk for Skin Breakdown
Darker than surrounding skin
Purplish/bluish hue
Warmer at first then cooler as tissue devitalizes
Appears taut, shiny, scaly
-
Three Pressure Related Factors Contrivuting to P. Ulcers
Pressure intesity
Pressure Tolerance
Tissue Tolerance
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Acute Wound
- Proceeds through orderly and timely process that results in sustained restoration.
- Example-trauma, surgical incision
-
What is the Dermis
Inner layer of skin
Provides tensile strengthm mech support, and structure
Contains collagen, blood vessels, and nerves
Fibroblasts, which produce collagen, present
-
What is the Basal Layer
Where cells of epidermis originate
Cells divide, proliferate, and migrate toward surface
-
Statum Corneum
Thin, outermost layer of epidermis
Keritinized cells
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