Phases of wound healing
The first phase of wound healing.
What is Hemostasis phase?
The skin may look purple or maroon localized area of discolored intact skin or a blood filled blister.
What is a Deep tissue injury?
The portion of the blood (serum) that is clear or slight yellow in appearance watery fluid.
What is Serous Drainage?
Age, Skin friction, chronic diseases, immobility.
What are risk factors for Pressure Injuries?
Fever, chills, redness.
What is infection?
The second phase of wound healing.
What is Inflammatory phase?
The skin is intact and has non blanchable redness.
What is a stage 1 pressure injury?
Contains serum and red blood cells. It is thick and appears red in color. Brighter red drainage indicates active bleeding, Darker drainage indicates old bleeding.
Keep skin clean and dry, Repositioning at or below 30 degrees when not eating or drinking. Raise heels off the bed.
What are interventions to prevent Pressure Injuries.
Partial or total rupture of the sutured wound with separation of underlying skin layers.
The third phase of wound healing.
What is Proliferative/ repair phase?
Full thickness skin loss. Visible subcutaneous fat or adipose tissue. No exposed tendons, ligaments, cartilage or bone. wound edges may appear rolled under.
What is a stage 3 pressure injury?
Contains both serum and blood.
What is Serosanguineous Drainage?
Inspect the skin, apply pressure reducing mattress. Use Braden scale to document and assess risk for skin breakdown in a measurable meaningful way for patient care.
What are interventions to prevent Pressure Injury?
An open wound that involves the protrusion of the visceral organs (intestines). Abdominal cavity.
What is Evisceration?
The fourth phase of wound healing
What is Remodeling/ maturation phase?
Full- Thickness skin and tissue loss with cartilage, bone, ligaments or tendons exposed.
What is stage 4 pressure injury
The result of infection. It is thick and contains white blood cells, tissue debris and bacteria. It may have a foul odor. Color may vary green, tan yellow etc.
What is Purulent Drainage?
Vascular disorders, Inadequate nutrition and hydration, sensory deficits.
What risk factors for Pressure Injury?
Sudden bright red bleeding noted on wound site.
What is Hemorrhage?
The rolled or curled edges of a wound, where epidermal cells roll inward and downward instead of migrating across the wound surface. This creates a barrier to wound closure and healing process.
What is Epibole?
The wound takes longer to heal than expected due to tissue damage, drainage, underlying comorbidities such as diabetes, poor circulation.
What is Delayed Healing?