2025-2026
Wound assessment includes - ANS-- size
- depth (superficial, partial, or full thickness)
- drainage type and amount
- colour of bed
- type of tissue
- location
- odour
- pain
Periwound assessment - ANS-- redness
- edema
- temperature
- pain
- induration (hardness)
- maceration (skin softening from moisture)
- sensation
Types of exudate - ANS-- Serous
- Purulent (signals infection)
- Sanguinous (bright red = active bleeding)
- Serosanguinous (pale red)
4 stages of wound healing - ANS-1. hemostasis
2. inflammatory
3. proliferative
4. remodelling
Primary intention - ANS-surgical closure ex. stitches
Secondary intention healing - ANS-healing using granulation > epithelization
Tertiary intention - ANS-Wound is left open to get clean then it is surgically closed
Wound classifications - ANS-surgical vs non-surgical
acute vs chronic
superficial vs partial thickness vs full thickness
red vs yellow vs black
,Wound healing complications - ANS-- infection
- fistula formation
- dehiscence: wound splits open
- evisceration (dehiscence where organs protrude from the body)
- adhesions (scar tissue fuses two parts of the body)
- contractures (scar tissue pulls skin together)
- hypergranulation
- hemorrhage
- formation of hypertrophic scars and keloids
Causes of delayed wound healing - ANS-- nutrition
- deficiency in vitamin C, protein, zinc
- inadequate blood or oxygen supply
- smoking
- corticosteroid drugs
- infection
- anemia
- old age, obesity
- diabetes mellitus
- cold temperatures
Wound irrigation options - ANS-- sterile saline
- sterile water
- tap water
*enough pressure to clean debris without damage (8-15 psi)
Surgical debridement - ANS-Removing non viable tissue
Mechanical debridement - ANS-Wet to dry tissue > rip off dead tissue
Autolytic debridement - ANS-Uses synthetic dressings over a wound to allow the eschar to be
self-digested by the action of enzymes that are present in wound fluids
Enzymatic debridement - ANS-involves the use of a topically applied chemical substance that
breaks down and liquefy wound debris
Biosurgical debridement - ANS-Using organisms to debride things ex. maggots
Wound packing steps - ANS-1. absorb drainage
2. protect the wound
3. remove non viable tissue
4. fill dead space
5. maintain moisture within the wound
, Commercial wound care products - ANS-Silver, seaweed, charcoal, enzymes, antimicrobial,
foam, gel films, non-adherent
Negative pressure wound therapy - ANS-Vacuum suction promotes wound healing and wound
closure through the application of uniform negative pressure on wound bed which removes
excess wound fluid while providing a moist wound healing environment
- results in mechanical tension on wound tissues, stimulating cell proliferation, blood flow to
wounds, and the growth of new blood vessels
Care strategies for supporting the psychological effects of wounds - ANS-- Social support and
emotional disclosure
- Increase social interaction
- Adequate sleep
- Adequate nutrition
- Support/assist with ADLs and hygiene needs
- Use appropriate dressing to absorb drainage and reduce odour
Acute illness with chronic illness examples - ANS-- infection in a diabetes patient
- surgical procedure in a chronic renal failure patient
- covid-19 in a person with asthma
Comorbidity - ANS-the simultaneous presence of two chronic diseases or conditions in a patient
Multimorbidity - ANS-The simultaneous occurrence of several chronic medical conditions
- polypharmacy and multiple treatments
- psychological strain and stress
- functional decline
- more frequent and longer hospitalizations
Chronic illnesses in older people causes - ANS-- lifestyle choices (smoking, alcohol, sugar,
sedentary)
- environmental exposures
- immune system decline
Government mediated strategies for preventing chronic illness - ANS-- banning smoking in
public places
- raising taxes on alcohol
- enforce bans on alcohol advertising
- reduce salt content of food
- replace trans fat with polyunsaturated fat
Psychosocial dimensions of illness - ANS-- quality of life
- illness behaviour
- self efficacy