Updated RATED A+ 2026
wound
break in the con nuity of body structure, caused by violence, trauma, or surgery to ssue
bodies
ex; of acute wounds
surgical incisions, trauma c wounds, lacera ons, burns
ex; of chronic wounds
PI, diabe c ulcers, malignant
acute wound
wound that proceeds through an orderly & mely repara ve process --> sustained restora on
of anatomical & func onal integrity
phases of wound healing
1) inflammatory phase
2) prolifera ve phase
3) remodelling phase
what's a part of the prolifera ve phase?
prolifera on, granula on & contrac on
what happens during inflammatory phase?
1) hemostasis. (vasoconstric on)
2) platelets + fibrin forms, clot forma on
3) histamina, vasodila on, increased capillary permeability, erythema, swelling & warmth
what happens day 1-3 inflammatory phase?
neutrophils released to injury site, phagocytosis of debris beings.
what happens during day 3-24 of prolifera ve phase?
1) granula on ssue appears in wound
2) contrac on of wound edges
,3) resurfacing by epithelializa on --> dermal regen.
4) vascular bed reestablished
what happens during day 24-2 yrs of remodelling phase?
1) collagen fibers reorganize & remodel
2) permanent scar
3) a/ains 80% of original strength
Primary inten on healing
wound that is closed by suture or wound closers & healing occurs by collagen synthesis; lower
risk of infec on, and heals quickly w/ minimal scarring.
secondary inten on healing
wound edges are not approximated. heals by granula on ssue forma on, wound contrac on
& epithelializa on.
has a prolonged phase of inflamma on due to increased me needed for phagocytosis of
necro c ssue.
ter ary inten on healing
wound is le5 open for several days as it could be contaminated. has an increased risk of
infec on, so closure of wound is done later un l risk of infec on is resolved.
why is the wound kept open for ter ary healing?
to allow exudate to drain, prevent the spread of deep infec on & aiding granula on.
medical asepsis
aka, clean technique.
includes procedures used to reduce & prevent the spread of microorganisms
ex; of medical asepsis
hand washing, clean gloves, cleaning environment rou nely.
ex; of surgical asepsis
aka surgical technique.
requires more stringent techniques, elimina ng all microorganisms.
when do you use surgical asepsis?
, when a pa ent's kin is broken, or if the nurse performs an invasive procedure in a body cavity
that is normally free of microorganisms.
ex; of surgical asepsis procedures
- protec ve clothing
- opening sterile packages
- sterile field
- pouring sterile solns
- surgical hand scrub
- gowning & gloving
Principles of Surgical Asepsis
- a sterile object remains sterile only when touched by another sterile object
- a sterile object or field out of range of vision or an object held below a person's waist is
contaminated
- a sterile objec ve or field becomes contaminated by prolonged exposure to air.
complica ons of wound healing
hemorrhage, infec on, dehiscence, eviscera on, fistula forma on
hemorrhage nsg dx d/t
slipped suture, dislodged clot, infec on, or eroded blood vessel
hemorrhage nsg dx manifested by
- external-saturated sanguinous dressings
- internal-distension of body part
- change in drain output
- signs of hypovolemic shock
infec on nsg dx d/t
- exposure to bacteria, contaminated or trauma wound shows S&S, surgical post-op infec on.
infec on nsg dx manifested by
fever, tenderness, pain @ wound site, erythema, edema, indura on, warmth, elevated WBC,
inflamed edges, foul odor, purulent drainage, delayed healing
life threatening infec on S&S