Inflammation wound healing stage - lasts 3-6 days. Bleeding controlled with vasoconstriction, fibrin accumulates, and clot forms. Macrophages engulf microorganisms and cellular debris, Proliferation stage of wound healing - lasts 3-24 days. Replaces lost tissue with connective/granulated tissue and collagen. Wound contracts and edges reduced, new epithelial cells are made, Maturation/remodeling - occurs on day 21 of injury. Strengthen the collagen scar and focuses on restoration to normal. Can take more than 1 year in this phase, Primary intention wound - little or no tissue loss, edges approximated, heals rapidly, low risk of infection, minimal scarring. Example: Closed surgical incision with staples, sutures, etc, Secondary Intention wound - loss of tissue, wound edges widely separated, approximated. Longer healing time, increase risk for infection, scarring, heals by granulation. Example: pressure injury left to open to heal, Tertially Intention wound - widely separated, deep, spontaneous opening of a previously closed wound. Closure of wounds occur when they are free of infection and edema. Huge risk of infection, extensive drainage and tissue debris, long healing time. Example, abdominal wound initially left open until infection is resolved and then close, Factors affecting wound healing-age - loss of skin turgor, skin fragility, decrease in peripheral circulation and oxygenation, slower tissue regeneration, decrease in nutrient absorption, decrease collagen, impaired immune system, dehydration, RED wound bed - Health regeneration of tissue- needs to be protected, YELLOW wound bed - Presence of purulent drainage- needs to be cleansed, BLACK wound bed - Presence of eschar that hinders healing- needs removal, COCA drainage assessment  - color, odor, consistency, amount, Serous drainage - watery/clear, Sanguineous drainage - Red blood cells- bright means it is actively bleeding/dark means older blood, Serosanguineous - Both serum and blood-mix of pus and blood- newly infected wound, Purulent drainage - Greenish, odor, indicate infection., Intervention to promote wound healing - Adequate protein intake, hydration(2-3L/day), enough calories., Damp to damp   - mechanically debrides a wound, must be kept moist, Hydrogel - made of mostly water, provides cooling, rehydration, and fills space. Use for infected, deep wounds, Hydrocolloid  - an occlusive dressing that swells in the presence of exudate, maintains a granulating wound bed and can stay for up to 5 days, Alginates - nonadherent dressing that conform to the wound’s shape and absorb exudate. Provides moist wound bed and packs wound, Vacuum assisted closure system - foam strips laid into the wound bed with an occlusive sealed drape. Suction tubing placed for negative pressure. Speeds tissue generation, decreases swelling, and enhances healing in a moist but protected environment, Dehiscence - partial or total rupture of a sutured wound, usually with separation of underlying skin layers, Evisceration  - a dehiscence that involves the protrusion of visceral organs through a wound opening, stage 1 pressure ulcer - Skin intact, reddened, nonblachable area-protect, Stage II pressure ulcer - partial thickness skin loss with exposed dermis. Involves epidermis and dermis-wound bed is viable with reddish/pinkish bed without slough, Stage III pressure ulcer - Full thickness skin loss: Full thickness skin loss- adipose tissue with possible granulation tissue; some slough or eschar may be present. no bone or muscle visible, Stage IV pressure ulcer - : full thickness skin and tissue loss. Skin and tissue loss with cartilage, bone, fascia, muscle, ligaments, or tendon exposed, Unstageable pressure ulcer - obscured, full thickness skin and tissue loss. No determination of stage because eschar and slough obscures the wound bed so actual depth of injury is unknown, Braden scale - Screening tool to assesses monitor client risk for skin breakdown, Deep Tissue Injury - persistent non-blanchable deep red, maroon, or purple discoloration. Intact skin,

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