2 Wound Care Flashcards
1
Q
primary intention
A
wounds without tissue loss
- edges approximated
- low infection risk
- heals quickly
- dry or no dressing
Ex: surgical incision
2
Q
secondary intention
A
wounds with tissue loss
- edges not approximated (partial thickness, full thickness)
- high infection risk
- heals slowly
- wet to dry dressing
Ex: pressure ulcer, burn, severe injury
3
Q
tertiary intention
A
wounds in which closure is purposefully delayed
- moderate risk for infection
- moderate scar
- heals quickly once closed
- dressing moist when open, dry when closed (open to allow moisture into wound)
Ex: contaminated wound, traumatic injury
4
Q
full-thickness wound repair: inflammatory
A
- triggered by trauma
- increased blood flow, edema, serous exudate
- 24 hours after injury
5
Q
full-thickness wound repair: proliferative
A
epithelialization
- collagen scar formation
- 3 to 24 days after injury
6
Q
full-thickness wound repair: remodeling
A
collagen scar strengthens
- tensile strength of skin never 100% again
- scar goes from red to white
- may last > 1 year
7
Q
full-thickness wound repair (3 phases)
A
inflammatory
proliferative
remodeling
8
Q
dehiscence
A
separation of epidermis and dermis
9
Q
evisceration
A
full thickness separation with protrusion of organs
10
Q
assessment (ABCDE)
A
A pproximate size & depth B ody location C olor (wound bed, surrounding tissue) D rainage (amount, color, odor) E dges (approximation, skin surrounding, drain)
11
Q
fistula
A
opening between an organ and outside or between two organs
12
Q
HELPR LF
A
H eat E dema L oss of Function P ain R edness
L eukocytosis ( > 10k) F ever
13
Q
sanguinous
A
fresh bleeding
14
Q
serosanguinous
A
thin, watery, pale red (blood & plasma)
15
Q
serous
A
clear, thin, watery (plasma)
