CHpt 36: Wound care Flashcards
skin tear
break or rip in the skin that separates the epidermis from underlying tissues
incision
open wound w/ clean straight edges, usually intentional from a sharp instrument
ulcer
shallow,deep crater like sore of the skin or mucous membrane
purulent drainage
thick,green,yellow,brown drainage
partial-thickness wound
when dermis and epidermis are broken
wound
break in the skin or mucous membrane
diabetic foot ulcer
partial-thickness wound caused by the scraping away or rubbing of the skin
serosanguineous drainage
thin,watery drainage that is blood tinged
infected wound
containing large amounts of bacteria that shows signs of infection
circulatory ulcer
open sore on lower legs, or feet caused by decreaed blood flow through arteries or veins
hematoma
sweling that contains blood
phlebitis
inflammation of a vein
contaminated wound
wound with high risk of infection
gangrene
condition which there’s death of tissue
unintential wound
wound resulting from trauma
arterial ulcer
open wound on lower legs and feet caused by poor arterial flow
serous drainage
clear, watery fluid
infected wound
dirty wound
clean-contaminated wound
wound that occurs from surgical entry of urinary,reproductive,respiratory, gastro-intestinal system is
chronic wound
wound that doesnt heal easily
venous ulcer
open sore onn lower legs or feet from poor blood flow through the veins
puncture wound
entry of the skin and underlying tissues may be intentional on unintentional
intentional wound
wound created for therapy
penetrating wound
open wound that breaks the skin and enters a body arena, organ or cavity
dehiscence
seperation of wound layers
vascular ulcer
aka circulatory ulcer
edema
swelling caused by fluid collecting in tissues
full-thickness wound
occurs when the dermis, epidermis and subcutaneous tissue are penetrated. Muscle and bone may be involved
trauma
accident/violent act that injures the skin, mucous membranes, bones, and internal orgnan
evisceration
seperation of the wound along w/ the protrusion of abdominal organ
stasis ulcer
aka venous ulcer
sangunienous drainGE
bloody drainage
shock
occurs when tissues doesnt get enough oxygen
excoriation
loss of epidermis by scratching or when skin rubs against skin, clothing, other materials
ulcers of the feet are caused by…
decreased blood flow through arteries or veins
a measure to prevent venous ulcers(stasis) is…
remind person not to sit with legs crossed
maturation phase
scar gains strength. red,raised scar becomes thin and pale (day 21-3years)
proliferative phase
(day 3-21) means to multiply rapidly, dcells multiply to repair the wound
inflammatory phase
(3 days) bleeding stops, scab forms to protect against microbes
during wound healing, what phase is happening when the wound is a year old
Maturation
first intention (wound healing)
wound is closed, via glue, staples, stitches etc
second intention(wound healing)
for contaminated/infected wounds. wounds are cleaned and dead tissue removed
third intention (wound healing)
wound left open and closed later, combines first and second intention. Infection and poor circulation are common reasons for third intention
whats a sign of internal hemorrhage
hematoma
if you observe signs of shock or hemorrhage, you should…
report it to the nurse @ once
when you are assigned to change dressings you should change your gloves when…
change gloves after removing old dressing
how does a binder promote healing
reduce swelling, promote comfort and revent injury
a bind should be applied w/ what amount of force…
firm, even pressure
skin tears are portals for…
microbes
when a person has circulatory ulcers, report any…
skin tears
what two diseases are common causes of arterial ulcers
high BO, diabetes
with primary healing… wound edges are held together with
sutures,staples,clips,glue,adhesive bandages
when changing a dressing, what should you do if the old dressings stick to the wound
remove carefully
if a person has drainage from a wound, how is it measured
weighing dressings by graphing them
noting the # and size of dressings
measureing amount of drainage in collection containers
whats the purposes of transparent adhesive film dressing
wound keep moist
drainage
