Fundamentals Wound Care Flashcards
Shallow crater where the skin or mucous membranes is missing
Ulceration
Opening in skin or tissue caused by sharp pointed object
Puncture
Clean separation of skin, tissue with smooth, even edges
Incision
Stripping away of large amounts. Skin, tissue leaving cartilage and bone exposed
Avulsion
Wound in which surface layer scraped away
Abrasion
Separation of skin tissue were edges or torn and irregular
Laceration
Closed, discolored wound caused by blood trauma
Contusion
How should you wrap when applying an ace wrap or other dressing on an extremity
Distal to proximal
What is the debridement
Remove dead tissue from wound
Allows bodies own enzymes to soften, liquefy tissue
Autolytic
Involves physical removal of debris of a wound
Mechanical
Requires use of sterile scissors, forceps, or similar items
Sharp
Topically applied chemical substances are utilized
Enzymatic
What should you know about eye irrigation’s
Pull eye lid down and squirt liquid in eye sack
What should you know about ear irrigations
Do not use force one putting something in the ear
What is a special concern about hot and cold applications
Always keep a layer of fabric between heat and cold on skin
What is the best treatment for wounds
Prevention
How do wounds heal
From inside to outside
What are the types of wound closures for healings
Staples, stitches, and steri-strips
Stage 1
Skin is not broken and does not blanche, tingling at site
Stage 2
Skin is broken, skin has blisters, allows infection to enter
Stage 3
Full thickness loss and wound is deeper
Stage 4
Life-threatening, patient could end up with osteomyelitis
Unstageable
Tissue loss(dead or slough) slough is attached to wound
Deep tissue pressure injury
Intact or non-intact skin, skin does not blanche
What is the purpose of drains
To remove drainage so the wound can heal
Tissue destruction through the epidermis extending into but not through the dermis is
Partial thickness
Tissue destruction extending through the dermis to involve subcutaneous tissue and possibly bone and muscle
Full thickness
Course or pathway that can extend in any direction from the wound, results in dead space
Tunneling
Tissue destruction underlying intact skin along wound margins
Undermining
A drainage pathway from a deep focus of acute infection through tissue and or bone to an opening on the surface
Sinus tract
Thin,watery,clear
Serous
Thin, bright red
Sanguineous
Thin, watery, pale red to pink
Serosanguineous
A wound that is not infected
Clean
This can be a surgical wound caused by trauma that has been grossly contaminated by breaking asepsis
Contaminated
A wound that was surgically made, it’s not infected, but that has direct contact with a normal flora in the respiratory tract
Clean-contaminated
An infected wound is one in which the infectious process is already established
Infected
Higher in number of micro organisms present but is without sign of infection
Colonized
A wound in which the skin remains intact is considered a
Closed wound
A wound in which the skin integrity has been breached is a
Open wound
How often should skin assessment be done
On a daily basis
When the wound is clean with little tissue loss, such as surgical incision, the edges are approximated and the wound
is sutured closed
First Intention
