Module 4: wound care Flashcards
Tissue trauma
Result of cuts, blows, poor circulation, surgical incision etc
Two basic kinds of wounds
Open and closed
Open wound
The surface of the skin or mucous membrane is no longer intact
Types of open wounds (6)
Incision, laceration, abrasion, avulsion, ulceration, puncture
Incision
Clean seperation of skin and tissue with smooth even edges
Laceration
Seperation of skin and tissue where edges are torn and irregular
Abrasion
Wound where the surface layers of skin are scraped away
Avulsion
Stripping away large areas of skin and underlying tissue, leaving cartilage and bone exposed
Ulceration
A shallow crater in which skin or mucous membrane is missing
Puncture
Opening of skin, underlying tissue, or mucous membrane caused by a sharp pointed narrow object
Closed wound
No opening of the skin or mucous membrane usually caused by blunt trauma or pressure
Contusion
Injury to soft tissue underlying the skin from the force of contact with a hard object; aka a bruise
Systemic condition
Affects the entire body
Systemic factors that affect wound healing
Age, nutrition, body build, chronic disease, circulatory problems, weakened immune system, radiation therapy
Localized condition
Affects only one system or body part
Local factors that affect wound healing
Moist wound environment, infection, necrotic tissue, trauma, edema, etc
Necrotic tissue (eschar)
Dead or devitalized tissue; dark in color, usually black, and leathery in appearance; must be removed before wound can heal
Purulent
Pus-like
Wound observations to report
Redness, drainage, heat, edema, fever, bruising, maceration
Maceration
Water logged appearance of wound edges
Cytotoxic
Antiseptic cleaning solutions that harm healing tissue
Direction to clean wound
Work from clean area near the wound to outward to less clean areas
Wet-to-dry dressings
Used for healing surgical incisions; sterile procedure
Transparent film dressings
Adhesive membranes of various sizes and thickness; should allow 1.25 inch of dressing surrounding entire wound; waterproof and protect from bacteria; used for minor pressure ulcers and wounds w/ necrotic tissue; for skin tears in elderly; changed every 3-5 days
Hydro colloid dressings
Made of gelatin or pectin; provides moist environment for healing; used for pressure ulcers etc; will debride necrotic tissue; left in place for 7 days
Debridgement
Medical removal of dead damaged or infected tissue
Montgomery straps
Long strips of adhesive attached to skin on either side of wound
Decubiti
Bedsore
Exudate
Fluid (pus or clear) that leaks out of blood vessels into nearby tissue
Fresh tissue
Granulates on the walls of the wound
