WEEK 11 WOUND CARE Flashcards
What is the term for a wound that is a straight line and closed with sutures or staples?
Surgical incision
What is the term for a wound that is superficial, affecting only the epidermal layer?
Abrasion
What is the term for a wound that was created by penetrating the skin with a sharp object?
Puncture
What is the term for a wound that is torn or cut open, has jagged edges, and likely contaminated by foreign material?
Laceration
What is the term for a wound that is a localized open sore?
Ulcer
What is the difference between friction and shear?
Friction: A force acting parallel to the skin’s surface (e.g. sheets sliding against skin)
Shear: Combination of pressure and friction (e.g. sliding down in bed)
What is the definition of a stage I pressure injury?
Damage to epidermis only (Intact area of non-blanching erythema)
What is the definition of a stage II pressure injury?
Damage extends into but no deeper than the dermis (Appears like a blister)
What is the definition of a stage III pressure injury?
Damage extends into, but no deeper than the subcutaneous layer (Area appears like a crater, may have undermining/tunneling)
What is the definition of a stage IV pressure injury?
Damage to full thickness of skin and subcutaneous layers
(Muscle, bone, tendon visible, may have undermining/tunneling)
What are the 6 categories assessed with the braden scale?
- Sensory perception
- Moisture
- Activity
- Mobility
- Nutrition
- Friction/shear
A braden scale score of LOWER than 18 indicates what?
High risk for pressure injury
What is approximation, and what kind of wounds can be approximated?
Bringing wound edges together
Lacerations and incisions can be approximated
What is the difference between healing by primary intention and healing by secondary intention?
Primary: edges are approximated, minimal tissue loss, minimal scarring
Secondary: cannot be approximated, considerable tissue loss, greater risk of scarring/infection
What are the 3 stages of wound healing, and how long do they last?
- Inflammation (3-6 days)
- Proliferation (Days 3-21)
- Remodelling/maturation (1-2 years)
What may palpation of a hard lump under the skin of a wound indicate?
Hemorrhage/bleeding
Why are the chest and abdomen more at risk of dehiscence?
Areas under high pressure
What are 5 words used to describe amount of drainage, and what do they mean?
- Absent: no drainage
- Scant: <5%
- Minimal: 5-25%
- Moderate: 25-75%
5: Copious: >75%
What are 6 areas to assess in a circular wound?
- Location
- Drainage
- Size
- Type/stage
- Wound bed
- Surrounding skin
What is the term for a buildup of dead cells in a wound bed, usually tan in colour?
Slough
What is a term for hardened necrotic tissue in a wound bed, usually black or brown in colour?
Eschar
What is the term for softened wound edges due to moiture, usually white in colour?
Maceration
Why should a wound be palpated during assessment?
Assess for induration
What is the term for a procedure to remove dead cells such as slough or eschar?
Debridement
