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TERM 4 N2260 SKILLS 4 > WEEK 13 COMPLEX WOUNDS > Flashcards

WEEK 13 COMPLEX WOUNDS Flashcards

1
Q

What are 2 types of wounds classified by cause?

A

Intentional (planned) or unintentional (unplanned)

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2
Q

What are 2 types of wounds classified by intactness of skin?

A

Open or closed

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3
Q

What are 3 types of wounds classified by cleanliness?

A

Clean, contaminated, or infected

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4
Q

What are 3 types of wounds classified by degree of tissue involvement?

A

Superficial, partial thickness, or full thickness

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5
Q

What are 3 types of wounds classified by colour and type of tissue in the wound bed?

A
  1. Red, pink, or granulation
  2. Yellow or slough
  3. Black or necrotic
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6
Q

How are complex wounds usually classified?

A

Unintentional
Open
Partial/full thickness
Contaminated/infected

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7
Q

What are 4 examples of chronic wounds?

A
  1. Pressure wounds
  2. Coccyx wounds
  3. Diabetic foot ulcers
  4. Vascular wounds
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8
Q

What type of medications contribute to delayed wound healing?

A

Corticosteroids

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9
Q

What condition is often confused with pressure ulcers?

A

Moisture-associated skin damage

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10
Q

What are 5 factors to include in a holistic wound assessment?

A
  1. Temperature
  2. Pain
  3. Emotional coping
  4. Impact on ADLs
  5. The actual wound
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11
Q

What are 9 factors to include in assessing the actual wound?

A
  1. Cause
  2. Location
  3. Drainage
  4. Odor
  5. Wound edges
  6. Wound bed
  7. Size
  8. Undermining or tunneling
  9. Surrounding skin
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12
Q

What is the term for yellow, stringy, dead tissue attached to the wound?

A

Slough

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13
Q

What does granulation tissue look like?

A

Pink to red

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14
Q

What is the method for measuring wound depth?

A

Place a moistened cotton swab in the deepest aspect of the wound and measure distance to skin level

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15
Q

What is the method for measuring undermining and tunneling of a wound?

A

Use the “clock method” with the client’s head as 1200

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16
Q

What is dead space?

A

The space under the overhang of tissue in undermining

17
Q

What are 2 local treatments for wound infection?

A
  1. Antimicrobial dressings
  2. Irrigation
18
Q

What are 3 products used to increase moisture in dry wounds or arterial ulcers?

A
  1. Saline soaked gauze
  2. Intrasite gel
  3. Waterproof/occlusive dressing
19
Q

What are 2 products used to decrease moisture in infected wounds or venous ulcers?

A
  1. Iodine impregnated dressing
  2. Mesalt
20
Q

What are 5 types of debridement and a brief explanation of each?

A
  1. Biological: sterile maggots
  2. Autolytic: self-digestion by own enzymes
  3. Surgical: in OR
  4. Mechanical: use of friction (e.g. irrigation)
  5. Enzymatic: chemical liquefaction by prescribed topical agents
21
Q
A

TERM 4 N2260 SKILLS 4 (10 decks)

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