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Wound Flashcards

1
Q

Wound

A

Is a damaged soft tissue or skin

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2
Q

How does the wound occur

A

It occurs as a result of trauma and tissue trauma maybe because of
1. Cuts
2. Blows
3. Poor circulation
4. Strong chemical
5. Excessive heat or cold

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3
Q

Wound classification based on (ccd)

A
  1. Causes ( intentional , unintentional )
  2. Cleanliness ( contaminated or infected )
  3. Depth ( superficial , partial , thickness or full thickness )
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4
Q

Body wound are either

A

Intentional : occurs during therapy ex. Operation
Unintentional : accidental fracture an arm in an automobile collision

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5
Q

Closed wound ;

A

Tissue are traumatised without a break in the skin

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6
Q

Open wound :

A

When the skin is open

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7
Q

Types of wounds

A

Open
Closed
Surgical

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8
Q

Open wounds

A

A wound in which the surface of the skin is no longer intact it may be intentional such as an incision by surgeon or unintentional by accident

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9
Q

Type of open wounds (iLA-UP)

A
  1. Incision wounds
  2. Laceration wounds
  3. Abrasion wounds
  4. Ulceration wounds
  5. Puncture wounds
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10
Q

Incision wound

A

A clean separation of skin and tissue with smooth even edges cause by sharp instruments can be shallow or deep

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11
Q

Laceration wounds :

A

A separation of skin and tissue in which the edges are torn and irregular

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12
Q

Abrasion wounds :

A

A wound in which surface layer of the skin are scraped away could be intentional or unintentional

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13
Q

Ulceration wounds

A

A shallow crater in which skin is missing

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14
Q

Puncture wounds

A

Penetration of skin and often the underlying tissue causes by a sharp instrument intentional or unintentional

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15
Q

Closed wounds

A

One in which there is no opening in the skin or mucus membrane

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16
Q

How closed wounds occur

A

Due to blunt trauma or pressure

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17
Q

Types of closed wounds

A

Contusion wounds

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18
Q

Contusion wounds

A

Injury to soft tissue underlying the skin from the force of contact with a hard object sometimes called a bruise because of damaged blood vessels

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19
Q

Surgical wounds

A

Results from incising tissue with a laser or instrument called a scalpel

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20
Q

Surgical care involves :

A

Use of dressing
Caring for drains
Removing suture or staples
Applying bandages
Administration of irrigations

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21
Q

Wound repair is dependent on

A
  1. Magnitude of tissue damage
  2. The integrity of the skin
  3. Regen or scar formation
22
Q

Resolution

A

A reparative process in which cells that are slightly injured recover and reestablish their normal function

23
Q

Regeneration

A

Occurs when some cells are destroyed and duplicates are produced to take their place

24
Q

Scar formation

A

When cells are extensively destroyed and there is no potential for regeneration the integrity is restored by replacing it with scar tissue

25
Q

Healing is referred to as

A

Regeneration of tissues

26
Q

The ______ of healing are the same for all wounds

A

Phases

27
Q

The rate depends on factors including :

A
  1. Type of healing
  2. Location
  3. Size
  4. Health of client
28
Q

Phases of healing

A
  1. Inflammatory
  2. Proliferative
  3. Maturation or remodeling phase
29
Q

Inflammatory phase

A

• Starts after an injury immediately
• Lasts 3-6 days
• there are two major process occur in this phase called hemostasis( stopping of bleeding ) which results from Vado contraction of large blood vessels in the affected area
• phagocytosis cells engulf microorganisms other cells or foreign bodies

30
Q

Proliferative phase

A

• lasts from 3-4 to 21 post injury
• collagen begin to synthesise
• granulation tissues start to grow

31
Q

Maturation phase :

A

• starts by 21 day and can extend to 2y
• fibroblasts continue to make collagen

32
Q

Goals of wound care

A
  1. Removal of necrotic tissue to promote wound healing
  2. Prevent , eliminate , control infection
  3. Absorb drainage (exudates )
  4. Maintain a moist wound environment
  5. Protect the wound from further injury
  6. Protect the surrounding skin from infection and trauma
33
Q

Complications of wound healing

A
  1. Infection : become apparent 2-11 post op
  2. Haemorrhage : normal when some escape of blood from wound when abnormal caused by dislodged clot ,slipped stitch , erosion(تاكل)of blood vessels
  3. Dehiscence : factors : obesity , poor nutrition, multiple trauma , failure of suturing , excessive coughing , vomiting and dehydration , occur 4-5 day post op
34
Q

Dressing a wound

A

The process of applying a protective sterile to a wound and giving a necessary care by using a septic technique when used

35
Q

Purposes of wound dressing

A
  1. Keep the wound clean
  2. Control bleeding
  3. Protecting the wound injury
  4. Maintaining a moist environment
  5. Asses the healing process by keeping edges of wound in close approximation
  6. Absorb drainage or discharge from a wound
36
Q

Drains

A

Tubes that provide means for removing blood and drainage from a wound

37
Q

Types of drains

A

Open
Closed

38
Q

Debridement

A

Physical removal of affected tissue by debridement is the most effective method of cleaning the wound

39
Q

Infected tissue is best removed by

A

Surgical debridement

40
Q

Methods of debridement includes

A

Chemical
Enzymatic
Mechanical
Autolytic

41
Q

Pressure ulcer

A

Specific tissue injury caused by an impairment in blood supply or any lesion caused by unrelieved pressure resulting in damage to the underlying tissue

42
Q

Common sites of ulcer

A
  1. Bony Prominences of the low spine
  2. Posterior pelvis
  3. Hips
  4. Heels
  5. Elbows
  6. Shoulders
  7. Ear and back if head
43
Q

Why tissue in that area is more vulnerable

A

Because they have less body fat to act as a pressure - absorbing cushion

44
Q

Factors developing ulcer sores

A
  1. Pressure
  2. Friction
  3. Shearing
  4. Moisture
45
Q

Risk for development of ulcer sores

A
  1. Inactivity
  2. Immobility
  3. Malnutrition
  4. Dehydration
  5. Sedation
  6. Vascular disease
46
Q

Pressure sore stages

A

4 stages

47
Q

S1

A

Cellular damage has occurred if skin is not able to resume its normal colour when pressure is relived

48
Q

S2

A

• Blistering or a shallow break in skin (skin tear)
• impairment of skin may lead to colonisation or infection

49
Q

S3

A

• serous drainage from leaking plasma or purulent drainage
• white or green tinged fluid caused by wound infection
• area is painless

50
Q

S4

A

• tissue is deeply ulcerated exposing muscles and bones
• dead tissue may produce a rank odor
• local infection which is the rule rather than infection easily spreads through the body causing a fatal condition as sepsis

51
Q

Client education

A
  1. Assessment of pressure ulcer
  2. Managing tissue kids
  3. Ulcer care
  4. Bacterial colonisation and infection
    5 operative repair of pressure ulcer

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