Wound Assessment + Neurovascular Assessment Flashcards
Contusion
damage to vessels causing bleeding below skin surface (bruising)
Incision
A sharp object, wound edges aligned
Laceration
tearing of tissue - edges not aligned
Abrasion
rubbing or scraping of layers
Penetrating
foreign object entering skin at high velocity (would also leave a puncture wound)
Thermal
Burns
high or low temperatures
Pressure Ulcers
injuries to skin and underlying tissue resulting from prolonged pressure on the skin
Diabetic Ulcer
a wound impacted by poor circulation and sensation due to diabetes
Venous/Arterial Ulcers
a wound on the leg or ankle caused by abnormal or damaged veins or arteries and poor circulation
Surgical Wound Classification
- Clean wound edges
- Controlled bleeding
- Wound made under sterile conditions
Non-Surgical or Traumatic Wound Classification
- Occur in a non-sterile environment
- Contamination likely
- Wound edges jagged
- Bleeding uncontrolled
Phases of wound healing
Hemostasis
Inflammatory
Proliferative
Remodeling
Haemostasis
0-24 hours
Inflammatory
0-4 days
Proliferative
3 days to 2/3 weeks
Remodelling
2-3 weeks to 6-12mths or longer
Acute
Wounds which progress through the phases of wound healing in an orderly and timely manner until skin is restored
Heal within weeks
Chronic
Do not progress normally thourgh the reparative wound healing phases and healing time is delayed
Can take months to heal
Primary Intention
surgical incision or paper cut
Secondary Intention
takes longer, more debris, exudate.
Debris may need to be cleaned away before healing can take place
Tertiary Intention
delayed primary intention, contaminated would left open and suture closed liquid has been drained..
Dehiscence
Wound opens after previous closure
Evisceration
Wound edges seperate to the extent abdominal organs protrude through the wound
Hyper-granulation
Excess of granulation tissue
Treatment for hyper-granulation
flatten with pressure if needed and use producers to decrease moisture level if needed
Slough
Dead cells and debris accumulate in exudate
Maceration
Occurs when skin is in contact with moisture for too long
Necrosis
Necrotic tissue
Thick, Dry, Black
Arteries and Veins in Arm
Brachial
Radial
Ulnar
Arteries and Veins in Leg
Femoral
Popliteal
Dorsalis
Posterior Tibialis
Pedis
5 P’s of Neurovascular Assessment
Pain
Pulse
Pallor
Paresthesia
Paralysis
Pink
Arterial pressure is normal
Whitish
decreased arterial supply
Bluish
venous stasis
your veins can’t send the blood from your legs back to your heart.
Paraesthesia
abnormal condition in which you feel sensation of numbness, tingling or prickling
