Wound Assessment + Neurovascular Assessment Flashcards

1
Q

Contusion

A

damage to vessels causing bleeding below skin surface (bruising)

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2
Q

Incision

A

A sharp object, wound edges aligned

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3
Q

Laceration

A

tearing of tissue - edges not aligned

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4
Q

Abrasion

A

rubbing or scraping of layers

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5
Q

Penetrating

A

foreign object entering skin at high velocity (would also leave a puncture wound)

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6
Q

Thermal

A

Burns
high or low temperatures

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7
Q

Pressure Ulcers

A

injuries to skin and underlying tissue resulting from prolonged pressure on the skin

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8
Q

Diabetic Ulcer

A

a wound impacted by poor circulation and sensation due to diabetes

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8
Q

Venous/Arterial Ulcers

A

a wound on the leg or ankle caused by abnormal or damaged veins or arteries and poor circulation

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9
Q

Surgical Wound Classification

A
  • Clean wound edges
  • Controlled bleeding
  • Wound made under sterile conditions
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10
Q

Non-Surgical or Traumatic Wound Classification

A
  • Occur in a non-sterile environment
  • Contamination likely
  • Wound edges jagged
  • Bleeding uncontrolled
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11
Q

Phases of wound healing

A

Hemostasis
Inflammatory
Proliferative
Remodeling

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12
Q

Haemostasis

A

0-24 hours

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13
Q

Inflammatory

A

0-4 days

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14
Q

Proliferative

A

3 days to 2/3 weeks

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15
Q

Remodelling

A

2-3 weeks to 6-12mths or longer

16
Q

Acute

A

Wounds which progress through the phases of wound healing in an orderly and timely manner until skin is restored
Heal within weeks

17
Q

Chronic

A

Do not progress normally thourgh the reparative wound healing phases and healing time is delayed
Can take months to heal

18
Q

Primary Intention

A

surgical incision or paper cut

19
Q

Secondary Intention

A

takes longer, more debris, exudate.
Debris may need to be cleaned away before healing can take place

20
Q

Tertiary Intention

A

delayed primary intention, contaminated would left open and suture closed liquid has been drained..

21
Q

Dehiscence

A

Wound opens after previous closure

22
Q

Evisceration

A

Wound edges seperate to the extent abdominal organs protrude through the wound

23
Q

Hyper-granulation

A

Excess of granulation tissue

24
Treatment for hyper-granulation
flatten with pressure if needed and use producers to decrease moisture level if needed
25
Slough
Dead cells and debris accumulate in exudate
26
Maceration
Occurs when skin is in contact with moisture for too long
27
Necrosis
Necrotic tissue Thick, Dry, Black
28
Arteries and Veins in Arm
Brachial Radial Ulnar
29
Arteries and Veins in Leg
Femoral Popliteal Dorsalis Posterior Tibialis Pedis
30
5 P's of Neurovascular Assessment
Pain Pulse Pallor Paresthesia Paralysis
31
Pink
Arterial pressure is normal
32
Whitish
decreased arterial supply
33
Bluish
venous stasis your veins can't send the blood from your legs back to your heart.
34
Paraesthesia
abnormal condition in which you feel sensation of numbness, tingling or prickling