Wound Care Flashcards
Reduction of blood flow to tissue
Tissue ischemia
If tissue ischemia is relieved, vasodilation creates redness called
Hyperemia
Why wouldn’t erythematous area blanch?
Deep tissue damage
When normal red areas of light skinned patients are absent
Blanching
What are 3 related factors of developing pressure ulcers?
- Pressure intensity
- Pressure duration
- Tissue tolerance
Extrinsic factors of tissue tolerance are:
Shear, friction, and moisture
Systemic factors of tissue tolerance are:
Poor nutrition
Age
Low blood pressure
Risk factors for pressure ulcers
- Impaired sensory perception
- Impaired mobility
- Alteration in LOC
- Shear
- Friction
- Moisture
- Nutrition
- Tissue perfusion
- Infection
- Pain
- Age
- Psychosocial impact of wounds
Red, moist tissue composed of new blood vessels
Granulation tissue
Stingy substance attached to wound bed
Slough
Brown or black necrotic tissue
Eschar
Amount, colour, consistency and odour of wound drainage
Exudate
Response cause redness and swelling, and moderate exudate at wound edges.
Inflammatory response
Epidermal cells at wound edged quickly resurface and migrate across wound bed
Proliferation and migration response
New epithelium undergo reestablishment of epidural layers
Remodeling phase
Clear, watery plasma
Serous
Thick, yellow, green, tan or brown
Purulent
Pale red watery mixture of clear and red fluid
Serosanguineous
Bright red indicates active bleeding
Sanguineous
What would the nurse assess from a wound?
- Redness
- Swelling
- Drainage
- Wound closure
- Temperature
- Pain
- Wound cultures
Partial or total separation of wound layers
Dehiscence
Increased amount of serosanguinous drainage may indicate
Dehiscence
Protrusion of visceral organs through wound opening
Evisceration
Abnormal passage between two organs or organ and outside of body
Fistula
Localized collection of blood underneath tissues
Hematoma
Removal of non viable, necrotic tissue
Debridement
Purple or maroon localized area of discoloured intact skin or blood-filled blister. Area is painful, form, mushy, boggy, warmer or cooler.
Deep tissue injury
Intact skin with nonblanchable redness, usually over bony prominence.
Stage 1
Partial thickness loss of dermis presenting as shallow ulcer with red pink wound bed, without sough. May also be intact or open or ruptured serum-filled blister.
Stage 2
Full thickness tissue loss. Subcutaneous fat may be visible. Slough present but does not obscure tissue depth. May include undermining and tunnelling.
Stage 3
Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present, often with undermining and tunnelling.
Stage 4
Full thickness tissue loss, base of ulcer covered by slough or eschar.
Unstageable
Wound that is closed
Primary intention
Wound edges are not approximated
Secondary intention
Wound closure is delayed until risk of infection is resolved, then wound edges are approximated
Tertiary intention
Ulcer caused by inadequate blood flow
Arterial ulcers
Superficial and irregularly shaped wound usually with large amount of exudate caused by edema
Venous Ulcers
Superficial partial-thickness wound with little bleeding
Abrasion
Jagged unintentional wound sometimes with more profuse bleeding
Laceration
Small circular wound with edges coming together toward center
Puncture
