Wound Management (Borrowed from Prof. Courtney/NUR 330) Flashcards
Define puncture wounds
Usually a small, circular wound with the edges coming together toward the center. Main concern is infection and internal bleeding.
Define primary intention
Skin edges are approximated, risk of infection low. Healing is quick with little scarring. Example: surgical incision.
Define Wound
A disruption of the integrity and function of tissues in the body.
Define Granulation Tissue
Red, moist tissue composed of new blood vessels. Indicates a progression toward healing.
Define friction
The force of two surfaces moving across one another. Example: skin is dragged across bed linen
Define tissue ischemia
The occlusion of capillaries for a prolonged period of time. The tissue is receiving insufficient oxygen and perfusion.
Define pressure ulcer
impaired skin integrity related to unrelieved, prolonged pressure
Define sheer
The sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary. Example: May occur when transferring a patient from bed to stretcher when the patient’s skin is pulled across the bed.
Define slough
soft yellow or white tissue attached to wound bed.
Define abrasion
A scraping or rubbing away of the epidermis resulting in a partial thickness wound that appears weepy with little bleeding
Define laceration
An open, torn, jagged wound which may bleed profusely depending of depth and location.
Define secondary intention
The wound involves loss of tissue and is left open until it becomes filled by scar tissue. Longer healing time.
Define approximation
The wound edges are closed and the risk of infection is low.
Define eschar
Thick layer of dead, dry tissue that covers a pressure injury or thermal burn. May be allowed to come off naturally or surgically removed. Black, brown, tan in color.
Define exudate
Another name for drainage: fluid that is excreted by damaged cells. assess the color, amount, consistency and odor.
Define induration
hardening of a tissue
Define blanchable hyperemia
when a wound blanches (turns lighter in color) in response to light finger pressure and immediately turns red when pressure is removed. This is good. The wound is trying to overcome the ischemic episode
Define nonblanchable erythema
a wound that does not blanch (turns lighter in color) in response to light finger pressure on the wound. This is not good. The wound may have deep tissue damage.
Define hyperemia
Redness of a wound
Define stage 1 pressure ulcer
nonblanchable erythema of intact skin. patient may report change in sensation, change in temperature over the area or firmness.
Define stage 2 pressure ulcer
The wound bed is pink or red, moist. May present as a blister either intact or ruptured. Adipose tissue is not visible.
Define stage 3 pressure ulcer
adipose tissue is visible. full thickness loss of skin. slough and or eschar may be visible.
Define deep tissue pressure injury
persistent nonblanchable deep red, maroon, or purple discoloration.
Define stage 4 pressure ulcer
exposed bone, muscle, tendon, ligament, or cartilage. Slough and or eschar may be visible. Epibole (rolled edges) tunneling and undermining often occur.
Define debridement
the removal of nonviable necrotic tissue
Define mechanical debridement
involves wet dressing being applied to a wound; when dry, the dressings are removed causing light debridement within the wound bed. Also, wound irrigation and whirlpool treatments
Define autolytic debridement
lysis of necrotic tissue by the white blood cells and natural enzymes from the body
Define chemical debridement
involves the use of a topical enzyme preparation such as Dakin’s solution or sterile maggots.
Define surgical debridement
use of scalpel or scissors to remove dead tissue
