Wound Managment Flashcards

1
Q

Define puncture wounds

A

Usually a small, circular wound with the edges coming together toward the center. Main concern is infection and internal bleeding.

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2
Q

Define primary intention

A

Skin edges are approximated, risk of infection low. Healing is quick with little scarring. Example: surgical incision.

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3
Q

Define Wound

A

A disruption of the integrity and function of tissues in the body.

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4
Q

Define Granulation Tissue

A

Red, moist tissue composed of new blood vessels. Indicates a progression toward healing.

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5
Q

Define friction

A

The force of two surfaces moving across one another. Example: skin is dragged across bed linen

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6
Q

Define tissue ischemia

A

The occlusion of capillaries for a prolonged period of time. The tissue is receiving insufficient oxygen and perfusion.

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7
Q

Define pressure ulcer

A

impaired skin integrity related to unrelieved, prolonged pressure

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8
Q

Define sheer

A

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.

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9
Q

Define slough

A

soft yellow or white tissue attached to wound bed.

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10
Q

Define abrasion

A

A scraping or rubbing away of the epidermis resulting in a partial thickness wound that appears weepy with little bleeding

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11
Q

Define laceration

A

An open, torn, jagged wound which may bleed profusely depending of depth and location.

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12
Q

Define secondary intention

A

The wound involves loss of tissue and is left open until it becomes filled by scar tissue. Longer healing time.

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13
Q

Define approximation

A

The wound edges are closed and the risk of infection is low.

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14
Q

Define eschar

A

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.

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15
Q

Define exudate

A

Another name for drainage: fluid that is excreted by damaged cells. assess the color, amount, consistency and odor.

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16
Q

Define induration

A

hardening of a tissue

17
Q

Define blanchable hyperemia

A

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

18
Q

Define nonblanchable erythema

A

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.

19
Q

Define hyperemia

A

Redness of a wound

20
Q

Define stage 1 pressure ulcer

A

nonblanchable erythema of intact skin. patient may report change in sensation, change in temperature over the area or firmness.

21
Q

Define stage 2 pressure ulcer

A

The wound bed is pink or red, moist. May present as a blister either intact or ruptured. Adipose tissue is not visible.

22
Q

Define stage 3 pressure ulcer

A

adipose tissue is visible. full thickness loss of skin. slough and or eschar may be visible.

23
Q

Define deep tissue pressure injury

A

persistent nonblanchable deep red, maroon, or purple discoloration.

24
Q

Define stage 4 pressure ulcer

A

exposed bone, muscle, tendon, ligament, or cartilage. Slough and or eschar may be visible. Epibole (rolled edges) tunneling and undermining often occur.

25
Q

Define debridement

A

the removal of nonviable necrotic tissue

26
Q

Define mechanical debridement

A

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

27
Q

Define autolytic debridement

A

lysis of necrotic tissue by the white blood cells and natural enzymes from the body

28
Q

Define chemical debridement

A

involves the use of a topical enzyme preparation such as Dakin’s solution or sterile maggots.

29
Q

Define surgical debridement

A

use of scalpel or scissors to remove dead tissue