wounds Flashcards
what do you document about wounds?
- skin integrity status (open vs. closed)
- length of time healing (acute vs. chronic)
- depth/severity
- cleanliness/contamination
- description of wound
what is wound approximation?
are the edges pulled together or not?
can pain be good?
yes because it indicated blood and nerve supply
what does reeda stand for?
r - redness e - ecchymosis e - edema d - drainage a - aproximation
sanguineous
bloody
serosanguinous
more pinkish
serous
clear
purulent
pus/infected
secondary intention
a wound is left open to heal from inside out
influences wound healing
- age
- malnutrition
- wound size
- oxygenation/smoking
- immunosuppressive drugs
- diabetes
- radiation
- wound stress
fistulas
tunnel or opening where it shouldn’t be
- rectovaginal fistula
dehiscence
wound separation
evisceration
organs penetrating through wound - more serious, surgical emergency
venous stasis ulcer
- venous pulling edema
- problem with venous return
- typically in lower extremities
- treated with compression therapy
arterial ulcer
- caused by insufficient blood supply
- inadequate oxygen supply
- white and cold
what is a common dressing for wounds?
wet to dry (gets rid of necrotic tissue)
what is cold used for?
swelling
what is heat used for?
to promote blood flow
our job is to prevent
hospital-acquired pressure injuries
shearing force
the pressure exerted against the skin when a pt is moved or repositioned in bed
friction
skin injury that resembles an abrasion, most often on elbows and heels
pressure injury scoring
the higher the score, the less risk for pressure injuries
