Wounds Flashcards
Open wound
occurs from intentional/un-intentional wounds
skin surface broken=portal of entry for microorganisms
bleeding, tissue damage, increased risk for infection, delayed healing
Intentional wound
the result of a planned invasive therapy/treatment
- wound edges clean
- bleeding controlled
- wound made in sterile environment=decreased risk of infection
unintentional wounds
occur from unexpected trauma (accidental) ex. stabbing/gunshot
- occur in UNSTERILE environment, contamination likely
- increased risk for infection
- increased healing time
Stage 1 pressure ulcer
intact skin
area of persisent redness on light skin
are of persistent red, blue or purple hue on darker skin
does not blanch
stage 2 pressure ulcer
partial-thickness skin loss of epidermis/dermis
superficial; abrasion, blister, shallow center
Stage 3 pressure ulcer
full thickness skin loss
damage or necrosis of subq tissue
deep crate with or without undermining
Stage 4 Pressure ulcer
full thickness skin loss
extensive destruction, tissue necrosis
damage to bone muscle, tendons, joints, sinus tracts is possible
unstageable pressure ulcer
can’t see wound base
incision
cuting or sharp instrument; wound edges in close approximation and aligned
contusion
blunt instrument, overlying skin remains intact but tissue underneath has been damaged
abrasion
friction; rubbing or scraping epidermal layers of skin; top layer of skin abraded
laceration
tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue
puncture
blunt or sharp instrument puncturing the skin; intentional or accidental
penetrating
foreign object entering the skin or mucous membrane and lodging in underlying tissue; fragments possibly scattering throughout tissues.
avulsion
tearing a structure from normal anatomic position; possible damage to blood vessels, nerves and other structures
chemical
toxic agents such as drugs, acids, alcohols, metals, and substances released from cellular necrosis
thermal
high or low temperatures; cellular necrosis as a possible result
Irradiation
Ultraviolet light or radiation exposure
Pressure ulcers
compromised circulation secondary to pressure or pressure combined with friction
venous ulcers
injury and poor venous return, resulting from underlying conditions, such as imcompetent valves or obstruction
arterial ulcers
injury and underlying ischeia, resulting from underlying conditions, such as atherosclerosis or thrombosis
diabetic ulcers
injury and underlying diabetic neuropahy, peripheral arterial disease, diabetic foot structure.
primary intention
well approximated wounds whose skin edges are tightly together.
secondary intention
wounds healing with edges that are not well approximated. Take longer to heal and form more scar tissue
if a wound that is healing by primary intention becomes infected how will it heal?
secondary intention
tertiary intention
wounds that are left open for several days to allow edema or infection to resolve or fluid to drain and then are closed.
serous drainage
composed primarily of the clear, serous portion of the blood and from serous membranes. Clear and watery.
sanguineous drainage
consists of large numbers of red blood cells and looks like blood.
serosanguineous drainage
a mixture of serum and red blood cells. it is light pink to blood tinged.
purulent drainage
made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Thick and often has a musty smell and varies in color.
Penrose drain
provides a sinus tract
t-tube
for bile drainage
jackson-pratt
decreased dead space by collecting drainage
hemovac
decreases dead space by collecting drainage
gauze, iodoform gauze, NU Gauze
allow healing from base of wound.
