Wounds Flashcards
intact skin
area of persisent redness on light skin
are of persistent red, blue or purple hue on darker skin
does not blanch
Stage 1 Pressure Ulcer
partial-thickness skin loss of epidermis/dermis
superficial; abrasion, blister, shallow center
Stage 2 Pressure Ulcer
full thickness skin loss
damage or necrosis of subq tissue
deep crate with or without undermining
Stage 3 Pressure Ulcer
the result of a planned invasive therapy/treatment
- wound edges clean
- bleeding controlled
- wound made in sterile environment=decreased risk of infection
Intentional Wound
full thickness skin loss
extensive destruction, tissue necrosis
damage to bone muscle, tendons, joints, sinus tracts is possible
Stage 4 Pressure Ulcer
Can’t see wound base
Unstageable Pressure Ulcer
cutting by sharp instrument; wound edges in close approximation and aligned
Incision
blunt instrument, overlying skin remains intact but tissue underneath has been damaged
Contusion
friction; rubbing or scraping epidermal layers of skin; top layer of skin abraded
Abrasion
tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue
Laceration
blunt or sharp instrument puncturing the skin; intentional or accidental
Puncture
foreign object entering the skin or mucous membrane and lodging in underlying tissue; fragments possibly scattering throughout tissues.
Penetration
tearing a structure from normal anatomic position; possible damage to blood vessels, nerves and other structures
Avulsion
toxic agents such as drugs, acids, alcohols, metals, and substances released from cellular necrosis
Chemical
high or low temperatures; cellular necrosis as a possible result
Thermal
Ultraviolet light or radiation exposure
Irradiation
compromised circulation secondary to pressure or pressure combined with friction
Pressure Ulcer
injury and poor venous return, resulting from underlying conditions, such as incompetent valves or obstruction
Venous Ulcer
injury and underlying ischemia, resulting from underlying conditions, such as atherosclerosis or thrombosis
Arterial Ulcer
injury and underlying diabetic neuropathy, peripheral arterial disease, diabetic foot structure.
Diabetic Ulcer
well approximated wounds whose skin edges are tightly together.
Primary Intention
wounds healing with edges that are not well approximated. Take longer to heal and form more scar tissue
Secondary Intention
occur from unexpected trauma (accidental) ex. stabbing/gunshot
- occur in UNSTERILE environment, contamination likely
- increased risk for infection
- increased healing time
Unintentional Wound
wounds that are left open for several days to allow edema or infection to resolve or fluid to drain and then are closed.
Tertiary Intention
occurs from intentional/un-intentional wounds
skin surface broken=portal of entry for microorganisms
bleeding, tissue damage, increased risk for infection, delayed healing
Open Wound
If a wound that is healing by primary intention becomes infected how will it heal?
Secondary Intention
