Wounds & Skincare Flashcards
Stage 1 Pressure Ulcer
nonblanchable erythema signaling potential ulceration
Stage 2 Pressure Ulcer
Partial-thickness skin loss involving epidermis and possibly dermis
Stage 3 Pressure Ulcer
full-thickness skin loss involving damage or necrosis of subcutaneous tissue
Stage 4 Pressure Ulcer
full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures.
Primary Intention Healing
Tissue surfaces approximated (closed).
There is Minimal or no tissue loss
Formulation of minimal granulation tissue and scarring
Secondary Intention Healing
Has Extensive tissue loss
Edges cannot be approximated
Repair time is longer, takes longer to repair secondary intention healing
Scarring is greater
There is a greater Susceptibility to infection
Teritary Intention healing, or Delayed primary intention healing
The wound is initially left open for 3-5 days
In tertiary intention healing there is Edema, infection to resolve, or exudate to drain
The wound is Then closed with sutures, staples, or adhesive skin closur
Inflammatory Phase of Healing
Initiated immediately after injury; lasts 3 to 6 days.
What does the Inflammatory Phase involve?
Involves vascular and cellular responses intended to remove any foreign substances and dead and dying tissues. The blood supply to the wound increases, bringing it the oxygen and nutrients that it needs to heal.
Proliferative Phase of Wound Healing
From post injury day 3 or 4 until day 21 This is the second phase of wound healing. Starting about 24 hours after injury, Fibroblasts, which are connective tissue cells, migrate into the wound and begin to synthesize collagen.
The Maturation Phase
From day 21 until 1 or 2 years post injury Fibroblasts continue to synthesize collagen.
The collagen fibers themselves, which were initially laid in a haphazard fashion, reorganize into a more orderly structure.
During the maturation phase, the wound is remodeled and contracted.
The scar becomes stronger but the repaired area is never as strong as the original tissue
What Braden Scale Score is considered at risk?
15-18,which would require a turning schedule
What dressing would be used for a stage 2-4 pressure ulcer? Or for Autolytic Debridement of eschar, and
Partial Thickness Wounds
Hydrocolloids
What type of dressing is indicated for Clean, Moist wounds?
Collagen
What type of dressing is indicated for Venous Stasis ulcers, Surgical Wounds, Wounds undergoing chemical debridement agents?
Clear Absorbent Acrylic
