WOUNDS

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created 6 years ago by MEKR
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Types of wounds including ulcers and healing
updated 6 years ago by MEKR
Grade levels:
Professional
Subjects:
nur170
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1

Epithelial

new pink or shiny tissue (skin) that grows in from the edges or as islands on the wound surface

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Closed/resurfaced

wound is completely covered with epithelium (new skin)

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Granulation Tissue:

pink or beefy red tissue with a shiny, moist, granular appearance

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Dehiscence

is the failure of wound healing in which the surgical wound separates and opens to the fascial level - "Let go"

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Evisceration

-Total separation of wound layers
-Protrusion of visceral organs through a wound opening.
-Emergency situation

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Fistulas

Abnormal passage/tract between two organs or between two organs and the outside of the body

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Pressure Ulcer on Heel

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Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Discoloration of skin, warmth, edema, hardness or pain may also be present. Darkly pigmented skin may not have visible blanching.
Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" person (a heralding risk).

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Stage 1

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Partial-thickness loss presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosanguineous filled blister.
Further description: Presents as a shiny or dry shallow ulcer without sloughing or bruising. This stage should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration, or excoriation.

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Stage 2

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Full-thickness skin loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present. May include undermining and tunneling.
Further description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue, and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

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Stage 3

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Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Often includes undermining and tunneling.
Further description: The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue, and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule), making osteomyelitis or osteitis possible. Exposed bone/tendon is visible or directly palpable.

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Stage 4

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Full-thickness tissue loss in which the base of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, black) in the wound bed.
Further description: Until enough slough and/or eschar are removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined, but it will be either a Stage III or IV. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body’s natural (biological) cover" and should not be removed.

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UNSTAGEABLE/UNCLASSIFIED: FULL THICKNESS SKIN OR TISSUE LOSS-DEPTH UNKNOWN

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Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
Further description: The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.

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(SUSPECTED) DEEP TISSUE INJURY

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Tunneling

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Sinus tract/dead space: pathway extended in any direction from the wound.

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Undermining

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*Area of tissue destruction underlying
intact skin along the wound margins
*Space between the surrounding skin and the wound bed
*Usually involves significant portion of wound edge
*May extend entirely around wound
*Subcutaneous fat necrosis
*Usually indicates aerobic and anaerobic bacteria are present

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Serous drainage

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Clear, watery plasma

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Purulent drainage

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Thick, yellow, pale green, or white: indicates infection

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Serosanguineous drainage

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Pale, red, watery: mixture of serous and sanguineous

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Sanguineous drainage

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Bright red: indicates active bleeding

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Primary Intention

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Wound healing by primary intention such as a surgical incision; healing occurs by connective tissue deposition.
Edges of wound are approximated/closed together with staples or sutures. Uncomplicated, heals fast minimal tissue loss, minimal scarring

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Secondary Intention

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Incision line is left open & healing occurs by formation of granulation tissue and contraction of wound edges by scar formation. Used w/ tissue loss, open, jagged edges. Extensive scarring

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Tertiary Intention

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Not closed immediately: Infected Wound is left open until no evidence of infection or swelling-Sutured 3-5 days post surgery
Wound edges are not approximated, and healing occurs by formation of granulation tissue and contraction of wound edges.