Tissue Integrity and Would Management Flashcards

tear in skin, puncture

irregular in shape

simple of complicated

rubbing off of skin surface

Blunt force injury (results in closed hematoma)

a cut produced surgically by a sharp instrument that creates and opening into an organ or space in the body

is a stab wound made for a drainage system

Free of Microorganisms

Sew wound closed

hook edges of skin together with staple, pull straight from the middle

wound edges are healing together

what we want in surgery

fluid consisting of plasma which is secreted during the inflammatory phase of healing

Decreases/resolves day 5

seen by day 4

day 9 to 14

chronic venous insufficiency, peripheral artery disease, diabetes

venous disease, arterial disease, neuropathic disease

not infected or inflamed

clean/contaminated; minimal bacteria and closed after procedure

Contaminated; high bacterial count. May interfere with healing. If surgical might be left open and require long term management

Dirty wound; high bacterial count. Gangrene, necrotic, purulent drainage

begins immediately after surgery, lasts about 3-6 days

begins on day 3 or 4, Lasts 3 to 24 days

begins Day 21, can last months to 1-2 years

Termination of bleeding starts as soon as the injury occurs platelets adhere to the walls of the injured vessels and a clot begins to form. The fibrin in the clot begins to hold the wound together and bleeding subsides...Example a scab(extra layer of protection

Usually happens in the first 2 hours after the injury

initial increase in the flow of the blood elements and water out of the blood vessels into the vascular space

This process causes the cardinal signs of inflammation

redness, heat, edema, pain and tissue dysfunction. White blood cells appear and begin to engulf the pathogen, if infection is not present these will decrease

collogen production appears during this phase, begins on the 3rd or 4th day after the injury and lasts 2 to 3 weeks

healing begins when granulation tissue is visible, 3 weeks after surgery fibroblasts begin to exit the wound and the would continues to gain strength

Internal wounds heal faster than external wounds..Keyloid may form during this phase

wounds with skin tissue close together, little tissue is lost, minimal scaring result

would edges are not close together, pus has formed, ad the would must granulate to heal, pus like drainage, would may be OPEN to drain, drain is placed or packed, with gauze to allow it to drain , the necrotic or dead tissue dissolves and the wound fills with granulation tissue

a contaminated would is left open and closed later after the infection is under control, granulation tissue begins to grow and then that tissue is sutured together, results in larger deeper scar tissue

Threads of wire, silk, steel, cotton, linen, or nylon are used to sew body tissue together.

Dissolvable, may be placed in deep tissue layers in deep wounds and superficially to close the wound.

Retention ones may be left in place for up to 3 weeks.

• Made of stainless-steel wire
• Primarily used in abdominal incisions and orthopedic surgery
• Remove every other suture or staple and place steri strips if the incision starts to
come apart leave the other in place.

• Usually removed in 7 to 10 days after surgery.
  ▪ May be done all at once or in phases.
  ▪ Steri strips are usually used after the suture or staple is removed.

Stringed tape which holds the skin together.

Tape which holds the skin together.

Sticky piece of clear material.

Less than 14/100mL

Less than 12/100 mL

Length(measure head to foot), Width(measure side to side) and Depth (Use cotton
swab or wound measurement device)

narrow channel or passageway extending any direction from the base
of the wound. Use clock face to describe location.

leaking slowly from the wound

accumulation of body fluid from a body cavity, wound or other source of discharge.

Greater than 300 mls

bloody fluid, indicates active bleeding

pale, red, watery. It is a mixture of serous and
sanguineous fluid

clear, watery plasma

Healthy(cover wound), granulation tissue,

Purulent drainage (Clean Wound)

Yellow/gray (Clean wound)

Eschar (Debride wound)

color, texture, temperature and description of any areas that
are open, stripped or have a rash.

Airtight device that prevents environmental contaminants from
entering the wound

JP, Hemovac, Chest tube drainage, foley catheter

passes through and open-ended tube into a receptacle or onto a dressing. This kind of
drain is placed to help fluid escape the surgical site. Examples can be used post-op for
an anal fistula.

Penrose Drain

uses a pump or some type of suction to extract the fluid. Gentle suction can be used to help gravity move the exudate. Ex. JP drain, Hemovac, Chest tube