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Wound Care Chapter 26

front 1

Dehiscence

back 1

separation of outer wound layers

front 2

Evisceration

back 2

rupturing of a wound

front 3

Eschar

back 3

hard, dry, leathery daed tissue

front 4

graunlation tissue

back 4

new tissue developing between two cavities in a wound

front 5

Surgical incision

back 5

  • sharply defined edges
  • under sterile conditions
  • well-approximated-close together-touching

front 6

Abrasions

back 6

superficial open wound

  • scrapes or rub type wound
  • superficial
  • heals well when kept clean

front 7

Lacerations

back 7

open wound made by accidental cutting or tearing of tissue

  • common-knives, pieces of glass or metal
  • jagged edges

front 8

Puncture wound

back 8

open wound when a sharp item pierces the skin

  • round hold that penetrates into deeper tissue
  • dependent on the length and diameter of the sharp item

front 9

Penetrating wounds

back 9

similar to a puncture wound

  • object remains embedded in tissue

front 10

Pressure ulcers

back 10

wound resulting from pressure

  • skin maybe intact and erythemic or skin may be broken

front 11

Deep tissue injury

back 11

area over a bony prominence that differs from surrounding tissue; may be blister- like or a discoloration

front 12

stages of pressure ulcers

back 12

  • stage 1- erythema
  • stage 2- partial-thickness of dermis
  • stage 3- full thickness loss; damage to epidermis, dermis, and subcutaneous tissue
  • stage 4-full thickness loss; damage to deep tissue, muscle, fascia, tendon, joint capsule, and or bone

front 13

unstageable

back 13

eschar covers the wound, making it impossible to tell the depth

front 14

Slough

back 14

avascular, devitalized tissue

-necrotic

-can be white, yellow,tan, gray

front 15

risk factors for pressure ulcer development

back 15

  • being elderly
  • being emaciated or malnourished
  • being incontinent of bowel or bladder
  • being immobile or decreased mobility

front 16

venous stasis ulcer

back 16

develop when venous blood flow is sluggish

  • usually in lower extremities

front 17

Arterial ulcer

back 17

distal portion of the lower extremity, over ankle or bony areas of foot (top of the foot or toe, outside edge of the foot)

-deep with "diff" edges

front 18

Diabetic Ulcer

back 18

on the foot- at mid foot- ball of the foot, over the metatarsal heads, or on top of toes with Charcot deformity

-often very small

-dry (necrotic)

front 19

hemostasis

back 19

immediate- minutes to hours

goal is to stop bleeding and form a stable clot.

front 20

inflammatory phase

back 20

hours-3 days; sometimes up to 5-7 days

goal: clean up invaders and debris; cal in repair crew

front 21

proliferation phase

aka- reconstruction

back 21

goal: fill the defect and over it

front 22

maturation phase

aka: remodeling phase

back 22

starts when wound is closed, strengthens the scar

front 23

types of wound closures for healing

back 23

  • primary intention- wound is clean with little tissue loss, edges are approximated, and wound is sutured closed
  • secondary intention- there is greater tissue loss, wound edges are irregular, and wound is left open
  • tertiary intention- wound is left open for some time to form granulation tissue and then sutured closed

front 24

factors affecting wound healing

back 24

  • age
  • chronic illness
  • diabetes mellitus
  • hypoxemia
  • lifestyle choices
  • lymphedema

front 25

chronic illness

back 25

illness affecting major body systems (heart,lung,kidney,neuro)

front 26

diabetes mellitus

back 26

causes decreased circulation due to narrowed peripheral blood vessels.

front 27

hypoxemia

back 27

decreased oxygen delivered to the wound via the bloodstream caused impaired healing

front 28

lymphedema

back 28

area around the wound is edematous

front 29

radiation exposure

back 29

causes breakdown of underlying connective tissue

front 30

wound tension

back 30

extra tension placed on the wound edges can lead to ischemia and necrosis

front 31

sangulneous

back 31

red, bloody

front 32

serous

back 32

clear to pale yellow

front 33

serosanguineous

back 33

blood and serous fluid-light red to pink

front 34

purulent

back 34

thick drainage-various colors

front 35

billous

back 35

dark greenish-often after gallbladder surgery

front 36

hemovac

back 36

active drain uses suction

front 37

Jackson-pratt

back 37

active drain uses suction

front 38

T-tube

back 38

passive drain uses gravity

front 39

penrose

back 39

open drain; not commonly used because can provide pathway for pathogens

front 40

hydrophilic foam dressing

back 40

super absorbent-moderate to heavy exudating wounds

front 41

hyrdofiber dressing

back 41

for wounds with large amount of drainage

front 42

medihoney dressing

back 42

provides a most environment conductive to wound healing and is indicated for lightly to moderately exuding wounds

front 43

hydrogel dressing

back 43

provides moisture to wound

-soothing and cooling

-use for wounds with minimal drainage

front 44

polyvinyl dressing

back 44

sem-permable- allow oxygen in, keep bacteria out

front 45

negative pressure wound therapy

back 45

uses gentle. negative pressure to remove drainage and contaminants, a canister collects drainage

front 46

pico dressing

back 46

negative pressure dressing-less negative pressure

front 47

wet to damp/ wet to dry

back 47

must fill entire wound including tunneling and or undermining

squeeze out excess liquid before starting to pack-do not want it dripping wet

-pack wound loosely-light ad fluffy

front 48

cold therapy

back 48

best the first 24 to 48 hours after an acute injury

front 49

heat therapy

back 49

when the goal is comfort

front 50

cryotherapy (cold therapy)

back 50

decreases pain and swelling by slowing blood flow

-checking the skin often

front 51

heat therapy (themotherapy)

back 51

used for sub-q or chronic problems muscle or joint pain

-not appropriate for new injury-can worsen the injury

front 52

what should you document for hot cold therapy?

back 52

what, where, when, settings, response, safety, policy