Term
| partial thickness vs full thickness wound |
|
Definition
partial- epidermis and partial dermis
heals by regeneration
ex. clean surgical wound or abrasion
full thickness wound
extends into both layers (epidermis and dermis)
pressure ulcers |
|
|
Term
| four phases of wound healing |
|
Definition
hemostasis- right after injury blood clotting begins
inflammatory phase- WBCs/macrophages move to area
proliferation phase- vascular bed reestablished, replacement tissue, surface repaired
remodeling phase- collagen is remodeled, scar tissue thin, flat white line |
|
|
Term
LOCAL factors effecting wound healing
pressure/edema
dessication
maceration
repeated trauma
necrosis
infection |
|
Definition
edema increases pressure, decreases blood flow
dessication- cells dehydrate
maceration- overhydration impairs skin integrity
trauma- delays healing
necrosis- dead tissue
infection- more energy spent on fighting microorganism |
|
|
Term
| SYSTEMIC factors affecting wound healing |
|
Definition
age- children/healthy adults heal faster
circulation/oxygenation- good circulation
nutrition- protein, vitamin A & C
wound condition- specific condition of wound
health status- corticosteroids, post op radiation therapy (lower immune system) diabetes |
|
|
Term
|
Definition
| bleeding from a wound site. Is normal during & immediately after initial trauma. Hemorrhage occurring after hemostais indicates a slipped surgical suture, dislodged clot, infection, or erosion of blood vessel. |
|
|
Term
|
Definition
| localized collection of blood underneath the tissues. Appears as a swelling, change in color, sensation, or warmth or mass that often takes on a bluish discoloration. |
|
|
Term
|
Definition
| Partial or total separation of wound layers. This most commonly occurs before collagen formation ( 3-11 days after injury). Commonly occurs in abdominal surgical wounds when a patient strains suddenly (coughing, vomiting, sitting up) |
|
|
Term
|
Definition
| protrusion of visceral organs through a wound opening. Emergency that requires surgical repair. Nurse should place sterile towel soaked in sterile saline over the extruding tissues to reduce chance of bacterial invasion & drying of the tissues. |
|
|
Term
|
Definition
| wound infection is the second most common healthcare-associated infection (nosocomial). CDC states that a wound is infected if it has purulent drainage coming from it, ***even is culture is not taken or culture is negative. |
|
|
Term
| managing wound dehiscense |
|
Definition
splinting
watch for serosanguinous drainage
cover with sterile towel moistened with NSS
call MD
manage like open wound |
|
|
Term
| management of evisceration |
|
Definition
place pt in fowlers position
cover exposed abdominal organs with sterile towels moistened with NSS
call MD/ prepare pt for surgery |
|
|
Term
|
Definition
| between rectum and vagina- abnormal passageway from fluid accumulation |
|
|
Term
| Risk factors for pressure ulcers |
|
Definition
Impaired Sensory Perception- are unable to feel when a portion of their body undergoes increased, prolonged pressure or pain
Impaired mobility- unable to independently change positions are at risk
Alteration in level of consciousness- confused/disoriented patients may not be able to communicate to a health care provider that they are feeling discomfort. Coma patients are unable to feel pressure and unable to move themselves.
Tissue tolerance:
Shear- shear force is the sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary. This causes damage in deep in the tissues, causing undermining of the dermis.
Friction- The force of two surfaces moving across one another, like when skin is dragged across a coarse surface such as bed linens. Friction affects the epidermis, the top layer of the skin. Happens in patients who are restless or who have spastic conditions.
Moisture- Prolonged moisture softens skin, making it more susceptible to damage. Skin moisture originates from wound drainage, excessive perspiration, fecal/urinary incontinence.
poor nutrition and hydration
low blood pressure- inadequate circulation |
|
|
Term
| nurse must turn/reposition pt every |
|
Definition
|
|
Term
|
Definition
pressure ulcer risk
lower score = higher risk
score from 6-23/ a score of 19 or higher means pt is at low risk with no treatment at this time |
|
|
Term
|
Definition
stage 1- nonblanchable erythema, intact skin
stage II- partial thickness (epidermis and partial dermis) skin loss or blister
stage III- full thickness skin loss, fat visible but not bone, tendon or muscle
stage IV- full thickness tissue loss, bone, muscle, tendon exposed
unstageable- base of wound cannot be visualized, depth unknown, full thickness loss covered by slough or eschar |
|
|
Term
|
Definition
red, moist, new blood vessels- indicates healing
slough- yellow or white, should be removed for wound healing
eschar- black necrotic tissue, needs to be removed |
|
|
Term
| how to document/assess existing ulcer |
|
Definition
location
stage I-IV
size- lxwxd
tunneling under the wound
color and type of exudate/ odor
periwound condition- redness, warmth, signs of maceration
type of tissue in wound base- eschar, slough, granulation |
|
|
Term
|
Definition
r=red=protect
- proliferative phase, granulation tissue protect with moist sterile dressing
y=yellow=cleanse
-presence of slough or exudate clean to promote healing
b=black=debrid
remove necrotic tissue so wound can heal |
|
|
Term
|
Definition
serous- clear, watery
sanguineous- bloody
serosanguinerous- mix of serous and blood, pink
purulent- thick, yellow, puss, odor |
|
|
Term
pressure ulcers require __________ technique
surgical dressings require ___________ technique |
|
Definition
pressure ulcers are non-sterile, medical asepsis is acceptable
surgical dressings require aseptic technique |
|
|
Term
|
Definition
top to bottom
inside to outside
clean area to less clean area |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
