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26 Cards in this Set
- Front
- Back
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when wound infection is suspected
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- patient may be febrile or have abnormal vital signs
- wound is red or swollen - purulent odorous drainage - increased warmth of surrounding tissue |
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Wound care does this
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promotes wound cleansing and debriding of necrotic tissue
enhances healing process and prevents recurrent infection |
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Healing Stages I and II pressure ulcers go through epidermis but not into...
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dermis
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Healing stages III and IV go through epidermis and...
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dermis and extend into subcutaneous fat and deeper structures
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Hyperemia is
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redness. does not blanch to the touch.
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hyperemia alone is associated with stage..
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stage 1 pressure ulcer
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Ischemia occurs if pressure is continuous for...
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2 to 6 hours
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Ischemia signifies Stage.... pressure ulcer
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2
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stage 2 pressure ulcer may take up to this amount of time to disappear
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36 hours or more to disappear
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stage 2 pressure ulcer could be described as
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abrasion, blister, shallow crater...a superficial ulcer
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stage 3 pressure ulcer occurs after this many hours of continuous pressure
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6 hours
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A full thickness skin ulcer may be
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stage 3 or stage 4
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a stage 3 ulcer does not penetrate the
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fascia
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4 stages of wound healing process
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1. inflammatory
2. proliferation 3. epithelialization 4. remodeling/scar formation |
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Inflammatory stage of wound healing process takes ____ days
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2 to 5
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collagen is layed down in the ____ stage of the wound healing process
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proliferative
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scar formation/remodeling may occur after
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3 weeks to 2 years
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serous means
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clear fluid
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purulent refers to
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pus
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fetid means
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malodorous
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venous ulcers heal __quickly/slowly?
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slowly
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whirpool is an example of ___ debridement
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mechanical
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sugical debridement is performed under
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anesthesia
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E-stim
Ultrasound polsed short-wave diathermy ultraviolet light whirlpool pulsative lavage with suction hyperbaric oxygen and wound vac are considered: |
adjunctive therapies in wound care
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factors affecting wound healing
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age
chronic disease perfusion/oxydation neurologically impaired skin medication nutrition local ischemia |
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goals of wound care should be and should include
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Patient/wound-focused
specific temporal, measurable realistic behavioral and functional |
