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39 Cards in this Set

  • Front
  • Back
primary wound healing
wound edges have been put together
minimal tissue loss
low risk of infection
minimal granulation tissue and scarring formation
abdominal, knee, hip incisions (surgical)
secondary wound healing
considerable tissue loss
can't put edges together or do not want to put them together
wound is dark pink to red
longer repair time, more scarring and risk of infection
pressure ulcers, burns
tertiary wound healing
wound is left open for a few days post-op - and then wound edges are approximated
pretty deep w/ lots of drainage and tissue debris
high risk of infection
inflammatory phase
hemostasis and phagocytosis
blood clot, erythema (redness), warmth, tenderness @ site, edema
forms epithelial cells at site of wound
begins within minutes
proliferative phase
can last up to 3 weeks after injury
collagen forms (whitish protein substance that adds tensile strength to wound)
wound fills in with connective tissue or granulation tissue and top is closed by epithelium
maturation phase
collagen scar gains more strength and remodels area of the skin
takes between 3 weeks and 2 years to heal
massive bleeding
(slipped stitch, erosion of blood vessel, dislodged clot)
bacteria (all wounds are contaminated)
bacterial overgrows and prevents healing
leads to fever and high WBC count
is apparent 2-11 days post-op
separation of wound's edges - revealing underlying tissue
happens in obese patients of after sudden straining
protrusion of visceral organs through a dehisced surgical wound
abnormal passage/opening between two organs or between an organ and outside of the body
clear or slightly yellow and thin
result of infection
made of WBC's, tissue debris, and bacteria
thick and color is specific to infectious organism
can be odorous
thick and reddish
has serum and RBC's
most common from uncomplicated surgical incision
blood-streaked or blood-tinged serous drainage
has serum and blood and is usually water.
Branden Scale
out of 23 points
sensory perception, moisture, activity, mobility, nutrition, friction & shear
Norton Scale
mental state, activity, mobility, incontinence
stage 1 pressure ulcer
erythema (persistent)
if palpated - will not blanch (turn white)
stage 2 pressure ulcer
partial loss of skin (superficial)
can have an abrasion, shallow crater, or blister
can be swollen or painful
usually 100% red with chance of healing in several weeks
stage 3 pressure ulcer
full thickness skin loss with subQ tissue
presents a deep crater with or without adjacent tissue
can be smelly and require months to heal
stage 4 pressure ulcer
extensive damage to underlying structures (incl. tendons, muscles, and bones)
can be small but w/ extensive tunneling underneath.
usually smelly and infeection can cause sepsis.
can take months/years to heal
necrotic tissue that is black or dark brown and feels leathery
protect and cover
try to avoid changing the dressing and moisten it
cleanse gently, applying antimicrobial agent, use transparent film or hydrocolloid dressing
have liquid or 'slough' and purulent drainage
use wet-to-damp dressings, wound irrigation, absorbent dressings, and hydrogel or other exudate absorbers to remove dead tissues.
antimicrobial agents
debridement of eschar
sharp debridement
must have training - NP/PA
remove necrotic tissue and thick eschar
stage IV ulcers
wet to dry dressings
wound irrigations
change every 4-6 hours
remove stringy exudate
for small to moderate wounds
topical enzymatic agent
for devitalized tissue
moisture retentive dressing with enzymes
liquify selective dead tissue
transparent film
temporary second skin and semipermeable
ideal for small, superficial wounds and partial-thickness burns/ulcers
stick well - are barriers to bacteria
allow wound to breathe, keeps it moist, seals in wound fluid and lets enzymes digest tissue
impregnated non adherent with petroleum
use on open wounds, ulcers that might get infected, diabetic foot
not for stage III/IV (wounds w/ exudate)
will stay moist
waterproof adhesive wafers, pastes, or powders
goes on the body and stays for 72 hours
stage I or II
inner layer absorbs exudate and forms a hydrated gel over the wound and outer film provides a seal
glycerin or water-based non adhesive jellylike sheets, granules, or gels
keeps wound moist and only change on a day
impregnate gauze by putting hydrogel on gauze
stage II, III, IV and wounds w/ infections
polyurethane foams
nonadherent hydrocolloid dressings
need to be taped down or sealed
requires a secondary dressing and surrounding skin must be protected to prevent maceration
soft, absorbent, put the FOAM side on the patient
nonadherent dressings of powder, beads or granules, ropes, sheets, or pastes
verb absorbent, becomes a gelled mush, made from seaweed, lightly pack
stage 1 treatment
apply diaper rash creams to help protect the skin
frequent turning, using pressure-relieving devices, or pressure-reducing surfaces, repositioning
keep client clean, dry, and well-nourished
stage 2 treatment
maintain a moist healing environment
use saline or occlusive dressing that promotes natural healing but prevents scar formation
stage 3 treatment
debride by using wet-to-try dressings, surgical intervention, and proteolytic enzymes
stage 4 treatment
wound should be covered with non-adherent dressings
changed every 8-12 hours