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44 Cards in this Set

  • Front
  • Back
types of wounds
contusions
abrasions
puncture wounds
penetrating wounds
lacerations
pressure ulcers
wounds are catergorized as?
open or closed
contusion is?
a closed discolored wound caused by blunt trauma, better known as a bruise, skin is intact, the leakage of blood causes the skin to be discolored, bright red to purple, blue, bluish green, and finally yellow as the contusion heals.
abrasion is?
a superficial open wound, includes scrapes, scratches, rub type wounds, skin is broken, such as a carpet burn, skinned knee, they heal well if kept clean
puncture wound is
open wound that results when a sharp item, such as a needle, nail, or piece of wire, pierces the skin, resulting wound is a round hole in the skin that extends down into the deeper tissues
penetrating wound is?
similiar to puncture, with the difference being that the offending object remains embedded in the skin.
laceration is?
open wound makde by the accidental cutting or tearing a tissue. common sources of lacerations include: knives and pieces of glass and metal, it has jagged edges
pressure ulcers
is a wound resulting from pressure and friction. the skin may be intact and erythemic (reddened) or the skin may be broken. if the skin is broken, the ulcer may be superficial or very deep
wounds fall under these categories?
clean
clean-contaminated
contaminated
infected
colonized
clean wound is?
a wound that is not infected
clean contaminated wound is?
a wound that was surgically made, is not infected, but has direct contact with the normal flora in either the respiratory tract, urinary tract, or GI tract, it has more potential to become infected.
contaminated wound is?
this can be surgical wound or a wound caused by trauma that has been grossly contaminated by breaking asepsis
infected wound is?
an infected wound is one in which the infectious process is already established, evidenced by high numbers of microorganisms, and either contain pus, or dead tissue.
classic signs of infected wound are?
erythema--redness
increased warmth
edema-swelling
pain
odor
drainage
colonized wound is?
a colonized wound differs from an infected wound in that it has a high number of microorganisms present but is without signs of infection
ischemia
reduced blood flow to tissues
pressure ulcer is known as
decubuitus ulcer
bed sore
most common sites for pressure ulcers are?
sacrum
buttocks
greater tronchanters
elbows
heels
ankles
occiput
scapulae
risk factors for pressure ulcers
who they are?
elderly
emaciated or malnourished
incontinent of bowel or bladder
immobile
impaired circulation or chronic metabolic conditions
elderly
the skin of elderly is thinner
less elastic
more susceptible to friction and shearing force
emaciated or malnourshished
emaciation is the state of being very lean or having very little muscle
incontinent of bowel or bladder
with incontinence of bowel or bladder, the skin or fhte perineal area tends to be wet much of teh time, leading it to become macerated or (softened)
immobile
this includes patient who are paralyzed, or have casts or splints, as well as those restricted to a bed or chair
CHECK SKIN AT LEAST EVERY 8 HOURS MINIMUM
BED FAST PT'S: CHECK EVERY 2 HOURS
impaired circulation or
chronic metabolic conditions
chronic metabolic conditions such as diabetes result in impairment of circulation, which can increase the risk of ischemic tissue
staging pressure ulcers
6 stages from redness to deep craters involving muscle and even bone, scale is only for staging ulcers
1
2
3
4
unstageable
deep tissue injury DTI--
begins with an area over a bony prominence that differs from the surrounding tissue, may be a blister, may not, may look like a bruise
stage 1 ulcer
erythema
remains for 15-30 min after releiving pressure
it will not blanch (turn white)
do not massage
may feel tingling, burning at site, further damage can be prevented
stage 2 ulcer
partial thickness loss of dermis
intact serum-filled blisters
broken blisters reveal shallow, pink or red ulcerartion, shiny or dry, erythema around, may feel warmer, harder to heal than #1, infection is possible
stage 3 ulcer
full thickness loss damage to epidermis, dermis, subq tissue, not involving muscle or bone, undermining and tunneling, depth of tissue loss is discernable if slough is present, tend to be infected, has drainage, take longer to heal than #1 or 2, a great deal of granulation tissue must be produced to fill the wound and repair the damage
stage 4 ulcer
full thickness loss, deep tissue necrosis of muscle, fascia, tendon, joint capsule and sometimes bone. may be tunneling, mining, infection can affect the bone, extremely slow to heal, depending on pts health status
unstageable ulcers
full thickness tissue loss, impossible to stage, due to wound bed of slough and eschar, do not remove eschar,
pallor
related to impaired circulation, which is a major risk factor for skin breakdown
erythema
indicates the increased capillary blood flow associated with inflammation
jaundic
also known as yellowing of hte skin, jaundice is a sign of an abnormally high serum level of bilirubin, which can make skin itch and be more susceptible to loss of integrity
brusing
discolored areas, make notations of any such areas that are found, so it is easy to determine if new breakdown occurs
skin turgor
is it elastic or non elastic
lets you know if pt's skin is hydrated
if patient with multiple risk factors for skin breakdown check skin
every 2 hours, look for excessively dry skin as evidenced by flaking or peeling, areas of broken skin, exoriated or blistered
reposition the patient every 2 hours
keep skin clean and dry
assess incontinent pts pads or linens every hour, eep linens free of wrinkels, add lotion to immobile pt, assess pressure points every one to two hours
immobile pts should be lifted with a draw sheet or mechanical lift rather than dragged across the bed or chair
pressure relieveing devices:
sheepskin pads, foam eggcrate, gel filled pads, air filled , air fluidized beds
other wounds found in hospitalized patients they are?
pressure ulcers
stasis ulcers
draining sinus tracts
surgical incisions
stasis ulcers--develop when the venous blood flow is sluggish, gen in lower extremities, allowing deoxgenated blood to pool in the veins
these ulcers develop from chronic valve problems, blood clots and other conditions that interrupt venous blood flow such as chronic venous insufficiency, the resulting edema damages surrounding tissues and causes ulcers to develop, very difficult to heal
draining sinus tracts--is a channel or tunnel that develops between two cavities or between an infected cavity and the surface of the skin, known as a fistula, a sinus tract that forms due to an infection
usually produces purulent drainage that is thick yellow or green, if the sinus tract opens onto the skins surface it usually has to be irrigated and packed with strips of absorb the drainage until the infection clears and the trace can be allowed to heal
surgical incisions--intentionally made, linear with sharp defined edges than most wounds, two edges of an incion should have good approximation, they should close together,
may be closed with sutures, staples, steri strips, skin adhesive
stopped at page 563
on phases of the healing process