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20 Cards in this Set

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Intentional Wound
Wound occuring during operations or venipuncture.
Unintentional Wounds
Wounds that are accidental
Clean Wounds
Uninfected wounds in which minimal inflammation is encountered and the respiratory, alimentary, genital and urinary tracts are not entered.
Clean-contaminated wounds
surgical wounds in which the resp, alimentary, genital or urinary tract has been entered. No sign of infections
Contaminated wounds
fresh, open, accidental wounds and surgical wounds involving a major break in sterile technique or a large amt of spillage from the gastrointestinal tract. Show evidence of inflammation
Dirty/Infected wounds
Wounds containing dead tissure and wounds with evidence of a clinical infection
Pressure ulcers/decubitus ulcers/ Pressure sores or bedsores
Any lesion caused by unrelieved pressure that result in damage to underlying tissue
Cause of Pressure Ulcer
Ishcemia
Reactive hyperemia
a bright red flush on the skin occurring after pressure is relieved
Mechanism for preventing pressure ulcers
Friction
rubbing; the force that opposes motion
Factor in Pressure Ulcers
Shearing Force
a combination of friction and pressure which when applied to the skin results in damage to the blood vessels and tissues
Factor in Pressure Ulcers
Position that causes Pressure Ulcer
Fowler's Position
Way to lay down a patient
Immobility
Refers to a reduction in the amt and control of movement a person has
Risk Factors for Decibitus Ulcers
Inadequate Nutrition can cause.....
weight loss, muscle atrophy, loss of subcutaneous tissue
Risk Factors for Decibitus Ulcers
Moisture from incontinence promote.....
maceration (tissue softened by moisture)
Risk Factors for Decibitus Ulcers
Digestive enzymes can cause....
excoriation (area of loss of the superficial layer of the skin)
Risk Factors for Decibitus Ulcers
Stage 1
Nonblanchable erytherma
Stages of Pressure Ulcer
Stage 2
Partial thickness skin loss involving the epidermis and possibly the dermis
Stages of Pressure Ulcer
Stage 3
Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia.
Deep crater with or without undermining of adjacent tissue
Stages of Pressure Ulcer
Stage 4
Full-thickness skin loss with tissue necrosis.
Stages of Pressure Ulcer