Nur 111 Exam 3

Front 1

Open Wound

Back 1

An open wound occurs from intentional or unintentional trauma. The skin surface is broken, providing a portal of entry for microorganisms. Examples: Lesions and abrasions

Front 2

Closed Wound

Back 2

Results from a blow, a force, or strain caused by trauma such as a fall, an assault, or car crash. The skin surface is not broken but there is soft tissue damage. Examples: Ecchymosis and Hematomas

Front 3

Acute Wound

Back 3

Such as surgical lesions, usually heal within days to weeks. The wound edges are well approximated and the risk of infection is lessened.

Front 4

Chronic Wound

Back 4

These do not progress through the normal sequence of repair. The healing process is impeded. The wound edges are often not approximated, the risk of infection is increased and the normal healing time is delayed. Chronic wounds remain in the inflammatory phase of healing.

Front 5

Intentional wound

Back 5

Is the result of planned invasive therapy or treatment. Ex. Surgical. The wound edges are clean, and bleeding is usually controlled.

Front 6

Unintentional wound

Back 6

These are accidental. These wounds occur from unexpected trauma. Contamination is likely. Wound edges are usually jagged, multiple traumas are common, and bleeding is uncontrolled. High risk for infection and longer healing time.

Front 7

Wound healing: Primary Intention

Back 7

Wounds healed by primary intention are well approximated (skin edges tightly together) Intentional wounds with minimal tissue loss, such as surgical incisions heal by primary intention.

Front 8

Wound healing: Secondary Intention

Back 8

Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds such as burns or trauma, require more tissue replacement and are often contaminated.

Front 9

Wound healing: Tertiary (Delayed Primary)

Back 9

Wounds healed by tertiary,"", are those wounds left open for several days to allow edema or infection to resolve or exudate to drain, and then are closed.

Front 10

Clean Wound

Back 10

No entry into the respiratory, gastrointestinal, genitourinary or oropharyngeal tracts.

Front 11

Clean-contaminated Wound

Back 11

Entry into the respiratory, gastrointestinal, genitourinary or oropharyngeal tracts under controlled conditions.

Front 12

Contaminated Wound

Back 12

open, traumatic, accidental wounds; major break in aseptic technique.

Front 13

Dirty-Infected Wound

Back 13

any wound that does not properly heal and grows organisms, old traumatic wound, surgical incision into are infected area (ruptured bowel).

Front 14

Partial-thickness

Back 14

All or a portion of the dermis is intact

Front 15

Full-thickness

Back 15

The entire dermis and sweat glands and hair follicles are severed

Front 16

Complex

Back 16

The dermis and underlying subcutaneous fat tissue are damaged or destroyed.

Front 17

Superficial

Back 17

On the surface of the skin. EXS. Paper cut

Front 18

Phases of Healing

Back 18

Hemostasis
Inflammation
Proliferation
Maturation

Front 19

Hemostasis Phase

Back 19

Occurs immidaately after the inital injury. Blood vessels constrict & blood clotting begins thru platelet activation and clustering. Then same blood vessels dilate & capillary permeability increases, allowing plasma & blood components to leak out forming exudate which cause swelling and pain. (heat &redness)

Front 20

Inflammatory phase

Back 20

Lasts 4-6 days. White blood cells move to the wound. Leukocytes arrive first to ingest bacteria & cellular debris 24 hrs later macrophages enter the injury, ingest debris and release growth factors for epithelial cells and new blood vessels. Fibroblasts also fill wound. manifestations include Pain, heat, redness, and swelling at the site of injury.

Front 21

Proliferation phase (fibroblastic, regenerative, or connective tissue phase.)

Back 21

Lasts for several weeks. New tissue is built to fill wound space, thru the action of fibroblasts. Capillaries grow across the wound, bringing oxygen and nutrients required for continued healing. A thin layer of Epi cells forms and blood across the wound is reinstituted. The new tissue, granulation tissue forms the foundation for scar tissue development.

Front 22

Fibroblasts

Back 22

Connective tissue cells that synthesize and secrete collagen &produce specialized growth factors responsible for inducing blood vessel formation as well as increasing the number and movement of endothelial cells.

Front 23

Granulation tissue

Back 23

Forms the foundation for scar tissue development. It is highly vascular, red, and bleeds easily.

Front 24

Maturation Phase

Back 24

Final Stage of healing. 3 weeks after injury, continuing for months or years. Collagen is remodeled, making the healed wound stronger and more like adjacent tissue. New collagen continues to be deposited which compresses the blood vessels in the healing wound so that the scar eventually becomes a flat thin line.

Front 25

Scar

Back 25

An avascular collagen tissue that does not sweat, grow hair, or tan in sunlight. Scar tissue is strong but less elastic that uninjured tissue.

Front 26

Wound complications:

Back 26

Hemorrhage
Infection
Fistula
Dehiscence
Evisceration

Front 27

Hemorrhage

Back 27

Excessive bleeding. May occur from a slipped suture, a dislodged clot at the wound site, infection, or the erosion of a blood vessel by a foreign body, such as a drain. Internal hemorrhage causes the formation of a hematoma.

Front 28

Infection

Back 28

Bacteria can invade a wound after the initial wound occurs. A contaminated wound is more likely to be infected. Wound infections also occur as a result of hospital-acquired infections. Symptoms include: Purulent drainage, increased drainage, pain, redness, and swelling around wound; increase body temperature and Increased WBC.

Front 29

Fistula

Back 29

An abnormal passage from an internal organ to the outside of the body or from one internal organ to another. Fistula formation is often the result of infection that has developed into abscess, which is a collection of infected fluid that has not drained.

Front 30

Dehiscence

Back 30

Is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed.

Front 31

Evisceration

Back 31

The most serious complication of dehiscence. The wound completely separated with protrusion of viscera thru the incisional area.

Front 32

Pressure Ulcer

Back 32

A wound with a localized area of tissue necrosis.

Front 33

Pressure intensity.

Back 33

The major predisposing gactor for a pressure ulcer is external pressure applied over an area, which results in occluded capillaries and poor circulation. leading to ischemia, edema, inflammation and ultimately necrosis and ulcer formation.

Front 34

Pressure duration

Back 34

A pressure ulcer may form in as little as 1-2 hours if the patient has not moved or been repositioned to allow circulation to flow.

Front 35

Tissue Tolerance

Back 35

Pressure ulcers develop when soft tissue undergoes pressure in combination with shear or friction.
How healthy the skin is

Front 36

Friction

Back 36

Occurs when 2 surfaces rub against each other.

Front 37

Suspected Deep Tissue Injury

Back 37

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Front 38

Stage 1

Back 38

Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

Front 39

Stage 2

Back 39

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

Front 40

Stage 3

Back 40

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Front 41

Stage 4

Back 41

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

Front 42

Unstageable

Back 42

Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown or black) in the wound bed.

Front 43

Grading system for edema

Back 43

1+: 2-mm depression
2+: 4-mm depression
3+: 6-mm depression
4+: 8-mm depression

Front 44

Turgor

Back 44

Skin elasticity. Clavicle best spot to assesss

Front 45

Reactive hyperemia (1st sign)

Back 45

Redness that occurs when pressure is released, allowing blood to rush back into the tissue. Visual Ischemia

Front 46

Blanchable erythema:

Back 46

Redness that blanches (turns white) when compressed with a fingertip and the immediately turns red again when pressure is removed.

Front 47

Nonblanchable erythema

Back 47

(1st sign of tissue destruction): more intense redness that doesn’t change when compressed with a fingertip.