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76 Cards in this Set
- Front
- Back
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Bandage |
piece of gauze or other material used to cover a wound |
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Biofilm |
a thick grouping of microorganisms |
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Debridement |
cleaning away devitalized tissue and foreign matter from a wound |
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Dehiscence |
separation of the layers of a surgical wound; may be partial, superficial, or a complete disruption of the surgical wound |
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Dermis |
Layer of the skin below the epidermis |
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Desication |
dehydration; the process of being rendered free from moisture |
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Dressing |
a protective covering placed over a wound |
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Epidermis |
superficial layer of the skin |
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Epithelialization |
stage of wound healing in which epithelial cells from across the surface of a wound; tissue color ranges from the color of "ground glass" to pink |
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Eschar |
a thick, leathery scab or dry crust that is necrotic and must be removed for adequate healing to occur |
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Evisceration |
protrusion of viscera through an incision |
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Exudate |
fluid that accumulates in a wound; may contain serum, cellular debris, bacteria, and white blood cells |
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Fistula |
an abnormal passage from an internal organ to the skin or from one internal organ to another |
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Friction |
occurs when two surfaces rub against each other; the resulting injury resembles an abrasion and can also damage superficial blood vessels directly under the skin |
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Granulation Tissue |
new tissue that is pink/red in color and composed of fibroblasts and small blood vessel that fill and open wound when is starts to heal |
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Ischemia |
deficiency of blood to a particular area |
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Maceration |
softening through liquid (overhydration) |
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Necrosis |
death of cells and tissue |
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Negative Pressure Wound Therapy (NPWT) |
activity that promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction of bacteria in the wound, and removal of excess wound fluid |
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Pressure Ulcer |
any lesion cause by unrelieved pressure that results in damage to underlying tissue |
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Purulent |
containing pus |
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Purulent drainage |
comprised of white blood cells, liquefied dead tissue debris, and both dead and live bacteria |
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Sanguineous |
containing or mixed with blood |
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Scar |
connective tissue that fills a wound area |
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Serosanguineous |
mixture of serum and red blood cells |
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Serous Drainage |
composed of clear, serous portion of the blood and from serous membranes |
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Shearing Force |
force created when layers of tissue move on one another |
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Subcutaneous tissue |
underlying layer that anchors skin layers to the underlying tissues of the body |
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Wound |
injury that results in a disruption in the normal continuity of a body tissue |
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Factors affecting wound healing |
Age Obesity Diabetes Comptomised circulation Poor nutrition Incontinence Life style Levels of stress Medications |
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Appropriate lab data- Albumin |
3.2-5.0 mg/dl |
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Appropriate lab data- Pre-Albumin |
15-36mg/dl |
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Appropriate lab data- Hct |
Female: 37-47% Male: 42-52% |
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Appropriate lab data- Hgb |
Female: 12-16 mg/dl Male: 14-18 mg/ dl |
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Wound healing: Inflammatory phase |
When: immediately after injury How long: 4-6 days Processes: macrophages ingest debris; release growth factors |
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Wound Healing: Proliferative Phase |
When: between 2-3 days of injuryHow long: several weeksProcesses: new tissue build with fibroblast action |
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Wound Healing: Maturation Phase |
When: begins about 3 weeks after injuryHow long: months to yearsProcesses: collagen organization, remodeled & contracted * scar stronger but never as strong as original tissue |
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Hemorrhage |
Excessive bleeding either internally or externally |
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Infection |
The multiplication of colonizing organisms and invasion of tissues |
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11 Risk Factors for Pressure Injury |
Inadequate nutrition Fecal/Urinary incontinence Decreased mental status Diminished sensation Hard support surfaces Excessive body heat Advanced age Chronic mental conditions Poor lifting/ transferring techniques Incorrect positioning Incorrect application of pressure relieving device |
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Braden scale |
Predicting Pressure Injury Risk Total score of 23 Scores below 18 are at risk |
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Stage 1 |
Nonblanchable erythema (redness of the skin) of intact skin |
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Stage 2 |
Partial- thickness skin loss with exposed dermis -abrasion -blister -shallow crater |
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Stage 3 |
Full-thickness skin loss involves damage or necrosis of subcutaneous tissue May extend down to but not through fascia Deep crater with or without undermining if adjacent tissue |
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Stage 4 |
Full thickness skin loss Adipose is visible;granulation tissue and epibole(rolled edges) often present Tissue necrosis/damage to: -muscle -bone -supporting structures (tendons, joint capsules) |
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Unshakeable Pressure Injury |
Obscure Full-thickness skin & tissue loss Actual depth of the ulcer is completely obscured by slough and/or eschar in the wound bed Cannot confirm extent of tissue damage |
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Deep tissue pressure injury |
Persistent nonblanchable deep red, maroon, or purple Results from intense or prolonged pressure & shear forces at the bone-muscle interface |
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Primary intention healing |
Tissue surfaces approximated (together) Minimal or no tissue loss Formulation of minimal granulation and scarring *incision |
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Secondary intention healing |
Extensive tissue loss Edges cannot be closed Repair time longer Scarring greater Susceptible to infection * MVA, Burn |
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Tertiary intention healing (Delayed primary closure) |
Initially left open Edema, infection or exudate resolves Then closed |
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Wound assessment |
Location Type Size in cm (L,W,D) Approximation Tunneling Undermining Wound appearance (red, yellow, black) Drainage type/ Amount Surrounding tissue (intact, excoriated, macerated, purple, erythema) |
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Prevention of impaired skin integrity |
Providing nutrition Maintaining skin hygiene Avoiding skin trauma Providing supportive devices |
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Providing nutrition |
-Fluid intake (2500ml/day) -Protein -Vitamins (C,A,B1,B5, zinc) -Dietary consult and supplements -Weight monitoring -Lab data monitoring (albumin,Hgb) |
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Maintaining skin hygiene |
-Mild cleansing agents (do not disrupt skin's natural barriers) -Avoid hot water, exposure to cold, low humidity -Moisturizing lotions/ skin protection -Reduce irritants (urine, feces, sweat) -Skin protestants (dimethicone-based creams or alcohol barrier film) -Do not massage over bony prominences |
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Avoiding skin trauma |
-Smooth, form& wrinkle free surfaces -Semi-Fowler's position (no more than 30 degrees) -Frequent weight shifts (every 15-30 mimutes) -Exercise and ambulation -Lifting devices -Reposition every 2h -Turning schedule |
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Providing Supportive Devices |
-Mattresses (overlay of foam and gel combination) -Specialty bed -heels off mattress using wedges, pillows -pressure-reducing devices to distribute wt during sitting |
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Wound Description- Necrotic Tissue |
Requirements: Debridement Examples: Hydrogel, impregnated gauze, hydrocolloid Enzyme preparations for chemical debridement |
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Wound Description- Granulation Tissue |
Requirements: Protection Examples: Hydrocolloid, hydrogel, or foam dressing |
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Wound Description- Dry Wound Base |
Requirements: Hydration Examples: Hydrogel or gauze w/ saline |
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Wound Description- Moderate to Heavy Exudate |
Requirements: Absorption Examples: Hydrocolloid, foam, alginate |
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Wound Description- Significant Depth |
Requirements: Packing Examples: Gauze, alginate, or wound filler |
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Wound Description- Erythema, warmth, edema, or tenderness |
Requirements: Infection Management Examples: Antimicrobial dsgs or solutions |
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Wound Description- Periwound skin maceration |
Requirements: protection Examples: skin sealent or barrier ointment |
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Dressings |
-Dry or Moist- Gauze -film dressing -hydrocolloid- protects surface from contamination -hydrogel- maintains a moist surface to promote healing -wound vacuum assisted closure(V.A.C.)- negative pressure to support healing |
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Purposes of dressings |
-protect wound from microbe contamination -aid in hemostasis -promote healing by absorbing drainage & debriding a wound -support or splint wound site -promote thermal insulation of the wound surface |
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Treating pressure injuries |
-minimize direct pressure -schedule & record position changes -provide devices to reduce pressure areas -clean and dress ulcer using surgical asepsis -never use alcohol or hydrogen peroxide -obtain culture & sensitivity if infected -teach client importance of moving -provide ROM excercises |
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RYB Color Guide for Wound Care |
-Red(protect)- avoid disturbing the regenerated tissue -Yellow(cleanse)- remove nonviable tissue -Black(debride)- remove so wound can heal |
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Red (protect) |
-gentle cleansing -covering periwound skin w/ alcohol free barrier film -filling dead space w/ hydrogel or alginate -covering wound with appropriate dsg (transparent film, hydrocolloid dressing, clear absorbent acrylic dsg, infrequent dsg changes) |
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Yellow (Cleanse) liquid "slough" w/ purulent drainage |
-cleansing to remove nonviable tissue -moist-to-moist NS dsg -irrigate wound -absorbent dsg material (impregnated hydrogel or alginate dsg, topical antimicrobial) |
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Black (Debride) thick necrotic tissue or eschar |
-require debridement (removal of dead tissue) sharp mechanical chemical autolytic fly larvae |
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Debridement Methods- Sharp |
Necrotic tissue removed with scalpel, nippers or scissors |
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Debridement Methods- Autolytic |
Occlusive dressing (transparent film or hydrocolloids) cause "melting: of necrotic tissue by phagocytoses |
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Debridement Methods- Enzymatic |
Urea active ingredient causing disintegration of slough and eschar |
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Debridement Methods- Mechanical |
wet to dry dressing (pulls away tissue) and pulse lavage as high-pressure water system streams, necrotic tissue is dislodged |
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Debridement Methods- Chemical |
topical use of enzymatic gels and solutions that can dissolve necrotic tissue from the wound. Enzymes: proteilytics, fibrolytics, collagenases |
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Promoting wound healing |
-fluid intake (2500ml/day) -protein, vitamins, and zinc -dietary consult -nutritional supplements -monitor weight/ lab values |
