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42 Cards in this Set

  • Front
  • Back
Clean Wound
uninfected, minimal inflammation, no entry of respiratory, genitourinary, alimentary systems. Closed wound
Clean Contaminated Wound
Surgical wound entering the respiratory, genitourinary, alimentary systems. No evidence of infection
Contaminated Wound
Open, fresh, accidental would with major break in sterile technique or large spillage from GI tract, evidence of inflammation
Dirty or Infected Wound
contains necrotic tissue, wounds with evidence of clinical infection including, odor, leakage, heat, fever
Partial Thickness Wound
confined to skin and dermis
Full Thickness Wound
dermis epidermis, muscle and some bone possible.
Factors affecting susceptibility to pressure ulcers
Immobility, malnutrition, incontinence, diminshed sensations, excessive body heat, advanced age, chronic medical conditions, obesity
Pressure ulcer etiology
pressure, shear, force
skin forced in an opposing direction while it stays stationary and bone moves
appearance of abrasion, two surfaces move against one another
6 Types of wound
Incision, contusion, abrasion, puncture (penetration of skin and underlying tissue), laceration (torn and deep), penetrating (deeper than puncture bullet, knife)
Stage I wound
Nonblanchable erythema
Stage II Wound
partial thickness skin loss involving epidermis and possibly dermis
Stage III Wound
Full thickness skin loss with damage or necrosis of subcutaneous tissue that may extend down to but not thru underlying fascia
Stage IV Wound
Full thickness skin loss with tissue necrosis or damage to muscle, bone or supporting structures.
Undermining in Wound
Wound extends under skin
Sinus Tracts
similar to undermining
Prevention of Pressure Ulcers
Skin Care, risk assessment, mechanical loading and support surfaces, education
Primary Intentions Wound Healing
wound with little or no tissue loss, skin edges aproximate, risk of infection is slight.
Secondary Intention Wound Healing
Loss of tissue, edges do not close, risk of infection and loss of tissue function is greater.
Delayed Primary Intention Wound Healing
Leave part of wound open intentionally
Phases of Wound Healing
Inflammation, proliferation, and maturation/remodeling
Inflammation phase of wound healing
Hemostasis- bleeding controlled platelets coagulate,
Phagocytosis- macrophages engulf debris,
Meds- anti inflammatory and steroids assist
Proliferation phase of wound healing
about 21 days. Production of new tissue- fibroblasts enter w/in 24 hours to make collagen.
Protraction- wound contracts and gets smaller ridges will be evident on incisions.
Epithelialization-Eschar- epithelial cells cover wound
Maturation/Remodeling fphase of wound healing
Reorganization of collagen. (watch for Keloid). Strength of scar is increased but only about80% as strong as original tissue.
develop if there is too much scar tissue
Factors affecting wound healing
age, nutrition, lifestyle, health, medications, tissue perfusion, infection, extent of would, wound environment.
Complications of wound healing
Hemorrhage, infection, dehiscence, evisceration, fistula.
Types of Debridement
Sharp, mechanical, chemical, autolytic(natural moisture and enzymes debride wound under transparent dressing)
Therapeutic effects of heat
good for vasodilation, increases capillary permeability, reduces viscosity of blood, reduces muscle tension. Never apply for longer than 1 hour. 15 minutes on and 15 off.
Therapeutic effects of cold
effective in initial treatment of breaks, sprains and bruises within the first 24 hours. Serves as a local anesthetic. reduces blood flow thus reducing edema (do not administer if tissue already edematous)Decreases muscle tension, increases blood viscosity. Reduces cell metabolism thus reducing o2 needs of tissue
Braden Scale for Wounds
Composite of six subscales, sensory perception, moisture, activity, mobility, nutrition, friction and shear. Score ranges from 6-23 lower the score the higher risk of pressure ulcer forming.
Granulation Tissue
red, moist tissue that is healing
Yellow tissue
appearance of slough(yellow stringy tissue) must be removed before wound can heal
necrotic black or brown tissue that must be removed to stage wound and to promote wound healing.
partial or total separation of wound layers
Norton Scale
5 risk factors for pressure ulcers, physical condition, mental condition, activity, mobility, incontinence.
Abnormal Reactive Hyperemia
Hyperemia over a pressure site lasting longer than 1 hour after the removal of pressure. Surrounding skin does not blanch.
Reactive Hyperemia
An area of blanched skin that is relieved of pressure turns red this is reactive hyperemia caused by vasodilation. This return of redness indicates an attempt to overcome ischemia.
Risks for Heat/Cold Therapy
Spinal cord injuries, age due to decreased sensation, open wound, stoma, broken skin, edema/scar formation, PVD, confusion
the tearing away forcibly of a part or structure. The complete separation of a tooth from its alveolus.
the softening of a solid by steeping it in fluid.