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42 Cards in this Set
- Front
- Back
Clean Wound
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uninfected, minimal inflammation, no entry of respiratory, genitourinary, alimentary systems. Closed wound
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Clean Contaminated Wound
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Surgical wound entering the respiratory, genitourinary, alimentary systems. No evidence of infection
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Contaminated Wound
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Open, fresh, accidental would with major break in sterile technique or large spillage from GI tract, evidence of inflammation
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Dirty or Infected Wound
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contains necrotic tissue, wounds with evidence of clinical infection including, odor, leakage, heat, fever
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Partial Thickness Wound
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confined to skin and dermis
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Full Thickness Wound
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dermis epidermis, muscle and some bone possible.
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Factors affecting susceptibility to pressure ulcers
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Immobility, malnutrition, incontinence, diminshed sensations, excessive body heat, advanced age, chronic medical conditions, obesity
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Pressure ulcer etiology
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pressure, shear, force
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Shear
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skin forced in an opposing direction while it stays stationary and bone moves
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Friction
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appearance of abrasion, two surfaces move against one another
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6 Types of wound
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Incision, contusion, abrasion, puncture (penetration of skin and underlying tissue), laceration (torn and deep), penetrating (deeper than puncture bullet, knife)
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Stage I wound
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Nonblanchable erythema
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Stage II Wound
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partial thickness skin loss involving epidermis and possibly dermis
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Stage III Wound
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Full thickness skin loss with damage or necrosis of subcutaneous tissue that may extend down to but not thru underlying fascia
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Stage IV Wound
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Full thickness skin loss with tissue necrosis or damage to muscle, bone or supporting structures.
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Undermining in Wound
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Wound extends under skin
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Sinus Tracts
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similar to undermining
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Prevention of Pressure Ulcers
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Skin Care, risk assessment, mechanical loading and support surfaces, education
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Primary Intentions Wound Healing
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wound with little or no tissue loss, skin edges aproximate, risk of infection is slight.
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Secondary Intention Wound Healing
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Loss of tissue, edges do not close, risk of infection and loss of tissue function is greater.
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Delayed Primary Intention Wound Healing
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Leave part of wound open intentionally
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Phases of Wound Healing
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Inflammation, proliferation, and maturation/remodeling
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Inflammation phase of wound healing
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Hemostasis- bleeding controlled platelets coagulate,
Phagocytosis- macrophages engulf debris, Meds- anti inflammatory and steroids assist |
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Proliferation phase of wound healing
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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 |
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Maturation/Remodeling fphase of wound healing
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Reorganization of collagen. (watch for Keloid). Strength of scar is increased but only about80% as strong as original tissue.
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Adhesions
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develop if there is too much scar tissue
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Factors affecting wound healing
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age, nutrition, lifestyle, health, medications, tissue perfusion, infection, extent of would, wound environment.
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Complications of wound healing
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Hemorrhage, infection, dehiscence, evisceration, fistula.
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Types of Debridement
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Sharp, mechanical, chemical, autolytic(natural moisture and enzymes debride wound under transparent dressing)
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Therapeutic effects of heat
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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.
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Therapeutic effects of cold
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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
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Braden Scale for Wounds
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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.
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Granulation Tissue
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red, moist tissue that is healing
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Yellow tissue
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appearance of slough(yellow stringy tissue) must be removed before wound can heal
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Eschar
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necrotic black or brown tissue that must be removed to stage wound and to promote wound healing.
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dehiscence
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partial or total separation of wound layers
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Norton Scale
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5 risk factors for pressure ulcers, physical condition, mental condition, activity, mobility, incontinence.
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Abnormal Reactive Hyperemia
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Hyperemia over a pressure site lasting longer than 1 hour after the removal of pressure. Surrounding skin does not blanch.
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Reactive Hyperemia
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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.
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Risks for Heat/Cold Therapy
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Spinal cord injuries, age due to decreased sensation, open wound, stoma, broken skin, edema/scar formation, PVD, confusion
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Avulsion
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the tearing away forcibly of a part or structure. The complete separation of a tooth from its alveolus.
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Maceration
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the softening of a solid by steeping it in fluid.
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