Wounds And Dressing

Front 1

What is a wound?

Back 1

any break in the external or internal surfaces of the body involving a separation of tissue and caused by external injury or force

Front 2

How are wounds classified if they are produced by a sharp instrument or object?

Back 2

incised, or cut

Front 3

What is a puncture?

Back 3

if it is caused by a pointed or narrow instrument
open wound which penetrates the skin and underlying tissue

Front 4

What is a laceration?

Back 4

if there is tearing of the tissue
made by object that tears tissue resulting in irregular wound edges

Front 5

What is a contusion?

Back 5

if there is a substantial amount of tissue bruised
closed wound
involves a blow from a blunt object resulting in swelling, discoloration, ecchymosis

Front 6

What is penetrating?

Back 6

open wound that penetrates the skin and the underlying tissue

Front 7

What is subcutaneous?

Back 7

if it involves the deep destruction of tissue w/ a relatively small opening, or none at all, in the surface

Front 8

What are septic wounds?

Back 8

infected wounds which are contaminated by bacteria which can cause suppuration or shedding of tissue

Front 9

What is an incision?

Back 9

open wound, painful
deep, shallow

Front 10

What is an abrasion?

Back 10

open wound involving the skin
painful
involves scrapping or rubbing the surface of the skin by friction

Front 11

What is partial thickness?

Back 11

confined to epidermal and dermal layers

Front 12

What is full thickness?

Back 12

involving the dermis and epidermis, subcutaneous tissue and possibly the muscle and bone

Front 13

What is a clean wound?

Back 13

an aseptically made wound, that does not enter the alimentary (guts), respiratory or genito-urinary tracts

Front 14

What is a clean contaminated wound?

Back 14

surgical wounds in which the alimentary, respiratory, and genitals or urinary tract has been entered; no infection

Front 15

What is a contaminated wound?

Back 15

wounds exposed to excessive amounts of bacteria; inflamed

Front 16

What is dirty or infected wounds?

Back 16

containing dead tissue and w/ evidence of clinical infection
purulent discharge

Front 17

What is a serous wound drainage?

Back 17

clean, watery; consists chiefly of serum derived from blood and serous membranes

Front 18

What is a purulent wound drainage?

Back 18

thick, yellow, green, tan, or brown; consists of serum and pus

Front 19

What is a sanguienous wound drainage?

Back 19

bright red, indicative of active bleeding; consists of serum and RBCs

Front 20

What is a serosanguineous wound drainage?

Back 20

pale, red, watery mixture of serous and sanguineous

Front 21

What are the two major processes included in the defensive or inflammatory phase?

Back 21

hemostatis
phagocytosis (inflammation)

Front 22

What is hemostatis?

Back 22

blood vessels constrict, platelets aggregate, bleeding stops, scabs are formed, preventing entry of infectious organisms

Front 23

What is the inflammatory process?

Back 23

inflammation increases blood flow, to wound resulting localized redness and edema, attracts WBCs and wound growth factors
results in calor (warmth) and rubor (hyperemia) redness
WBCs arrive to clear debris from the wound

Front 24

What happens during the proliferative phase of wound healing?

Back 24

collagen synthesis
establishment of new capillaries
creation of granulation tissue
wound contraction
epitheliazation

Front 25

What happens during the remodeling or maturation phase?

Back 25

final healing stage may continue for 1 year or more
remodeling of scar tissue to provide wound strength

Front 26

What is the first\primary intention healing? eg. of something that would have this type of healing

Back 26

partial thickness wounds
a clean incision is made w/ primary closure and minimal scarring and tissue loss
expected when the edges of clean surgical incisions are sutured together
rapid healing w/ minimal infection risk
tissue loss is minimal or absent if the wound is not contaminated w/ microorganisms
abrasion or skin tear

Front 27

What is the second intention healing? eg. of something that would have this type of healing

Back 27

granulation
accompanies traumatic open wounds w/ tissue loss or wounds w/ high microorganism counts
goes through a process that involves scar tissue formation
delayed healing and extensive infection risk
contaminated surgical wound, pressure ulcer

Front 28

What kind of medications can delay wound healing?

Back 28

steroids

Front 29

What is the greatest risk the 1st 48 hours after surgery?

Back 29

hemorrahge- persistent arterial and/or venous bleeding

Front 30

What would you do with a pt with emergent bleeding?

Back 30

apply pressure dressing to wound and monitor vitals

Front 31

What are the s/s of bleeding?

Back 31

decreased BP
increased HR
rapid, thready pulse
restlessness
diaphoresis
clammy, pale, cold skin
oliguria- decreased urine output

Front 32

What are the s/s of infection?

Back 32

increased temp
tenderness/pain around wound site
increased WBCs
inflamed wound edges
purulent drainage

Front 33

What is dehiscence?

Back 33

abdominal wound in which the layers below the skin separates

Front 34

What is evisceration?

Back 34

protrusion of the abdominal viscera

Front 35

What would you do if a pt had dehiscence w/ possible evisceration?

Back 35

support the site w/ a sterile dressing soaked in sterile normal saline
position the pt on back w/ knees bent to decrease the pull on the incision
notify MD

Front 36

What are the s/s of dehiscence?

Back 36

partially or totally disrupted wound edges
appreciable increase in wound drainage
sensation that something gave

Front 37

What are the s/s of evisceration?

Back 37

totally disrupted wound edges
apprecialbe increase in wound drainage
sensation that something let go
protrusion of viscera and/or organs through a ruptured wound

Front 38

What is fistula?

Back 38

abnormal passage between 2 organs or between an organ and the outside of the body

Front 39

What are the s/s of fistula?

Back 39

chronic drainage
skin breakdown

Front 40

What would you assess on a wound?

Back 40

etiology
location
stage
extent of tissue loss
phase of healing
wound size
presence of undermining, sinus tracts or tunnels
condition of the wound bed
volume of exudates
condition of periwound skin
presence of pain

Front 41

What are decubitus ulcers?

Back 41

any skin lesion caused by unrelieved pressure that results in damage to the underlying tissue

Front 42

What are the purposes of dressings?

Back 42

to protect the wound from mechanical injury
splint or immobilize a wound
absorb secretions
prevent contamination from blood drainage
promote homeostasis
to debride wounds
to kill/inhibit microorganisms
to provide a physiologic environment that is inducive to healing
provide mental and physical comfort

Front 43

What are dry-to-dry dressings?

Back 43

used for wounds closing by primary intention

Front 44

What are the advantages of dry-to-dry dressings?

Back 44

offers good protection, absorption and provides pressure

Front 45

What are the disadvantages of dry-to-dry dressings?

Back 45

adhere to wound surface when drainage dries; can cause pain and disruption of granulation tissue

Front 46

What is a wet-to-dry dressing?

Back 46

used for untidy or infected wounds that must e debrided and closed by secondary intention
saturate gauze with sterile NS or an antimicrobial solution for packing into the wound
cover wet dressings w/ dry
change when the dressing dries out

Front 47

What is wet-to-wet dressing?

Back 47

used on clean, open wounds or on granulating surfaces
provides a more physiologic environment which can enhance the local healing processes and assure greater pt comfort
surrounding tissue can become ulcerated
increase risk of infection

Front 48

What are the purposes of drains?

Back 48

placed in wound only when abdominal fluid collection is present
placed near the incision site
drains placed within the wound is attached to a portable suction with a collection container

Front 49

What are binders and bandages for?

Back 49

create pressure over body parts
immobilize body parts
reduce or prevent edema
secure a splint
secure a dressing

Front 50

What is hot therapy used for?

Back 50

used to dilate peripheral blood vessels to increase tissue metabolism, reduce blood viscosity and increased capillary permeability, reduces muscle tension and helps relieve pain

Front 51

What does cold therapy do to a wound?

Back 51

constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort, reduces blood flow to tissues
decreases the local release of pain producing substances such as bradykinin, histamine, and serotonin