Wound Care

Front 1

Absence of pathogens or pathogenic organisms.

Back 1

asepsis

Front 2

Clean technique that includes procedures used to reduce number of organisms present and prevent transfer of organisms; taught to at home patients.

Back 2

medical asepsis

Front 3

"sterile technique", prevents contamination of open wounds, serves to isolate operative area from unsterile environment and maintain sterile field for surgery. ex: inserting IV

Back 3

surgical asepsis

Front 4

Type of wound with surgical, clean, regular incision.

Back 4

intentional

Front 5

Type of wound that occurs through trauma and does NOT have regular edges. ex: pressure ulcer

Back 5

unintentional

Front 6

By cleanliness, type of wound that's clean.

Back 6

surgical

Front 7

By cleanliness, wound inside body, ex: ruptured appendix

Back 7

clean-contaminated

Front 8

By cleanliness, wound with cuts, stone, ex: from motorcycle accident.

Back 8

contaminated

Front 9

By cleanliness, wound like abscess that's not taken care of.

Back 9

dirty or infected

Front 10

By depth, wound that's just first level of skin extending into but not through dermis.

Back 10

partial thickness

Front 11

By depth, destruction through dermis to involve subcutaneous tissue under and possibly muscle or bone.

Back 11

full thickness

Front 12

Wound with clean cut, usually done on purpose.

Back 12

incision

Front 13

Wound also called crush, bruises and damages skin and underlying tissue; compression wound.

Back 13

contusion

Front 14

Wound that's a scrape, usually broad, shallow wound with irregular edges.

Back 14

abrasion

Front 15

Narrow and deep wound, typically small opening with sharp edges, increased risk of infection and risk of internal bleeding.

Back 15

puncture

Front 16

Narrow deep wound, "cuts"

Back 16

laceration

Front 17

Wound type caused by sharp, usually slender object which passes through skin into underlying tissue.

Back 17

penetrating wound

Front 18

Local anemia due to mechanical obstruction of blood supply.

Back 18

ischemia

Front 19

Redness

Back 19

hyperemia

Front 20

Hyperemia following arrest and subsequent restoration of blood supply to that area.

Back 20

reactive hyperemia

Front 21

Blood vessel expansion.

Back 21

vasodilation

Front 22

This type of hyperemia doesn't blanch when apply pressure ; deep tissue damage propable.

Back 22

non-blanching hyperemia

Front 23

Force of 2 surfaces moving across one another, ex: skin being dragged across sheets, affects epidermis

Back 23

friction

Front 24

Force exerted parallel to skin resulting from both gravity pushing down on body and resistance between client and surface; tissue damage occurs in deep tissue - skin and subcutaneous layers adhere to surface or bed and layers of muscle and bones slide in direction of dermis.

Back 24

shearing force

Front 25

Area may be painful and warm, intact skin with non-blanchable redness of localized area, usually over bony prominence.

Back 25

stage I pressure ulcer

Front 26

Partial thickness skin loss involving epidermis, dermis, or both; superficial, presents as abrasion, blister or shallow crater, red/pink wound bed, no slough

Back 26

stage II pressure ulcer

Front 27

Full thickness tissue loss, subcutaneous fat may be visible but tendon, bone, muscle not exposed. May include undermining and tunneling.

Back 27

state III pressure ulcer

Front 28

Full thickness tissue loss with exposed bone, tendon, muscle; slough or eschar may be present in some parts, often includes undermining and tunneling.

Back 28

stage IV pressure ulcer

Front 29

Type of wound healing where incision shut, usually surgical, healing occurs by epithelialization, quickly with minimal scar formation.

Back 29

primary intention

Front 30

Type of wound healing where incision left open and heals from inside out; loss of tissue so left open till filled by scar; wound edges NOT approximated.

Back 30

secondary intention

Front 31

Type of wound healing where wound open several days b/c of contamination/infection; close when risk of infection decreased.

Back 31

delayed primary closure (third intention)

Front 32

Skin edges closed, risk of infection low.

Back 32

approximated

Front 33

Combination of newly forming cells, blood vessels, and loose extracellular matrix.

Back 33

granulation tissue

Front 34

Phase of healing where bleeding controlled and clean bed established.

Back 34

inflammatory (reactive) phase

Front 35

Phase of healing where see appearance of new granulation tissue, new blood supply within 3-24 days, resurfacing of wound by epithelialization.

Back 35

proliferative phase

Front 36

Phase of healing where remodeling occurs, everything healing back to normal, can take up to a year and sometimes leave scar.

Back 36

maturation phase

Front 37

Partial or total separation of wound layers.

Back 37

dehiscence

Front 38

Total separation of wound layers and protrusion of visceral organs through wound opening.

Back 38

evisceration

Front 39

Abnormal passage between 2 organs or between an organ and outside of body.

Back 39

fistulas

Front 40

Yellow, green, brown drainage from wound.

Back 40

purulent

Front 41

Arrest of bleeding.

Back 41

hemostasis

Front 42

Risk assessment for pressure ulcer most commonly used; 23 possible points with risk factors of sensory perception, moisture, activity, mobility, nutrition, friction/shear.

Back 42

braden scale

Front 43

Risk assessment for pressure ulcer with 20 points possible, 5 risk factors of physical condition, mental condition, activity, mobility, incontinence.

Back 43

norton's scale

Front 44

Type of solution most commonly used for wound irrigation and cleansing.

Back 44

saline solution

Front 45

Type of dressing that traps wounds moisture over wound providing moist environment; ideal for small, superficial wounds such as partial thickness wounds or to protect high risk skin.

Back 45

transparent

Front 46

Gauze dressing that lays over clean wound with little or no drainage; has shiny non-adherent surface that won't stick to incisions but allows drainage to pass through.

Back 46

nonadherent

Front 47

Wound contact layer of this type of dressing forms gel as fluid absorbed and maintains moist healing environment; most useful on shallow to moderately deep normal ulcers - cannot absorb heavily draining wounds.

Back 47

hydrocolloids

Front 48

Gauze or sheet dressing impregnated with water or glycerin based amorphous gel; partial thickness to full thickness wounds, very soothing for painful wounds, doesn't adhere to bed.

Back 48

hydrogels

Front 49

Used for absorbing drainage around drainage tubes; for wounds with large amounts of exudate and wounds that need packing.

Back 49

polyurethane foam

Front 50

Used for infected wounds, highly absorbent dressing; alginate forms soft gel when comes in contact with wound fluid, for wounds with large amounts of exudate and wounds that need packing.

Back 50

exudate absorbers (alginates)

Front 51

Brown or black necrotic tissue.

Back 51

eschar

Front 52

Soft yellow or white tissue, stringy substance attached to wound bed.

Back 52

slough

Front 53

Wet to dry gauze dressing to debride wound, overvitalized and viable tissue both removed, not used routinely.

Back 53

mechanical debridement

Front 54

Synthetic dressing used over wound that allows eschar to be self-digested by action of enzymes present in wound fluids.

Back 54

autolytic debridement

Front 55

Topical enzyme prep that either digests or dissolves necrotic tissue.

Back 55

enzymatic debridement

Front 56

Removal of devitalized tissue by using scalpel, scissors, or other sharp instrument; used when signs of cellulitis or sepsis.

Back 56

surgical debridement

Front 57

Circulation to area to help heal.

Back 57

electrical stimulation

Front 58

Assists in wound closure by applying localized, negative pressure to draw edges of wound together.

Back 58

vacuum assisted closure

Front 59

Closed drainage system that works by suction, pulls drainage from body into collection area, exert low constant pressure as long as suction device fully compresed.

Back 59

hemovac and jackson-pratt wound drains

Front 60

Open drainage system placed on incision line, drainage collects on dressing letting gravity work to pull drainage out.

Back 60

penrose wound drain

Front 61

Most common location for pressure ulcers, accounts for 1/3 in acute and long term facilities.

Back 61

heel ulcers