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2013-01-23 20:09:59

wound care
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  1. exudate
    amount, color, consistency, and odor of wound drainage and is part of wound assessment.
  2. wound
    disruption of the integrity and function of tissues in the body
  3. primary intention
    • wound that is closed
    • surgical incision, wound that is sutured or stapled
    • healing occurs by epithelialization, heals quickly with minimal scar formation
  4. approximated
  5. secondary intention
    • wound edges not approximated
    • pressure ulcers, surgical wounds that have tissue loss
    • wound that heals by granulation tissue formation, wound contraction, and epithelialization
  6. tertiary intention
    • wound left open for several days, then wound edges are approximated
    • wounds that are contaminated and require observation for signs of inflammation
    • closure of wound is delayed until risk of infection is resolved
  7. partial-thickness wound repair
    • -inflammatory response
    • -epithelial proliferation (reproduction)
    • -migration and reestablishment of epidermal layers
  8. hemostasis
    injured blood vessels constrict, and platelets gather to stop bleeding
  9. fibrin
    • what clots form.
    • later provides a framework for cellular repair.
  10. inflammatory phase
    • damage cells and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and exudation of serum and white blood cells into damaged tissues.
    • results in redness, edema, redness and throbbing.
    • WBC's reach area within a few hours.
  11. primary WBC
  12. 2nd most important WBC
    monocyte which transforms into macrophages
  13. what do macrophages secrete
    growth factor
  14. what does growth factor attract
  15. fibroblasts
    synthesize collagen (connective tissue)
  16. proliferative phase
    the filling of the wound with granulation tissue, contraction of the wound, providing matrix for granulation.
  17. remodeling
    • maturation, the final stage
    • scare tissue forms
  18. hemorrhage
    bleeding from a wound site
  19. hematoma
    localized collection of blood underneath the tissues
  20. serous
    clear, watery plasma
  21. purulent
    • thick, yellow, green, tan, or brown
    • infection
  22. serosanguineous
    pale, pink watery, mixture of clear and red fluid
  23. sanguinous
    bright red, indicates active bleeding.
  24. dehiscence
    partial or total separation of wound layers
  25. evisceration
    protrusion of visceral organs through a wound opening.
  26. braden scale
    sensory perception, moisture, activity, mobility, nutrition, friction and shear
  27. vitamins needed for healing
    calories, protein, vit. c, vit. a, vit. e, zinc, fluid
  28. abrasion
    superficial with little bleeding and is considered a partial thickness wound
  29. laceration
    bleeds more profusely
  30. puncture
    bleed according to depth and size
  31. normal reactive hyperemia
  32. debridement
    removeal or nonviable, necrotic tissue
  33. types of dressing
    wet or dry
  34. vacuum assisted closure
    devise that assists in wound closure by applying localized negative pressure to draw the edges of a wound together
  35. sutures
    threads or metal used to sew body tissues together
  36. drainage evacuators
    convenient portable units that connect to tubular drains lying within a wound bed and exert a safe, constant, low pressure vacuum  to remove and collect drainage