Small wound produced by a stab with a sharp pointed object
A crater like wound formed from erosion of the skin/and or mucous membrane and underlying structures
Cut with a sharp object...knife, scalpel.
Propelled object enters skin and leaves a well defined hole
Death of one or more cells or a portion of tissue or organ
painful, pale, crater like lesion.
Found on Big toe, between toes or on upper aspect of a foot.
Is usally cold with a weak or absent pulse
Necrotic, superficial, crater like lesion with minimal pain on ankles or lower legs.
Usually caused by chronic venous congestion.
Produces Copious Exudate
Any lesion caused by unrelieved pressure resulting in damage of underlying tissue.
Ulcers that develope on the plantar surface of the foot, heel or anywhere pressure is exerted or an area where a person can have vascular or neurological complications from Diabetes
scraping or wearing away of skin
What delays wound healing?
Decreased blood supply
Ways you have decreased blood supply...
What does smoking cause?
Nicotine causes vasoconstriction of the vessels, increasing platelet adhesiveness, RBC proliferation is reduced (diminishing oxygen transport). Carbon monoxide diminishes oxygen transport and metabolism...less oxygen to tissues
How do you assess a wound?
How do you measure the size of a wound?
For length and width use the face of a clock.
Length use 12 and 6
Width measure from 3 to 9...is there tunneling?
Depth-insert a sterile cotton tipped swab in to deepest part of wound.
Record all measurements in cm
How do you describe slough of a wound?
Tell what % of the wound has yellow slough
What does approximation mean?
Do the edges of the wound come together? Or is it partially separated?
What is important about edema and swelling of a wound?
Is it present in or around it?
How can you tell if a wound is healing well?
If it is black...necrotic and dead
If it is dark pink to beefy red and moist...it is revascularized and is HEALTHY
What's the significance of yellow slough in a wound?
it is necrotic tissue which is ideal for bacterial growth.
Purulent or green and sticky, smelly= INFECTION
Must remove slough for wound to heel
What do you do when you have red, yellow and black in your wound?
Most severe must be removed first...
Black, yellow...want red
Primary intention and wound healing
When the skin heals with a thin scar tissue formed at the closure site. Wound edges approximate closely.
Achieved by sutures or staples
What happens if the doctor anticipates a large amount of drainage from a wound?
Large amount= Jackson Pratt or Hemovac.
The device is kept compressed and negative pressure will withdraw fluid from the wound.
Why is it important for fluid to be removed from the wound?
To get infectious debris away from the wound
Secondary intention and wound healing
The wound is left open to heal, permitting drainage of infectious material and debris from non sterile body cavity.