Wound Care

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Author:
Anonymous
ID:
70895
Filename:
Wound Care
Updated:
2011-03-05 16:22:56
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Wound Care
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Description:
Chapter 48 Wounds
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  1. This type of drainage is bright red and indicates active bleeding.
    Sanguineous
  2. This type of drainage appears thick yellow, green, or brown.
    Purulent
  3. This drainage appears clear and watery like plasma.
    Serous
  4. Abnormal passage between two organs or between an organ and the outside of the body.
    Fistula
  5. This type of drainage is a mixture between red and clear fluids.
    Serousanguineous
  6. This complication occures when visceral organs protrude through a wound opening. Requires immediate emergency surgey.
    Evisceration
  7. This happens when a wound fails to heal properly and the skin and tissue seperate.
    -Holding a pillow when coughing helps support the abdomen and healing tissue
    Dehiscence
  8. 5 Complication of wound healing
    • Hemorrage
    • Infection
    • Dihescence
    • Evisceration
    • Fistulas
  9. Three Phases of Full Thickness Wound Healing
    • Inflammatory Phase
    • Proliferative Phase
    • Remodeling
  10. Three Phass of Partial Thickenss Wound Repair
    • Inflammatory Phase
    • Epitheliat Proliferation and Migration
    • Reestablishment of Epidermal Layers
  11. Description of Full Thickness Wounds
    Extends into dermis

    Heals by scar formation because deeper tissues do not regenerate

    example-pressure ulcer
  12. Description of Partial Thickness Wounds
    • Shallow
    • Loss of Epidermis
    • Heals by regenration

    example- surgical wounds
  13. Primary Intenetion Wounds
    Wound is closed

    Healing occurs by epithelialization

    examples- surgery, sutured skin
  14. Tertiary Intention Wounds
    Wounds left open for several days, then wound edges approximated.

    Wounds that are contaminated require observation.

    Closure of wound in delayed because of risk of infection.
  15. Chronic Wound
    Wound fails to proceed through timely process and produces anatomical and functional integrity issues.
  16. Factors of Skin Surrounding the Wound Indicative of Wound Deterioration
    • Redness
    • Warmth
    • Maceration
    • Edema
  17. Eschar
    Black or brown necrotic tissue that needs to be removed for wounds to heal.
  18. Slough
    Stringy, soft yellow or white tissue attached to wound bed.
  19. Granulation Tissue
    Red and moist tissue composed of new blood vessels.

    Presence indicate progression towards healing.
  20. Unstageable ulcer
    Full Thickness tissue loss

    Base of ulcer covered by slough and/or eschar

    Cannot be staged until slough/eschar is removed
  21. Stage IV
    Full Thickness

    Exposed bone, tendon or muscle

    Often tunneling included
  22. Stage III
    Full Thickness

    Subcut fat visible

    Slough may be present but does not obscure the depth

    May include tunneling
  23. Stage II
    Partial Thickness

    Superficial

    Looks like a blister, abrasion, or shallow crater
  24. Stage I
    Intact skin

    Nonblanchable redness

    Localized

    Usually over bony prominence
  25. Facts About Staging System
    Cannot stage when ulcer is covered with necrotic tissue

    Do not progress from Stage IV to Stage III.. Simply classified as Healing Stage IV
  26. Assessment of Pressure Ulcer
    Depth of tissue involvement

    Type and % of tissue in wound bed

    Wound dimensions

    Exudated description

    Condition of Surrounding skin
  27. What is Shear?
    Skin and subcut tissue adhere to surface, while muscle and bone slide with direction of body movement.
  28. Risk Factors for P. Ulcer Development
    Impaired sensory perception

    Impaired mobility

    Level of consciousness

    Shear

    Friction

    Moisture
  29. Factors that impair tissue intolerance
    Poor Nutrition

    Age

    Low Blood Pressure
  30. Tissue Tolerance
    Ability of underlying skin structures to assist in redistributing pressure
  31. Characteristics of Dark Skin at Risk for Skin Breakdown
    Darker than surrounding skin

    Purplish/bluish hue

    Warmer at first then cooler as tissue devitalizes

    Appears taut, shiny, scaly
  32. Three Pressure Related Factors Contrivuting to P. Ulcers
    Pressure intesity

    Pressure Tolerance

    Tissue Tolerance
  33. Acute Wound
    • Proceeds through orderly and timely process that results in sustained restoration.
    • Example-trauma, surgical incision
  34. What is the Dermis
    Inner layer of skin

    Provides tensile strengthm mech support, and structure

    Contains collagen, blood vessels, and nerves

    Fibroblasts, which produce collagen, present
  35. What is the Basal Layer
    Where cells of epidermis originate

    Cells divide, proliferate, and migrate toward surface
  36. Statum Corneum
    Thin, outermost layer of epidermis

    Keritinized cells

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