Card Set Information
Chapter 48 Wounds
This type of drainage is bright red and indicates active bleeding.
This type of drainage appears thick yellow, green, or brown.
This drainage appears clear and watery like plasma.
Abnormal passage between two organs or between an organ and the outside of the body.
This type of drainage is a mixture between red and clear fluids.
This complication occures when visceral organs protrude through a wound opening. Requires immediate emergency surgey.
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
5 Complication of wound healing
Three Phases of Full Thickness Wound Healing
Three Phass of Partial Thickenss Wound Repair
Epitheliat Proliferation and Migration
Reestablishment of Epidermal Layers
Description of Full Thickness Wounds
Extends into dermis
Heals by scar formation because deeper tissues do not regenerate
Description of Partial Thickness Wounds
Loss of Epidermis
Heals by regenration
example- surgical wounds
Primary Intenetion Wounds
Wound is closed
Healing occurs by epithelialization
examples- surgery, sutured skin
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.
Wound fails to proceed through timely process and produces anatomical and functional integrity issues.
Factors of Skin Surrounding the Wound Indicative of Wound Deterioration
Black or brown necrotic tissue that needs to be removed for wounds to heal.
Stringy, soft yellow or white tissue attached to wound bed.
Red and moist tissue composed of new blood vessels.
Presence indicate progression towards healing.
Full Thickness tissue loss
Base of ulcer covered by slough and/or eschar
Cannot be staged until slough/eschar is removed
Exposed bone, tendon or muscle
Often tunneling included
Subcut fat visible
Slough may be present but does not obscure the depth
May include tunneling
Looks like a blister, abrasion, or shallow crater
Usually over bony prominence
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
Assessment of Pressure Ulcer
Depth of tissue involvement
Type and % of tissue in wound bed
Condition of Surrounding skin
What is Shear?
Skin and subcut tissue adhere to surface, while muscle and bone slide with direction of body movement.
Risk Factors for P. Ulcer Development
Impaired sensory perception
Level of consciousness
Factors that impair tissue intolerance
Low Blood Pressure
Ability of underlying skin structures to assist in redistributing pressure
Characteristics of Dark Skin at Risk for Skin Breakdown
Darker than surrounding skin
Warmer at first then cooler as tissue devitalizes
Appears taut, shiny, scaly
Three Pressure Related Factors Contrivuting to P. Ulcers
Proceeds through orderly and timely process that results in sustained restoration.
Example-trauma, surgical incision
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
What is the Basal Layer
Where cells of epidermis originate
Cells divide, proliferate, and migrate toward surface
Thin, outermost layer of epidermis