Study wound healing Flash Cards

 
Pile Management Card
wound healing

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This type of healing occurs when the wound is left open?
SECOND INTENTION
Healing is when tissue edges are approximated and there is no loss of skin layers?
PRIMARY INTENTION
True/False

There are 2 mechanisms by which wounds heal?
FALSE

3
Indicates plasma and the presence of RBC's?
SEROSANUINOUS DRAINAGE
Serosanuinous drainage?
THIN, WATERY, AND IS PINK OR RED.
Serous drainage?
CLEAR OR SLIGHTLY YELLOW
This gives you an indication of the health of a wound?
EXUDATE
Wound drainage is AKA?
WOUND EXUDATE
name the 4 types of wound debridement techniques?
-SURGICAL
-MECHANICAL
-ENZYMATIC
-AUTOLYSIS
A red wound is a clean healthy wound showing evidence of?
GRANULATION TISSUE
A full thickness wound involves what layer of the skin?
SUBCUTANEOUS
What layers of the skin does partial thickness wounds involve?
-EPIDERMIS
-DERMIS
A clean wound is one that is?
-CLOSED
-NO LEVEL OF INFLAMMATION/INFECTION
Considered full thickness. There is damage to the subcutaneous tissues but there is no break in the fascia. There is often drainage and the presence of eschar?
STAGE 3
Breaks in the skin that involve only the epidermal and/or dermal layers of skin. These wounds are considered superficial wounds?
-SALINE
-OCCLUSSIVE DRESSING THAT PROMOTES NATURAL HEALING, BUT PREVENTS FORMATION OF SCAR
How are stage 1 pressure ulcers treated?
-FREQUENT TURNING
-PRESSURE RELIEVING DEVICES
-POSITIONING
Skin remains intact but shows evidence of nonblanching erythema. This is redness that does not disappear once the source of the skin irritant is removed?
STAGE 1
When to wounds heal best?
WHEN THEY ARE KEPT MOIST
True/False

Healthy wound normally have some evidence of moisture on it's surface?
TRUE
Why is exudate an important part of wound assessment?
-DIAGNOSIS WOUND INFECTION
-EVAL EFFECTIVENESS OF TOPICAL THERAPY
-MONITOR WOUND HEALING
If left uncontrolled this can result in sepsis?
CELLULITIS
Characteristics of cellulitis?
BEGINS AS A SMALL RED OR DISCOLORED AREA THAT IS INDURATE (HARDENED), EDEMATOUS, AND WARM TO TOUCH AND PROGRESSES TO INVOLVE OTHER TISSUES.
Characteristics of osteomyelitis?
INFECTED EDEMA
Characteristics of staphlococcus?
-ERYTHEMA
-PUS
-FOUL ODOR
-EDEMA
-PAIN
Characteristics of pseudomonas?
-FEVER
-BLUE/GREEN DISCHARGE
-FRUITY SMELL
-BONE INFECTION
What is the normal blood cell count?
5,000-10,000
Characteristics of infected wounds?
-ERYTHEMA
-PUS
-EDEMA
-PAIN
-EXPOSED BONE
-TENDERNESS IN LYMPH NODES
-CHILLS/FEVER
-INDURATION (HARD/FIRM)
-ABNORMAL WBC COUNT
Venous insufficiency wound bed characteristics?
-HIGH EXUDATE
-IRREGULAR IN SHAPE
-TYPICALLY PARTIAL THICKNESS
-LOCATION: AROUND THE ANKLE
Venous insufficiency peri wound tissue characteristics?
-HEMOSIDEROSIS (BRONZE COLOR)
-LIPODERMATOSCLEROSIS (SCARRING OF THE SKIN AND FAT)
-STASIS DERMATITIS (A RED, ITCHY RASH)
-EDEMA
-PULSES ARE PRESENT BUT MAY BE DIMINISHED DUE TO PRESSURE
Characteristics of wound bed?
-ROUND
-BONY PROMINENCES
-MINIMAL TO NO PAIN
Peri wound tissue description?
-DRY
-FLAKING OF THE SKIN
-CALLUS FORMATION SURROUNDING WOUND
-DECREASE OF PROTECTIVE SENSATION WITH A 5.07 MONOFILAMENT
How are pressure ulcers treated and prevented?
POSITIONING AND FREQUENT MODIFICATION OF POSITION
Stage 4 pressure ulcer?
FULL THICKNESS SKIN LOSS WITH EXTENSIVE DESTRUCTION, TISSUE NECROSIS OR DAMAGE TO MUSCLE, BONE OR SUPPORTING STRUCTRUES
Stage 3 pressure ulcer?
-FULL THICKNESS SKIN LOSS INVOLVING DAMAGE OR NECROSIS OF SUBCUTANEOUS TISSUE, WHICH MAY ENTEND DOWN TO BUT NOT THROUGH UNDERLYING FASCIA.
-DEEP CRATER WITH OR WITHOUT UNDERMINING OF ADJACENT TISSUES
What stages involve full thickness pressure ulcers?
STAGES 3 AND 4
What are the primary forces of pressure ulcers?
PRESSURE AND SHEAR
Are the result of mechanical injury to the skin and underlying tissues?
PRESSURE ULCERS
Areas of local tissue trauma, usually developing where soft tissues are compressed between body prominences and any external surface for prolonged time periods
PRESSURE ULCERS
A pressure ulcer is a sign of what?
LOCAL TISSUE NECROSIS AND DEATH
What is the treatment for vascular ulcers?
COMPRESSION THERAPY
In addition to gauze, what other absorbant pads can be used for debridement?
-MELONIN
-TELFA
What are the negative effects of gauze?
-PERMEABLE TO BACTERIA
-TENDS TO PROMOTE BACTERIAL GROWTH
Wounds managed in a moist env't covered by an occlussive dressing?
DO NOT FORM A SCAB WHICH ALLOWS EPIDERMAL CELLS TO MOVE RAPIDLY OVER THE SURFACE OF THE DERMIS.
Why do scabs delay healing?
THEY HINDER THE MOVEMENT OF EPIDERMAL CELLS
Ulilizes moisture retention dressings to soften or disolve the nonviable tissues?
AUTOLYTIC
Use of topical prepared enzyme to digest/dissolve nonviable tissue?
ENZYMATIC
Technique which causes little or no damage to the viable tissues?
SELECTIVE DEBRIDEMENT
What are the indications for using non selective debridement?
-WOUND BED HAS >75% TISSUE NECROSIS
-STAGE III AND IV PRESSURE ULCERS
-FULL THICKNESS WOUNDS
-SOFTENING HARD ESCHAR
What are the goals of debridement?
-ASSISTS HEALING PROCESS THROUGH SECONDARY INTENTION HEALING

-DECREASES THE BACTERIAL BURDEN

-PREVENT LIMB LOSS
Debridement?
ACT OF REMOVING NACROTIC TISSUE OR FOREIGN MATERIAL FROM A WOUND BY EITHER MANUAL OR CHEMICAL TECHNIQUES
True/False

Venous insufficiency wounds take the longest to heal?
FALSE

ARTERIAL INSUFFICIENCY
Restriction in blood supply, generally due to factors in the blood vessels, ith resultant damage or dysfunction of tissue?
ISCHEMIA
What is the common cause of arterial insufficiency?
ATHEROSCLEROSIS
Where does venous insufficiency tend to occur?
IN THE SO CALLED (GAITER)
DISTAL ANKLE AROUND MEDIAL MALLEOLUS
What are the main causes of venous insufficiency?
-PRIOR DEEP VEIN THROMBOSIS
-VARICOSE VEINS
-CHRONIC CHF
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