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43 Cards in this Set
- Front
- Back
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Intentional Wounds
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trauma occurs during therapy - operations
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Unintentional Wounds
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accidental wounds
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Clean Wound
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uninfected wounds in which imflammation is encoutered and the resp, alimentary, genital, and urinary tracts are not entered . Usually closed wounds.
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Clean - Contaminated Wounds
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surgical wounds in which resp, alimentary, genital, and urinary tracts are entered. No signs of infection
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Contaminated wounds
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open, fresh accidental wounds involving major break in sterile technique or GI spillage. Evidence of inflammation.
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Dirty or Infected wounds
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wounds containing dead tissue and wounds with evidence of clinical infection, such as purulent drainage
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Pressure Ulcers
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lesion caused by unrelieved pressure that results in damage to underlying tissue
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Ischemia
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defiency in blood supply to the tissue
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Reactive Hyperemia
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Red flush that happens when pressure is taken off of skin
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Shearing Force
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combination of friction and pressure - Fowlers position
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Maceration
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Tissue softened by prolonged wetting or soaking
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Excoriation
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area of loss of superficial layer of skin due in part to feces, GI tube draining, and urine. AKA denuded skin
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Braden Scale for Predicting Pressure Sore Risk
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6 subscales
sensory perception, Moisture, activity, mobility, nutrition, and friction and shear force 23 points available - below 18 @risk |
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Norton's Pressure Area Risk Assessment Form Scale
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general physical condition, mental state, activity, mobility, and incontinence, meds. Possible score 24 15 or 16 should be indicators no predictors of risk
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Stage 1 of pressure ulcer
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redness but no ulceration
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Stage 2 of PU
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partial thickness skin loss involving epidermis and possible the dermis
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Stage 3 of PU
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Full thickness skin loss or necrosis of the epidermis. deep crater
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Stage 4 PU
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Full thickness Skin loss with tissue erosion, or damage to muscle, bone, or supporting structures
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Primary Intention Healing
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occurs when tissue surfaces have been closed and there is minimal or first intention healing - characterized by the minimal granulation tissue and scarring
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Secondary Intention
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edges that should not be closed.
1. repair time is longer 2,. scarring is greater 3. suscepitability to infection is greater |
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Inflammatory Healing Phase
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immediantly after injury and lasts 2-3 days hemostasis and phagocytosis occurs during this stage
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Proliferative Healing Phase
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second phase in healing - 3-21 day after injury. Fibroblasts begin synthezing collagenand it grows over wound called granulation tissue.
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Maturation phase
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day 21-1 or 2 years after injury. wound is remodeled and contracted. scar is stronger.
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Keloid
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hypertrophic scar - abnormal amount of collagen laid down
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Serous exudate
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chiefly serum (clear portion of blood) - blister from burn
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Purulent Exudate
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pus, consists of leukocytes
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Suppuration
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process of pus formation
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Sanguineous (hemorhaggic) Exudate
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large amounts of red blood cells - open wounds
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Serosanguineous exudate
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clear and blood tinged drainage - surgical incisions
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Hematoma
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localized collection of blood under the skin
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Necrotic Tissue
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black, brown, or tan tissue thqt is attached to rest of tissue but dead
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Dehiscense
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partial or total rupturing or a sutured wound
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Evisceration
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protrusion of organs from wound
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RYB Color Code
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based on color of wound - red, yellow, or Black
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Red wounds
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late regeneration phase of tissue repair - need to be protected - nurses protect by cleaning, protecting, fill with dressing, changing dressing
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Yellow wounds
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liquid to semiliquid slough accompanied by pus and previous infection
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Black Wounds
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thick nectrotic tissue - require debridgement (removal of necrosis material)
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Transparent Dressings
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wounds including ulcerated or burned skin area do onot require changing
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Hydrocolloid Dressing
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pressure ulcers - last 3 to 7 days
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Secure Dressings
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nurse tapes down
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Montgomery Straps
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tie tapes - used when many dressings are needed
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Binder
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specific bandage for a certain body part
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sitz bath
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used to soak clients pelvic area
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