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Wound Care

Fundamentals of Nursing Chapter 26 Wound Care

QuestionAnswer
A(n) __________ is a superficial open wound. Abrasion
A(n) __________ is an open wound that results when a sharp item pierces the skin. Puncture wound
A(n) __________ is similar to a puncture would except the object remains embedded in the skin. Penetrating wound
A(n) _________ is an open wound made by accidental cutting or tearing of tissue. Laceration
A(n) ________ is a wound resulting from pressure and friction. Pressure ulcer
A pressure ulcer is also known as... Decubitus ulcer or bedsore
How do pressure ulcers occur? Occurs when external pressure is exerted on soft tissues, especially over bony prominences for a prolonged period of time.
What is ischemia? Reduced blood flow to an area, usually due to the compression of tissues and capillaries.
What are the most common sites for pressure ulcers? Sacrum, buttocks, greater trochanters, elbows, heels, ankles, occiput, and scapulae.
A(n) ________ is a closed discolored wound caused by blunt trauma. Contusion
Another word for contusion: Bruise
Relating to contamination, wounds fall into on of the following categories: Clean, Clean-contaminated, Contaminated, Infected, or Colonized
Clean: A wound that is not infected.
Clean-contaminated: A wound that was surgically made, is not infected but has direct contact with the normal flora in the respiratory, urinary, or gastrointestinal tracts. Has potential to become infected.
Infected: A wound in which the infectious process is already established as evidence by high numbers of microorganisms and either purulent or necrotic tissue.
Purulent: Containing pus
Necrotic: Dead
The classic signs of infection are: Erythema, increased warmth, edema, pain, odor, and drainage.
Colonized: Differs from an infected wound in that it has a high number of microorganisms present without signs of infection.
Shearing force Occurs whenever the patient's skin and another item, such as bed linens or the surface of a chair, move in opposite directions while they are being pressed together by the weight of the body.
Risk factors for pressure ulcers Elderly, emaciated or malnourished, incontinent, immobile, impaired circulation or chronic metabolic conditions.
Created by: loweunde