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Concepts II
Chapter 26
| Question | Answer |
|---|---|
| ABRASION A superficial open wound (scrapes, scratches, or rub-type wound where the skin is broken) | |
| DEBRIDEMENT Surgical removal of the dead tissue, | |
| DEHISCENCE When there is a partial or complete separation of the outer layers of a wound | |
| ERYTHEMA Indicates the increased capillary blood flow associated with inflammation | |
| ESCHAR Hard, dry, dead tissue that has a leathery appearance (can be black, brown, or tan) | |
| EVISCERATION If an abdominal wound reopens, the abdominal contents may protrude through the opening (Lifethreatening) | |
| GRANULATION TISSUE New tissue begins to grow and fill in the wound; it looks red and semitransparent. (Is extremely fragile. If it is irritated or abraded, it bleeds easily.) | |
| HEMORRHAGE Bleed profusely (medical emergency) | |
| ISCHEMIA Tissues and capillaries that are compressed resulting in reduced blood flow to the bony prominences | |
| MRSA METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS This resistant form can live on the skin of healthy people without causing illness (VANCOMYCIN treats MRSA) | |
| NECROTIC When ischemia deprives tissues of adequate oxygen and nutrients the cells die (tissue death) | |
| PRESSURE INJURY WOUNDS Wound from pressure and friction (skin can be intake or nonintact) | |
| PURULENT thick and yellow or green | |
| SANGUINEOUS Looks like blood | |
| SEROSANGUINEOUS It looks pink | |
| SEROUS looks clearer to slightly yellow | |
| SINUS TRACT A channel or tunnel that develops between two cavities or between an infected cavity and the surface of the skin, sometimes known as a FISTULA (thick, yellow, and green purulent drainage) | |
| CONTUSION WOUNDS Closed discolored wound used by blunt trauma (known as a bruise) | |
| PUNCTURE WOUNDS An open wound from a sharp item such as a needle, nail, or piece of wire piercing the skin. (round hole in skin) | |
| PENETRATING WOUNDS An open wound like a puncture wound but offending object remains embedded in the tissue | |
| LACERATION WOUNDS An open wound made by accidental cutting or tearing of the tissue (knives, glass or metal) | |
| CLEAN WOUNDS Wound is not infected | |
| CONTAMINATED WOUNDS Can be a surgical wound or a wound caused by trauma that has been contaminated by breaking asepsis | |
| CLEAN-CONTAMINATED WOUNDS Wound was surgically made but is not infected (has potential to become infected) | |
| INFECTED WOUNDS An infected wound is one in which the infectious process is already established as evidence by high numbers of microorganisms of purulent drainage or necrotic tissue (signs are erythema, warmth, edema, pain, odor) | |
| COLONIZED WOUNDS High microorganisms present but is without signs of infection | |
| OPEN WOUNDS Skin that has been breached | |
| CLOSED WOUNDS Wound remains intake | |
| PRESSURE INJURY RISK FACTORS (for patients who are) Older, emaciated or malnourished, incontinent of bowel or bladder, immobile, impaired circulation or chronic metabolic conditions | |
| PREVENT PRESSURE INJURIES Using a Braden Scale for predicting pressure injury risks (skin assessments done on daily basis every 8 hours minimum) If patient is bedfast, assess the pressure points every 2 hours | |
| STASIS ULCERS Develop when venous blood flow is sluggish, generally in the lower extremities, allowing deoxygenated blood to pool in the veins. | |
| SURGICAL INCISIONS with sharp instruments is linear with more sharply defined edges than most wounds | |
| 3 PHASES OF HEALING | |
| PRIMARY WOUND CLOSURES The wound is clean with little tissue loss such as surgical incision the edges are approximated, and the wound is sutured, glued, stapled, or stitched close | |
| SECONDARY WOUND CLOSURES When there are greater tissue loss and the wound edges are irregular, the edges cannot be brought together. (Examples of this are a pressure injury or a traumatic wound.) | |
| TERTIARY WOUND CLOSURES Known as delayed primary closure healing, the wound is left open for a time to allow granulation tissue to form and then it is sutured closed. (a draining wound left open until the drainage ceases and then is suture closed) | |
| DIFFERENT FACTORS AFFECT WOUND HEALING SUCH AS Age and lifestyle of the patient additional illness and wounds, nutritional status, oxygenation, medications, and tension on the edges of the wound | |
| COMPLICATIONS OF WOUND HEALING Age, chronic illness, diabetes, hypoxemia, lifestyle choices, nutrition and hydration | |
| TYPES OF DRESSINGS Gauze (Abdominal dressing), Foam, Collagen, Wet to damp | |
| ERYTHEMIC Reddened | |
| PRESSURE INJURIES ARE ALSO KNOWN AS Pressure ulcers, decubitus ulcers, and bedsores that occur when external pressure is exerted on soft tissues over bony prominences for long times | |
| EMACIATED A state of being very lean | |
| Macerated Softened | |
| NATIONAL PRESSURE INJURY ADVISORY PANEL (NPIAP) Developed the staging scale (Stage I-Stage IV then Unstageable and Deep Tissue) | |
| STAGE I Erythema of intact skin over bony prominence that will NOT blanch or turn white when you touch it | |
| STAGE II Partial-thickness loss and exposed dermis (intact serum-filled blisters and broken blisters that are shallow, pink, or red ulceration that is moist (harder to heal; infection is possible) | |
| STAGE III A full thickness loss with damage to the epidermis, dermis, and subcutaneous tissue but not involving muscle or bone. rolled wound edges present (undermining and tunneling maybe seen; tend to be infectious) | |
| STAGE IV Full thickness skin and tissue loss (deep tissue necrosis of muscle, fascia, tendon, joint capsule, and sometimes bone; tunneling and undermining maybe present. deeper tissue such as bone known as osteomyelitis) extremely slow to heal | |
| UNSTAGEABLE ffull thickness tissue loss and impossible to stage because of wound bed being obscured by eschar or excessive slough | |
| DEEP TISSUE PRESSURE INJURY (DTPI) May be intact or nonintact skin. Deep red, marron, or purple in color and does NOT blanch. May form blood-filled blister and can break and reveal thin layer of eschar underneath | |
| Eschar should not be removed if completely covering a site (should be left alone to protect damaged tissue underneath it, if it comes off it reveals stage III or IV) | |
| MEDICAL DEVICE RELATED PRESSURE INJURY Occurs because of use of diagnostic device pressing against the patient's skin (splint, braces, or oxygen tubing) | |
| MUCOSAL MEMBRANE PRESSURE INJURY The use of a medical device in the area of mucous membranes. These injuries cannot be staged (damage to tongue or lips from endotracheal tube) | |
| PALLOR Is related to impaired circulation (major risk factor for skin breakdown) | |
| JAUNDICE Known as yellowing of the skin; is a sign of highly abnormal serum level of bilirubin which can make skin itch and susceptible to loss of integrity | |
| BRUISING Discolored areas; make notations of any such areas that are found so that it will be easy to determine whether new breakdown occurs | |
| SKIN TURGOR Elastic or non-elastic skin (dehydration or edematous from overhydration can cause skin breakdown) | |
| A FISTULA and SINUS TRACT can connect two body cavities or can tunnel from a body cavity or wound to the skin. (There is a fistula that connects the vagina and the rectum) | |
| To accurately assess a wound, you must know how a wound heals. Whether the wound is a surgical incision or a pressure injury or is the result of trauma, the steps in the healing process are the same and occur in three phases. | |
| Phagocytosis, specialized white blood cells (WBCs) called macrophages engulf and digest invading microorganisms and the remaining fragments of damaged cells | |
| RECONSTRUCTION PHASE Wound begins to heal also known as PROLIFERATION | |
| Inflammatory phase occurs when the wound is fresh and includes both hemostasis and phagocytosis. | |
| HEMOSTASIS The body stops bleeding | |
| Overproduction of collagen results in a thick, raised scar called a keloid. Keloids can form on any type of skin but are most common on darkly pigmented skin. | |
| MATURATION PHASE Known as Remodeling phase occurs when the wound contracts and the scar strengthen. Initially, a healing ridge develops just beneath the incision and approximately 1 cm on either side. | |
| WOUND CULTURAL/ SENSITIVITY A test to determine which antibiotics will be effective against an infected wound and kill infection | |
| WBC NORMAL RANGE COUNT 4500 to 11100 | |
| Bacteria normally found in the bowel are referred to as ENTEROCOCCI. One specific bacterium from this group, E. coli helps to break down food for digestion. | |
| When a wound is infected with bacteria called CLOSTRIDIA, the result is a condition known as GAS GANGRENE. This pathogen grows only in the absence of oxygen and is called an ANAEROBE. | |
| Gangrene most often occurs because of poor circulation to a body part, especially a digit or limb, or as a complication of an untreated infection in a wound. | |
| Infected wounds are DEBRIDED and may be treated in a HYPERBARIC CHAMBER. A chamber that delivers oxygen under high pressure to help kill anaerobic bacteria and promote wound healing. | |
| MALODOROUS bad smelling | |
| SEROPURULENT Both drainage and drainage with pus are present | |
| guaiac test test for blood in stool or emesis | |
| MONTGOMERY STRAPS Attach to the skin with adhesive on each side of the wound (slotted flaps lie over the dressing and lace up with narrow gauze strips that are tied together | |
| WET TO DAMP Maintain a moist bed and to wick out drainage from the wound (Remove the gauze in the wound helps to gently debride necrotic tissue) |
Created by:
Daarina Jones