Exam 1- Wounds 3 and Wounds part of 4 Flashcards Preview

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Flashcards in Exam 1- Wounds 3 and Wounds part of 4 Deck (50)
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Quiz question: three things that need to be present for a wound to heal

~blood flow
~environment (moist)


Quiz question: compare and contrast arterial and venous wound

~Arterial- deep, pale, dry, lateral, more likely to be painful, less common
~Venous- shallow, reddish, weepy, medial, less likely to be painful, more common (by 4x)


Quiz question: three types of debridement that are selective (vs nonselective)

(Selective- This is only going to get rid of the stuff that we want it to get rid of and Non selective- this will get rid of everything)
~Maggots (get only the dead tissue)
~Pulse lavage- only if the stuff under the pulse lavage is dead tissue; if the stuff under is also good tissue, it could also take away good tissue (Whirl pool- Non selective)
~Enzymatic- some would be selective and some non-selective
~Forceps/ wet gauze/ scalpel (mechanical)- can be selective depending on how you apply them (If a physician does it, it is more likely to be non-selective)
~Autolytic- your body should be completely selective unless something is going wrong


Quiz question: three points of education that you would want to give to a patient with a diabetic ulcer

~Wound positioning
~What’s your sugars; how often do you check it (80-120); when’s the last time you went to the doctor? Etc.
~Don’t go to nail salon; soak feet
~Don’t remove calluses
~Foot check
~Don’t wear compressions garments/ tight shoes/ shoes
~Proper shoes


What do you do before examining the wound?

Take vitals!
~you will have a baseline and comparison


What else will you do beside look at the wound?

~look at the whole person
~if they can walk, have them walk/ get them up
~do a gross motor screen
~sensory screen
~you have the same subj and obj
~see if they are active, if they smoke, etc


Wound: what are ways to record the size of a wound?

~Can draw it/ sketch a picture of it
~Take a picture of a wound
~trace the wound


Wound: what details of the size of the wound will you record?

~width, depth, length
~shape (is applicable)
~if there is undermining/ tunneling


Wound: what are details that you want to record about the wound? (8)

~direction of where the wound is located
~wound bed (wet/dry/ moist)
~is there neurotic tissue?


Periwound: what are details that you would want to record about the periwound? (3)

~turgor (firm, squishy, bogey, etc)
~regular/ irregular
~macerated/ desiccated


What do you look at during an examination of the wound? (5)

~the wound (wound bed)
~the periwound
~removal of dressing


Details about the exam of drainage

~the amount of the drainage








Details about the exam of pain

~before and after the dressing and after the cleaning of the wound
~you want to asses when it is the most painful and are you causing pain


Detail about the exam of removal of dressing

~How well did the dressing come off
~Did any not come off
~Was the dressing Wet/dry when it came off; (will you have to apply moisture if it is dry)
~Need to record everything so that the next person will know what to expect when they come in next time


What do you do with a black, dry heel?

~Don't do anything
~the heel is there for protection
~if you open it up, you can let in an infection


Are all wounds infected?



Are all wounds contaminated?

~it takes until 10^5 MRSE/VRE to became infected


what are signs of an infected wound? (6)

~changes in the wound: amount of drainage, color, odor
~periwound- irregular (can hit a vein)
~may not be able to walk easily
~temperature changes/ fever


Wound closure

~primary closure
~secondary closure
~tertiary closure


What is a primary closure? (3)

~When a physician closes a wound
~Staples, stitches, skin flap/ grafts, glue
~Dehiscence- breaks open/ can pop open (too much movement, infection); need to heal secondary then (Happened a lot with total knees, amputations, etc)


What is a secondary closure?

~mother nature/ when your body heals you on its own
~most happens this way


What is a tertiary closure?

~you body heals it on its own for a while and then a physician closed it up
~can't close up after too long bc of infection
~happens with burns- grafts


What is a primary dressing?

inside the wound; fills the wound and makes it look like the anatomy (never dip)


What is a secondary dressing?

on top of the primary dressing; will be dry


Details on gauze

~A woven material that can fit into any shape
~Can fit in any shape, squared, round, etc
~Folded, unflold
~Can wounds are already contaminated: They are all infected so no worries about keeping things sterile
~Most wounds are filled with gauze- cheap
~Fluff up and fill wound- don’t shove them in- can create pressure


Details on packing gauze

~Great for Tunnels
~Comes in packing stripes
~Leave a tail, have it moist
~Use the q-tip end (moisten) to help the packing gauze into the tunnel


When you put gauze (or anything else in a wound,

KEEP COUNT!! record what you put into a wound so that the next person will know exactly how much to remove


What do you call when the moisture gets through the primary dressing?