Wound Care Flashcards
(34 cards)
Primary Intention Healing
Occurs when surfaces have been closed. Example would be an incision that is sutured closed.
Approximated
Closed. To close.
Dehiscence
The bursting open of a previously closed wound.
Debridement
The process of removing necrotic tissue.
Eschar
A scab or dry crust that can form over damaged skin.
Should eschar be debrided?
Wet eschar should be removed. Dry/hard eschar should be left alone.
What is the benefit of larval therapy?
Maggots secrete digestive enzymes that break down necrotic tissue/bacterial growth and leave healthy tissue untouched.
Preferred dressings for deep exudate wounds?
Alginate, foam, and iodine dressings.
Why is Granulex sometimes used to prep stage 1 wounds?
Preserves skin integrity, increases blood supply.
Benefits of Hydrocolloid dressings/duederm, tegaderm?
They allow oxygenation to the wound, but are not permeable to moisture or bacteria.
How does wet to dry dressings debride?
Packing a wound with wet material, allowing it to dry and adhere to nectroic tissue, and removing the dry packing along with the tissue that has adhered. ouch.
Enzymatic debridement
Santyl, can aid in the removal of necrotic tissue or infection.
wound VAC
Creates neg. pressure. Reduced edema, increases oxygenation, decrease bacteria, promotes the granulation process.
Maceration
Tissues softened by prolonged wetness or soaking.
Key measures to prevent pressure injury
nutrition, skin hygiene, protection, repositioning, and supportive devices
Describe a stage 1 pressure injury
nonblanchable erythema of intact skin. May be sore or feel warm.
Describe a stage 2 pressure injury
partial thickness skin loss. Shallow, open ulcers with pink or red wound bed. May present as blisters.
Describe a stage 3 pressure injury
Full thickness skin loss. Damage or necrosis of subcutaneous tissue is visible. Slough or eschar may be present.
M in m.e.a.s.u.r.e.m.e.n.t
Length, width, depth, area
E in m.e.a.s.u.r.e.m.e.n.t
Exudate, quantity and quality
A in m.e.a.s.u.r.e.m.e.n.t
Appearance, what’s it look like? Tissue type?
S in m.e.a.s.u.r.e.m.e.n.t
Suffering? Pain?
U in m.e.a.s.u.r.e.m.e.n.t
Undermining. Pockets around wound under skin.
R in m.e.a.s.u.r.e.m.e.n.t
Re- evaluate. Monitor all parameters.
