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Flashcards in Wound Care Deck (60):
1

Intrinsic factors of wound healing

-age
-chronic diseases present
-perfusion/oxygenation
-immunosuppresison
-neurologically impaired skin

2

Extrinsic factors of wound healing

-medications
-nutrition
-irradiation and chemo
-psych stressors
-wound 'bioburden" and infection

3

Bioburden

-Whatever is colonized on a wound
-pathogens

4

Iatrogenic Factors for healing

-local ischemia due to pressure/other forces
-inappropriate wound care
-trauma
-wound extent and duration

5

Zones of Wound Healing

-zone of hyperemia
-zone of stasis
-zone of coagulation

6

Zone of coagulation

-area of necrosis
-will not heal

7

Zone of Hyperemia

-inflammatory response surrounding the wound
-normal tissue going through normal response
-redness of skin

8

Zone of Stasis

-part that may or may not heal
-important to protect this zone so it can heal
-hanging in the balance

9

Re-epithelialization

-recreation of a permeable barrier
-skin reinstituted as functional barrier
-epithelial cell migration from nearby tissues begins within hours of injury

10

Granulation Tissue

-new or budding tissue
-composed of capillaries and collagen
-fills defects of full-thickness wounds
-bleeds easily, relatively fragile

11

Demarcation

-clear differentiation between viable and non-viable tissue

12

Excoriated Tissue

-epidermal tissue abrasion
-to chafe, tear or wear off the skin
-often linear

13

Sinus Tract

-channel or passageway extending into viable tissues with one entrance only
-travels under skin

14

Tunneling

-narrow channel or passageway with openings on both ends

15

Abscess

-localized collection of pus

16

Induration

-palpably hard tissue
-often at edge of wound
-can indicate abscesses (must determine cause)

17

Drainage

-Exudate or transudate
-indicates inflammatory response

18

Exudate

-found in inflammatory stage of wound healing
-contains cells, proteins and other solid materials
-2 kinds: purulent or serous

19

Purulent

-milky/cloudy appearance but can be any color
-indicate infection

20

Serous

-thin, clear usually amber color
-mostly contains serum
-(Serosanguinous-thin with some RBC)

21

Transudate

-thin, cloudy drainage found in the proliferation stage of wound healing
-like exudate but has fewer cellular componenets

22

Dehiscence

-splitting of open wound
-separation of layers of surgical wound (partial, superficial or complete)
-bad

23

Risk Factor of Dehiscence

-obesity
-because adipose is less vascularized

24

Necrosis

-tissue death
-residual dead tissue can impede normal healing

25

Slough

-Yellow and thin covering of wound
-stringy appearance

26

Eschar

-more advanced necrosis
-soft or hard (leathery)
-represents full-thickness destruction of tissue
-black/dark colored

27

Necrotic tissue tends to become more______

-adherent to wound bed as level of damage increases

28

As necrotic tissue worsens, the color may____

-progress from white-grey to yellow to brown/black

29

Methods of Wound Closure

-first intent
-secondary intent
-third intent

30

First Intent Closure

-close the wound and done

31

Second Intent Closure

-larger wound must fill in on it's own

32

Third Intent

-intentionally left open to get rid of infection first

33

Debridement

-removal of dead tissue
-4 types

34

4 Types of Wound Debridement

-Mechanical
-Sharp
-Enzymatic
-Autolytic

35

Mechanical Debridement

-PT
-Pulsed lavage, whirlpool/flow-over hydrotherapy etc

36

Sharp Debridement

-with scalpel

37

Enzymatic Debridement

-put stuff on the wound to break down necrosis

38

Autolytic Debridement

-scab, body creates temporary roof
-healing under scab and scab falls off
-body does it on it's own

39

Ulcer

-loss of epidermis and dermis
-most are preventable

40

Common Locations of Decubitus Ulcers

-bony prominences
-ischium, sacrum, coccyx, olecranon, heels, occiput, scapulae, lateral malleoli, trochanters, acromion

41

Decubitus

lying down position

42

5 Risks/Causative factors for Decubitus Ulcers

-interface pressure (externally)
-Friction (skin on other surface)
-Shearing
-Maceration (softening due to excessive moisture)
-decreased skin resilience (dehydration)

43

Maceration

-softening due to excessive moisture

44

Grading decubitus ulcers

-grade I-IV
-IV is the worst
-stage I-skin is still intact
-don't massage area or use donut cushions

45

Osteomyelitis

-Bone infection

46

Signs of Infection

-redness
-fever
-increased temp
-discoloration
-drainage (smelly)

47

Prevention of Decubitus Ulcers

-MOBILITY
-assessment of surfaces in contact
-vigilance in the presence of incontinence
-multidisciplinary consultation (RN, NA, Family, Physicians)

48

Other Ulcer Types

-Arterial
-Venous
-Neuropathic

49

Modalities for Wound Care

-ESTIM
-US (pulsatile)
-SWD
-Whirlpool

50

Whirlpool

-softens eschar and other necrotic tissue
-turbulence provide mechanical debridement
-flow over therapy is better

51

Flow-Over Hydrotherapy

-wound cleansing with immediate flushing away of potentially infectious material
-more sanitary than whirlpool

52

Grade I Pressure Ulcer

-skin intact
-warmer/cooler than other skin
-firm or boggy consistency
-pain/itching sensation
-redness

53

Grade II Pressure Ulcer

-Partial thickness skin loss of epidermis and/or dermis
-superficial

54

Grade III Pressure Ulcer

-full thickness damage/necrosis to subq layer to fascia
-deep crater
-with/without undermining of adjacent tissue

55

Grade IV Pressure Ulcer

-Full thickness with necrosis or damage to muscle, bone or supporting structures (tendon, joint capsule)
-undermining and sinus tracts

56

Unstageable Pressure Ulcer

-wound covered with eschar
-or more than 50% necrotic tissue
-or filled with granulation tissue

57

Deep Tissue Injury (grade of pressure ulcer)

-pressure related injury to subq tissues under intact skin

58

Neuropathic ulcers

-weight bearing surfaces
-well-defined margins
-no undermining
-graunlation tissue present
-no pain

59

Arterial Ulcers

-deep pale base
-well defined edges
-black necrotic tissue
-dry
-cool leg
-painful

60

Venous Ulcers

-uneven edges
-ruddy granulation tissue
-warm leg, edema
-wet
-some pain