Wounds Flashcards
(58 cards)
What phase is a non-healing wound stuck in?
Stuck in the inflammation phase
What is a chronic wound?
An injury to the integument that has failed to heal by the generally predictable events that occur through the phases of wound healing
What are common barriers to wound healing (memorize!!)?
Inadequate microcirculation
Prolonged pressure from interstitial edema
Bacterial infection
Absence of adequate electrical potential
What are common barriers to wound healing (2)?
Tissue perfusion/oxygenation Nutrition Presence/abscence of infection DM steriod administration Immunosupression Aging Topical Therapy
What is a pressure ulcer?
Localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure (with or without shear and friction)
What are some common sites for pressure ulcers?
Sacrum Heel Ischium Lateral Malleolus Greater trochanter
What happens when an external load is placed on a tissue?
Shear/pressure closes the microcirculation and lymphatic systems when pressure is exceeded
What is tunneling?
Not sure yet
What is a stage 1 pressure ulcer?
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. color may differ from surrounding area
What is a stage 2 pressure ulcer?
A partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister
What is a stage 3 pressure ulcer?
- Full thickness tissue loss.
- Subcutaneous fat may be visible but bone, tendon or muscle are not exposed.
- Slough may be present but does not obscure depth of tissue loss
- May include undermining and tunneling
What is a stage 4 pressure ulcer?
- Full thickness tissue loss with exposed bone, tendon or muscle.
- Slough or eschar may be present on some parts of the wound bed
- Often include undermining and tunneling
What is a (suspected) deep tissue injury (DTI)?
Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear.
What is an unstageable pressure ulcer?
A full thickness loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed.
What are the two classifications of Chronic wound?
Partial thickness and full thickness
What is a partial thickness wound?
Breakdown of the epidermis and possibly penetrating into but not through dermis.
What is a full thickness wound?
Breakdown of the dermis into the subcutaneous tissue through fascia, may involve muscle, tendon and/or bone.
What are several causes of venous insufficent ulcers?
Muscle pump failure
Pericapillary fibrin deposits
What are some characteristics of venous insufficient ulcers?
Superficial Highly exudative minimal pain, relieved with elevation Irregular edge Hyperpigmentation Medial side of ankle Red wound base Dermatitis Hemosiderin staining
What are arterial insufficient Ulcers the result of?
Inadequate blood supply
may also have venous insufficiency
Below what ABI are arterial insufficient ulcers not likely to heal?
below 0.5
What are some characteristics of Arterial insufficient ulcers?
very painful Pain decreases with dependency Associated trophic changes in the skin Minimal exudate with dry eschar/necrosis Located on toes, fingers or interdigital spaces Blanched wound base and periwound tissue
What are some characteristics of post surgical wounds?
Closed by primary intention Treatment usually uneventful Healing occurs with protective dressing Generally well-defined Straight wound margins
What are some characteristics of traumatic wounds?
generally irregular wound margins
Visible inflammatory response margin
indurated wound margin
