Wounds Flashcards Preview

Nursing Concepts > Wounds > Flashcards

Flashcards in Wounds Deck (35)
Loading flashcards...
1

Open wound

occurs from intentional/un-intentional wounds
skin surface broken=portal of entry for microorganisms
bleeding, tissue damage, increased risk for infection, delayed healing

2

Intentional wound

the result of a planned invasive therapy/treatment
-wound edges clean
-bleeding controlled
-wound made in sterile environment=decreased risk of infection

3

unintentional wounds

occur from unexpected trauma (accidental) ex. stabbing/gunshot
-occur in UNSTERILE environment, contamination likely
-increased risk for infection
-increased healing time

4

Stage 1 pressure ulcer

intact skin
area of persisent redness on light skin
are of persistent red, blue or purple hue on darker skin
does not blanch

5

stage 2 pressure ulcer

partial-thickness skin loss of epidermis/dermis
superficial; abrasion, blister, shallow center

6

Stage 3 pressure ulcer

full thickness skin loss
damage or necrosis of subq tissue
deep crate with or without undermining

7

Stage 4 Pressure ulcer

full thickness skin loss
extensive destruction, tissue necrosis
damage to bone muscle, tendons, joints, sinus tracts is possible

8

unstageable pressure ulcer

can't see wound base

9

incision

cuting or sharp instrument; wound edges in close approximation and aligned

10

contusion

blunt instrument, overlying skin remains intact but tissue underneath has been damaged

11

abrasion

friction; rubbing or scraping epidermal layers of skin; top layer of skin abraded

12

laceration

tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue

13

puncture

blunt or sharp instrument puncturing the skin; intentional or accidental

14

penetrating

foreign object entering the skin or mucous membrane and lodging in underlying tissue; fragments possibly scattering throughout tissues.

15

avulsion

tearing a structure from normal anatomic position; possible damage to blood vessels, nerves and other structures

16

chemical

toxic agents such as drugs, acids, alcohols, metals, and substances released from cellular necrosis

17

thermal

high or low temperatures; cellular necrosis as a possible result

18

Irradiation

Ultraviolet light or radiation exposure

19

Pressure ulcers

compromised circulation secondary to pressure or pressure combined with friction

20

venous ulcers

injury and poor venous return, resulting from underlying conditions, such as imcompetent valves or obstruction

21

arterial ulcers

injury and underlying ischeia, resulting from underlying conditions, such as atherosclerosis or thrombosis

22

diabetic ulcers

injury and underlying diabetic neuropahy, peripheral arterial disease, diabetic foot structure.

23

primary intention

well approximated wounds whose skin edges are tightly together.

24

secondary intention

wounds healing with edges that are not well approximated. Take longer to heal and form more scar tissue

25

if a wound that is healing by primary intention becomes infected how will it heal?

secondary intention

26

tertiary intention

wounds that are left open for several days to allow edema or infection to resolve or fluid to drain and then are closed.

27

serous drainage

composed primarily of the clear, serous portion of the blood and from serous membranes. Clear and watery.

28

sanguineous drainage

consists of large numbers of red blood cells and looks like blood.

29

serosanguineous drainage

a mixture of serum and red blood cells. it is light pink to blood tinged.

30

purulent drainage

made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Thick and often has a musty smell and varies in color.