wounds

  1. phases of healing
    • inflammatory: 3-4 days
    • proliferative: 4-21 days
    • maturation: 3-4weeks
  2. primary healing
    wound margins are neat, surgical incision or paper cut
  3. secondary healing
    • -trauma, ulceration infection
    • - lots of exudate, wide irregular margins
    • -can not be approximated
    • -debris
  4. tertiary healing
    • -delayed suturing of a wound in which 2 layers of gran tissue are sutured together
    • -wound left open
    • -large deep scar
  5. stage 1
    nonblanchable erythema of skin intact
  6. stage 2
    partial thickness skin loss involving the epidermis, dermis or both
  7. stage 3
    full thickness skin loss involving damage to or necrosis of SQ tissue that may extend to but not go through fascia
  8. stage 4
    full thickness skin loss w/ extensive destruction, tissue necrosis, damage to supporting muscle or bone or supporting structures
  9. caloric intake
    30-35cal/kg/day
  10. protein intake
    1.25-1.5 g/kg/day
  11. normal protein intaeke
    .8/kg/day
  12. lab level that indicates malnutrition
    serum albumin

    the best level is the pre albumin level
  13. vit c intake
    1000 mg/day
  14. vit a intake
    1600-2000
  15. zinc intake
    15-30 mg
  16. fluid intake
    30-35 ml/kg/day
  17. hemorrage
    bleeding from wound site
  18. fistula
    abnormal passage way b/t systems
  19. dehiscense
    separation of edges
  20. evisceration
    seperation and organs protrude
  21. tegaderm
    • -adhesive
    • -occlusive seal
    • -moisture retaining
    • -not for wounds w exudate
  22. tegaderm is used on
    • stage I/II pressure ulcers
    • skin tears
    • cover iv and centrals
  23. gauze
    debrides wound mechanically if applied wet and allowed to partially dry
  24. gauze is used
    for cleaning, packing, covering
  25. ABD or surgical pad
    for big wounds
  26. hydrocolloids
    • thicker
    • moisture
    • absorption exudate
    • 3-7 days
  27. hydrocolloids good for
    stage 3/4 pressure ulcers not infected
  28. alginates
    highly absorbent
  29. alginates good for
    grafts, burns, ulcers w/ heavy exudate, infected wounds
  30. closed system
    • JP
    • Hemovac
  31. open drain
    penrose
  32. Wound VAC
    • -draws neg pressure
    • -closes wound
    • -pulls blood and o2 to surface
    • -pulls out exudate
    • -debrides
    • -DRESSING MUST BE SEALED
  33. types of wound debridment
    • autolytic-self
    • sharp-surgical
    • mechanical-scraping
    • enzymatic-enzymes
  34. braden scale scores
    • 9 or below- very high risk
    • 10-12- high risk
    • 13-14- moderate risk
    • 15-18- at risk gen pop
    • 13- at risk ICU
Author
ChelseaL
ID
339141
Card Set
wounds
Description
wounds
Updated