Balck or brown necrotic tissue which needs to be removed before healing can proceed
Eschar
Describes the amt of color, consistency and odor of wound drainage and is part of wound assessment
Exudate
Wound that proceeds through an orderly and timely reparative process that results in sustained restoration on anatomical and functional integrity
Acute wound
Wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity
Chronic wound
Wound extending into the dermis
Full thickness
loss of epidermis
Partial thickness
Continue exposure to insult to wound impedes wound healing for what type of wound?
Chronic
Healing process class.
Wound that is closed. Stapled or sutured. Healing occurs by epithelialization. heals quickly
Primary intention wound
Healing class
Wound edges are not approximated. Wound that is left open until if fills w/ scar tissue. Surgical wounds that have tissue loss.
Secondary intention
Wound left open for several days, then wound edges are approximated. Wounds that are contaminated and require signs of inflammatinon
Tertiary Intention
For partial thickness wound repair, the inflammatory response is limited to how many hours after wounding
24 hours
For Full thickness wound repair, the infalmmation stage last approximately how many days?
3 days
Response that causes redness and swelling to the area with a moderate amount of serous exudate
Inflammatory response
Stage in wound repar that has appearance of new blood vessels for reconstruction. Begins and lasts from 3 to 24 days.
Proliferation stage
Maturation, the final stage of healing. sometimes takes more than a year.
Remodeling
Hemmorghage infections are most likely between what amt of hours?
24-48 hours
Bleeding from a wound site, internally or externally
Hemorrage
Name the 6 subsclases that the Braden scale measures?
Sensory perception, moisture, activity, mobility, nutrition, friciton and shear
The golden standard for pressure ulcer risk assessment?
Braden Scale
The lower the score of the on the Braden Scale...
The higher risk for injury the pt will be
Partial to total seperation of wound layers. A client who is at risk for poor wound healing is at risk for this.
Dehiscence
Protrusion of visceral organs througn a wound opening
Evisceration
Name some factors that afftect pressure ulcer formation and healing
Nutrition, tissue perfusion, infection, age, psychosocial impact of wounds
If we find an ulcer, initail action is to...
document the location, size, color and what kind of drainage there is.
How often do acute wound need monitoring?
every 8 hours
What do we clean pressure ulcers with
normal saline, noncytotoxic solution
the removal of nonviable, necrotic tissue
Debridement
Type of Debridement. Wet to dry saline gauze dressing, wound irrigation and whirlpool treatments
Mechanical debridement
Type of Debridement. uses synthetic dressing over a wound to allow the eschar to be self- digested by the action of enzymes that are present in wound fluids
Autolytic Debridement
type of debridement. uses a topical enzyme preparations, Dakins solutions, or steril maggots.
Chemical Debridement
the removal of devitalized tissue by using a scapel, scissors, or other sharp instruments
Surgical Debridement
to control the bleeding of a wound in a first aid situation...
apply direct pressure on the wound with a sterile or clean dressing
If a wound is healing by secondary intention, the dressing needs to support what kind of environment?
Moist
Wet to dry dressing are only for what?
Debridement
What should the nurse do with dead wound space?
Fill it with dressing material
If a wound drain or wound vac is blocked, what should the nurse do?
notify the health care provider
A client shoul not be in a chair no longer than?
2 hours
Type of dressing that Protects the wound from surface contamination.
Hydrocolloid
Maintains a moist surface to maintain healing
Hydrogel
Uses negative pressure to support healing
Wound V.A.C
Before touching a wound and after performing hand hygiene the nurse should wear what?
Sterile gloves
Before performing the dressing change, the nurse should make the sure the patient is....
medicated
To clean a wound you need to start from the _ toward the_
wound incicsion toward the surounding skin
For irrigating a wound, allow the solution to flow from the _ to the _ contaminated area
least to most.
what size needle and what size syringe are used for wound irrigation that removes exudates
19 gauge needle and 35 ml syringe
portable untis that exert a safe, constant, low-pressure vacuum to remove and collect drainage
Drainage evacuation
Designed for the body part to be supported. Breast, abdominal
Binder
Name conditions that affect heat and cold therapy
very young and old clients, open wounds, broken skin, stomas, areas of edema, scar formation, peripheral vascualr disease (diabetes, arteriosclerosis), confusion, unconsciousness, spinal cord injury, abscessed tooth or appendix
