Wounds & Classifications
This wound is a result of unexpected trauma, has ragged edges, and is prone to infection.
What is an unintentional (accidental) wound?
This is done for patients who cannot move themselves every two hours and as needed.
What is turning/repositioning?
This complication does not present symptoms for 2-7 days. Diabetics, cancer patients, and the elderly are at a higher risk.
What is infection?
Nutrition, age, circulation, oxygenation, medications, and health status.
What are systemic healing factors?
This dressing is utilized over regular gauze because it is more absorbent.
What are SurgiPads/ABds?
This wound did not heal as expected, likely due to other health problems. It is contaminated (colonized) but may not be infected.
What is a chronic wound?
This injury occurs when tissues are moved in opposite directions by mechanical forces, such as when a patient is pulled up in bed and their skin is stuck to the bed.
What is a shearing injury?
This complication occurs when an abnormal passage is formed between two organs or an organ and the outside of the body.
What is a fistula?
This phase of healing begins after hemostasis and lasts 4-6 days. Macrophages ingest debris and release growth factors that attract fibroblasts that fill in the wound.
What is inflammation?
Autolytic, Biochemical, Mechanical, and Surgical.
This type of wound is made surgically under controlled conditions and is located in the respiratory, GI, genital, or urinary tract.
What is a clean-contaminated wound?
This stage of pressure injury is marked by full thickness tissue loss with slough and/or eschar covering the base of the wound and requires debridement.
What is an unstageable pressure injury?
This complication occurs in the first 24-48 hours and is obvious when dressings are saturated and blood pools under the patient.
What is (external) hemorrhage?
This local factor delays healing because the constant moisture decreases the pH to the skin, which allows an increase in bacteria.
What is maceration?
This type of wound closure is applied to the skin around the wound to hold it together. It cannot be used on "dirty" wounds like animal bites.
What is DermaBond/skin glue?
This type of wound only involves the epidermis or upper dermis and usually heals without any scarring or loss of function.
What is a partial thickness wound?
This type of pressure injury is characterized by purple or maroon intact skin that indicates underlying tissue damage cause by pressure.
What is a Suspected Deep Tissue Injury (DTI)?
Decrease in BP, increase in HR, diaphoresis, restlessness, and pale/clammy skin.
What are the signs and symptoms of hypovolemic/hemorrhagic shock?
AIDS, lupus, cancer, steroids, chemotherapy, and radiation.
What are causes of immunosuppression that delay wound healing?
This wound management system applies pressure to stress the tissue, help wound closure, remove edema, and decrease healing type.
What is a wound vac/NPWT?
This is a wound that occurs when a sharp object enters a body cavity and creates an opening.
What is a penetrating wound?
Remove pressure from area for 30 minutes, reevaluate skin, and implement pressure reduction measures.
What is the nurse's response when identifying blanchable redness?
Cover area with sterile towels--soaked in sterile saline, notify physician, lower HOB, and prepare to take the patient to surgery.
What is the treatment for dehiscence/eviseration?
Wound bacteria can create this as a self-made barrier to protect itself by being antibiotic resistant and causing a decreased immune response.
What is biofilm?
This wound closure method is a combo of nonsurgical and surgical management, in which the patient will temporarily have an open wound between surgeries.
What is delayed primary wound closure/tertiary intention?