wounds 308 exam 1

adhesion

bands of internal scar tissue that form between tissues and organs

dehiscence

separation of wound edges

evisceration

intestine protrude from wound

fistula formation

abnormal passage between organs or organ and skin

hypertropic scars

raised /large scars

hemorrhage

bleeding

what causes evisceration of dehiscence

coughing or sneezing

debridement

removing damaged tissue and debris from the wound

surgical debridement

healthcare provider physically cut/remove debris

how are wounds measured

length

width

depth

what is measured in depth

tunneling

undermining

mechanical debridement

physically removed or srubbed out

autolytic

body own enzymes break down the tissues

enzymatic

special enzymes are used to break down dead tissues

•Hyperbaric oxygen therapy

Topical or systemic delivery of O2 at increased atmospheric pressure

negatie pressure wound therapy

wound vac

what is a wound vac used for

acute and chronic wounds

what does a wound vac do

sucks out the fluid exudate bacteria and enhances the blood flow

what should you monitor with a wound vac

serum protein levels

fluid and electrolyte balance

coagulation studies

what should you always record with drains

drainage amount

hospital assesments

24 hours

long term care assesment

weekly for first 4 weeks

monthly/quarterly after

home care assesment

every nurse visit

when would you put on a dressing for pressure injury

stage 2 or higher

macerated

wound margins that are whtite soggy or soft due to excess mositure

hydrocolloid dressing

dressing that reacts with wound exudate to form a gel promoting a mosit environment

jackson pratt drain

uses bulb to create constant low pressure suction

devices used to reduce pressure

low air loss matress

wheelchair cushion

lift sheets

penrose

flat flexible tube that relies on gravity and capillary action

which type dressing us used for autolytic debridement and maintaing a moise environment

hydrogel