Exam (elaborations)
1216 Wound Care Questions & Detailed Answers 2024
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1216 Wound Care Questions & Detailed Answers 2024
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1216 Wound CareWound Stage 1
non-blanchable
redness
erythema
skin still in tact
Wound Stage 2
partial thickness
open ulcer w/ red-pink wound bed
without slough
blister like
shallow
Wound Stage 3
full thickness tissue loss WITHOUT bone
fat is visitble
slough may be present
Wound Stage 4
full thickness tissue loss
bone, tendon or muscle WILL be exposed
Slough my be present
,Unstageable Wound
dark
hard and adherent to wound edge
eschar present
Suspected Deep tissue injury
Depth unkown
Purple or maroon dark area
intact skin
underlying soft tissue from pressure and/or shear
Should intact stable eschar be removed from the heel?
NO
Primary Intention healing
well approximated wound margins
(lacerations, surgical incisions)
Secondary Intention healing
, Not approximated
loss of tissue has occured
gap, with granulation to fill gap
longer to heal
Tertiary intention healing
-wound healing is delayed
-found in large infected/contaminated wounds
-usually left open on purpose to ---prevent infection
Wound management
-prevent and manage infection
-clean the wound
-remove nonviable tissue
-maintain the wound in a moist environment
-eliminate dead space
-control odor
-eliminate or minimize pain
-protect the wound and peri wound skin
Acute Wounds
Wound that proceeds through an orderly and timely reparative process that results in sustained
restoration of anatomical and functional integrity.
What causes acute wounds?
Trauma
Surgical Incision
Acute wound implications for healing
wound edges are clean and intact
Chronic Wounds
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