Test 4

• Abrasion “rug rash”


  Friction, rubbing, or scraping of skin
• Contusion

  blunt instrument, overlying skin remains intact with injury to

  underlying soft tissue
• Incision “Intentional”

  cutting or sharp instrument; wound edges in close approximation/ aligned
• Laceration “jagged”

  tearing of skin and tissue with blunt or irregular instrument, tissue not aligned, often loose flaps of skin or tissue
• Penetrating Wound “stab wound”

  foreign object entering the skin or mucous membrane and lodging in underlying tissue
• Puncture “stepping on a nail or tack” 


  blunt or sharp instrument puncturing the skin, intentional/accidental
• Fistula “vaginal to rectal”

  abnormal passage from an internal organ to the skin
• Abscess


  collection of infected fluid that has not been drained
• *Children under 2, skin is thinner/ weaker

  *Infant’s skin easily injured/ easier for infection.
• Approximation 


  edges of wounds come together

  *Important because shows if wound is healing
• Non-approximated edges


  can be referred to as jagged
• Skin (or integument) largest organ. essential for maintain life. first line of defense, acts as barrier from microorganisms, infections
• Epidermis


  no blood vessels, regenerates quickly/ easily
• Dermis


  elastic connective tissue, nerve, glands, blood vessels
• Subcutaneous Tissue


  adipose tissue, fat is stored here, heat / cushion
• Intentional Wound


  results of planned invasive therapy/ treatment, purposefully for therapeutic purposes

  Wound edges clean/ bleeding controlled/ low risk for infection/ healing facilitated
• Example of Intentional Wound


  surgery, IV therapy
• Unintentional Wound


  accidental from unexpected trauma

  Wound edges jagged/ bleeding uncontrolled/ longer healing time/ high risk for infection
• Open Wound

  intentional/unintentional
• Example of Unintentional Wound

  accidents, gun shots, stabbing
• Examples of Open Wound

  incisions, abrasions
• Closed Wound


  from blow, force, strain

  Skin is not broken/ soft tissue is damaged/ internal injury and hemorrhage may occur
• Examples of Closed Wound


  falls, assault, MVCs
• Acute Wound


  Well healed within days- weeks/ wound edges well approximated/ low risk for infections
• Example of Acute Wound


  surgery
• Chronic Wound 


  No normal sequence of repair/ healing process impeded/ edges are not approximated/ high risk for infection/ remain in inflammatory phase*
• Examples of Chronic Wound

  arterial, venous, pressure injuries
• Pressure Injuries CAN be prevented
• Pressure injury 


  localized damaged skin and underlying tissue usually occurs over a bony prominence. develops when soft tissue is compressed between bony prominence and external surface for a prolonged period of time OR when soft tissue undergoes pressure in combination of shear/ friction
• Pressure injury are found

  sacrum and coccyx, followed by the trochanter and the calcaneus (heel)
• Intervention for Pressure injury

  change position every 2 hours (happens with obese patients often)
• Arterial Injury


  result of inadequate circulation of oxygenated blood from heart to extremity (circulation in arteries)
• Appearance of Arterial Injury


  small, round, pale, smooth border.
• Arterial Injury are located

  ankles, toes, shins
• Intervention for Arterial Injury


  Assess peripheral pulse/ capillary refill (posterior tibial/ dorsalis pedis)
• Venous Injury 


  occurs from venous stasis, because valves in veins are not working properly, deep vein obstruction. results in venous pooling/ edema which causes pressure
• Appearance of Venous Injury


  shallow, irregular edges, red, edema
• Venous Injuries are located

  inner ankle, lower part of calf
• Intervention from Venous Injury


  Assess for edema
• Infection Signs


  Pain, heat, redness, swelling at site/injury, drainage is increased/ possibly purulent, foul odor, wound edges may be separated, with dehiscence present. Increased WBC, increase temp (febrile), increased pulse