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Terms in this set (43)
What are the stages of wounds? Stage 1 (A)
Stage 2 (B)
Stage 3 (C)
Stage 4 (D)
Define stage 1 (A) of a wound only epidermis is affected
red, non blanching, unbroken
manage with self-care
Define stage 2 (B) of a wound affects all of epidermis and part of dermis
blistering, broken skin, drainage, blanching
can be managed with self care but may need to
refer if >2% BSA affected
Define stage 3 (C) of a wound entire epidermis and dermis affected and possibly
subcutaneous tissue
dry, leathery, painless (burns), profuse bleeding
(lacerations/punctures)
REFER
, Define stage 4 (D) of a wound entire epidermis, dermis, and subcutaneous tissue are
affected, possibly bone, muscle and tendon have are
affected
REFER
What are the three phases of wound 1. inflammatory phase
healing? 2. proliferative phase
3. maturation (remodeling) phase
Define the inflammatory phase of immediate response to injury (3-4 days)
wound healing
hemostasis
inflammation
Define the proliferative phase of formation of new tissue, capillaries, and inflammatory
wound healing cells
happens on day 3 or 4 and lasts for 3 weeks
Define the maturation (remodeling) would completely closes with new tissue and is
phase of wound healing resurfaced by epithelial cells
begins at week 3 and lasts for 60 days (2 months)
What are some factors that impair 1. poor vascularization - diabetes and anemia
would healing?
2. bacterial contamination - strep, staph, etc
3. nutritional deficiencies - vitamin C and E
4. Medications - immunosuppressants and
glucocorticosteroids