WCC flashcards
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32 cards. Read the term and the definition here. The deck at the top of this page is optional.
- Epidermis
- Avascular outer skin layer that receives oxygen by diffusion and provides the primary barrier; keratinocytes migrate from the basal layer during epithelialization.
- Hemostasis phase
- Immediate wound healing phase with vasoconstriction, platelet aggregation, and fibrin clot formation to stop bleeding and provide a provisional matrix.
- Inflammatory phase
- Early healing phase, usually days 0 to 4, marked by neutrophils, macrophages, and debridement of bacteria and debris.
- Proliferative phase
- Healing phase from about day 3 to 3 weeks involving fibroblast collagen deposition, angiogenesis, granulation tissue, wound contraction, and epithelialization.
- Wound area formula
- For simple wounds, area equals longest length times perpendicular width in centimeters, reported as square centimeters; irregular wounds require planimetry.
- Undermining measurement
- Measured in centimeters using a clock face with 12 o'clock at the patient's head; record extent from the wound edge under intact skin.
- PUSH tool
- Pressure Ulcer Scale for Healing scores wound area, exudate amount, and tissue type; total 0 to 17, with higher scores indicating worse healing.
- Braden Scale
- Six-item pressure injury risk tool scoring 6 to 23; lower scores indicate higher risk, and scores of 18 or less often trigger prevention.
- Stage 1 pressure injury
- Intact skin with non-blanchable erythema; in darker skin, color change may not blanch, but skin remains intact without open wound.
- Stage 3 pressure injury
- Full-thickness skin loss with adipose visible; fascia, muscle, tendon, cartilage, and bone are not exposed; slough or eschar may be present.
- Deep tissue pressure injury
- Intact or non-intact skin with persistent deep maroon or purple discoloration or blood-filled blister from pressure and shear damage to underlying tissue.
- Unstageable pressure injury
- Full-thickness pressure injury obscured by slough or eschar; true depth cannot be determined until enough necrotic tissue is removed to visualize wound base.
- Venous ulcer features
- Usually shallow, irregular, moist, and located near the medial malleolus, with edema, hemosiderin staining, and lipodermatosclerosis; compression is key therapy.
- Ankle-brachial index
- Ratio of ankle systolic pressure to brachial systolic pressure; values below 0.8 suggest arterial disease and compression must be used cautiously or avoided.
- Arterial ulcer features
- Punched-out, dry, pale, painful wounds often on distal or lateral legs, with weak pulses, hair loss, and shiny skin; compression is contraindicated if ischemia is severe.
- Lymphatic ulcer
- Ulcer associated with chronic lymphedema, often with hyperkeratosis, papillomatosis, and lymphorrhea; managed with decongestive therapy and compression when arterial flow allows.
- Monofilament test
- 10-g monofilament examination assesses loss of protective sensation in the foot; missed points indicate neuropathy and increased ulcer risk.
- Total contact cast
- Irremovable offloading device for plantar neuropathic ulcers that redistributes pressure and improves healing more than removable walkers.
- Charcot foot
- Neuropathic complication with a warm, red, swollen foot and possible deformity; requires immediate offloading and referral to prevent collapse.
- Probe-to-bone test
- Blunt sterile probe gently explores a diabetic foot ulcer; bone contact raises suspicion for osteomyelitis and warrants imaging and specialist evaluation.
- TIME framework
- Wound bed preparation model: T issue nonviable, Infection or inflammation, Moisture imbalance, and Edge nonadvancing; guides debridement and dressing selection.
- Autolytic debridement
- Selective, slow debridement using moisture-retentive dressings that let endogenous enzymes liquefy necrotic tissue; requires adequate perfusion and infection control.
- Sharp debridement
- Selective removal of necrotic tissue with sterile instruments; contraindicated in unassessed arterial insufficiency, coagulopathy, or ischemic tissue without vascular evaluation.
- Biofilm
- Polymicrobial community embedded in extracellular matrix that adheres to wound surfaces, resists antibiotics, and requires mechanical disruption plus antimicrobial therapy.
- Critical colonization
- Intermediate bioburden state with delayed healing, increased exudate, or new pain but without classic systemic infection signs; requires topical antimicrobial and debridement.
- Wound culture method
- For chronic wounds, obtain tissue biopsy or deep swab after cleansing rather than superficial swab; culture only when clinical infection is present.
- Hydrogel dressing
- Water-based topical dressing that rehydrates dry wounds and supports autolytic debridement; may macerate surrounding skin if exudate is moderate to high.
- Alginate dressing
- Highly absorbent dressing derived from seaweed that forms a gel in exudate; used for moderate to high exudate with a secondary cover, not dry wounds.
- Silver dressing
- Antimicrobial dressing for infected or critically colonized wounds; use for limited duration with reassessment because prolonged use may impair healing and select resistance.
- Protein needs in wounds
- Adults with pressure injuries and malnutrition often need 1.25 to 1.5 grams of protein per kilogram daily, with 30 to 35 kcal/kg/day.
- Teach-back method
- Education technique where the patient explains information in their own words; confirms understanding of offloading, skin checks, and warning signs.
- Premedication for dressing
- Give prescribed analgesia before painful dressing changes; timing depends on onset, and nonadherent dressings reduce trauma and pain.