Tunneling wound spread out underneath skin

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tunneling)- wound spread out underneath skin surrounding visible part of sore/portion of wound continues to travel into deeper tissues Granulation tissue- red moist tissue composed of new blood vessels, the presence of which indications progression toward healing. Abrasion- superficial with little bleeding and considered a partial-thickness wound Laceration- a torn ragged wound that sometimes bleeds more profusely Puncture wounds bleed in relation to depth and size of wound. Primary dangers are internal bleeding and infection. Primary intention healing- line up wound edges and heal Secondary intention healing- granulation tissue fills in space Tertiary healing- purposely leave wound open Ulcer Staging -Stage 1- intact skin with nonblanchable redness of a localized area, usually over bony prominence. -Stage 2- partial-thickness skin loss involving epidermis, dermis, or both. Ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. -Stage 3- Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. may include undermining and tunneling. -Stage 4- Full-thickness tissue loss with exposed bone, tendon, or muscle, often includes undermining and tunneling. Unstageable- full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, black) in wound bed. Types of Wound Drainage Serous- Clear, watery plasma Purulent- Thick, yellow, green, tan or brown Serosanguineous- pale, red, watery: mixture of clear and red fluid Sanguineous- Bright red: indicates active bleeding Partial-Thickness Wound Repair- (inflammatory, proliferation and migration, reestablishment of epidermal layers) Tissue trauma causes the inflammatory response which in turn causes redness/swelling and moderate amount of serous exudate, limited to the first 24 hrs. Epithelial proliferation and migration- epithelial cells begin to regenerate. A wound left open to air can resurface within 6-7 days vs wound that is kept moist can resurface in 4 days. (epidermal cells can only migrate across a moist surface). New epithelium is only a few cells thick and must undergo reestablishment of the epidermal layers where they slowly reestablish normal thickness and appear as dry, pink tissue.
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Skills Test 3 (ex: repair of a clean surgical wound or abrasion) Full-Thickness Wound Repair- ( inflammatory, proliferative, remodeling) - -Inflammatory begins within minutes of injury and lasts about 3 days. During hemostasis , injured blood vessels constrict and platelets gather to stop bleeding. Clots form a fibrin matrix that later proves a framework for cellular repair. -Proliferative Phase- appearance of new blood vessels begins and lasts from 3-24 days. Main activities are filling of wound with granulation tissue, contraction of the wound, resurfacing of wound by epithelialization.
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