HN-Chapter 12 Inflammation/Wounds
How should concurrent swab specimens be obtained?
-wound exudate -z-technique -Levine's technique
Secondary Intention
-wounds that need to heal from bottom-up and outside-in
Tertiary Intention
-wounds that were sutured but came undone or surgical wounds that were not closed immediately due to complications
Should one use antiseptics when cleaning a pressure ulcer?
No! because they are cytotoxic; just use normal saline water
what is the purpose of a wet-to-dry dressing?
purpose to trap necrotic tissue in dressing as dries
What are the two major components of the healing process?
regeneration repair
What is the most important nursing intervention for the prevention and treatment of pressure ulcers?
repositioning the patient a minimum of every 2 hours
When should pressure ulcer risk be assessed first?
upon admission
How often should one reassess a patient for pressure ulcers in long-term care?
weekly for first 4 weeks, then at least weekly or quarterly
How should a red wound be treated?
-protect wound -topical antibiotic -non-adhearing dressing -keep moist
How should a yellow wound be treated?
-require cleaning to heal -dressing that absorbs exudate and lenses surface -hydrocolloid dressings
How to treat Black wounds
--debridement of nonviable, eschar tissue --debridement, enzymatic, otolytic
Hyperbaric O2 therapy
--delivery of O2 at increased atmospheric pressure --allows O2 to diffuse serum
How do you cleanse a wound
--horizontal wound --vertical wound --drain or stab wound
How should a culture be done?
--obtained by wound exudate --done in z-technique --Levine's technique (goes deeper into wound)
How do you treat a Red Wound
--protect the wound --topical antibiotic --non-adhearing dressing --keep moist
How do you treat a Yellow wound
--require cleaning to heal --dressing that absorbs exudate and cleanses the wound --hydrocolloid dressings-binds to wound and forms a gel --use duodenum dressings
What is negative-pressure wound therapy?
--suction removes drainage and speeds healing --monitor serum protein levels and coagulation studies -wound vac has a pulling pressure-more suction than Jackson-Pratt
What is the purpose of wet-to-dry dressings
--the purpose is to trap necrotic or nonviable tissue in the dressing as it dries --dressing should be moist when applied and allowed to dry for 4-6 hours --when dressing changed, gently remove and do not soak packing before removal because that would decrease the removal of nonviable tissue
Primary Intention
-are surgical wounds that have been surgically closed
what is hyperbaric O2 therapy?
-delivery of O2 at increased atmospheric pressure -allows O2 to diffuse into serum -lasts 90 to 120 min
List the order of wound care for pressure ulcers
1. exudate absorbing 2. debriding 3. hydrating 4. antimicrobial 5. wound-assisted closure-vacuum therapy
Would should ulcer care be like?
Dressings should protect wound, be biocompatible and hydrate
What is the final phase of the inflammation process?
Healing process
Should you massage over bony prominences?
NO
should you soak the packing of a wet-to-dry dressing before removal?
NO- it will decrease the removal of nonviable tissue
RICE
Rest Ice Compression Elevation
What is RICE
Rest Ice Compression Elevation
What nutrients aid in capillary synthesis and collagen production by fibroblasts in wound healing?
Vitamin C
What nutrients aid in capillary synthesis and collagen production by the fibroblasts in wound healing?
Vitamin C
How should nutrition be changed for healing purposes?
caloric intake elevated to 30 to 35 cal/kg/day or 1.25 to 1.5 g protein/kg/day
How should a black wound be treated?
debridement of nonviable, eschar tissue in order to allow healing
How often should a person be shifted in a chair to prevent pressure ulcers?
every 15 minutes
How often should one reassess a patient for pressure ulcers in acute care?
every 24 hours
What is the final phase of inflammation
healing
Where should you measure a wound
measure from top to bottom and from side to side
what is negative-pressure wound therapy?
suction removes drainage and speeds healing
What are the three forms of debridement?
surgical mechanical enzymatic/autolytic
