Lewis chapter 11

An infection involves

invasion of tissues or cells by microorganisms such as bacteria, fungi, and viruses.

Clean wounds that are granulating and re-epithelializing should be

kept slightly moist and protected from further trauma until they heal naturally

A pressure ulcer is

localized injury to the skin and/or underlying tissue (usually over a bony prominence) as a result of pressure or pressure in combination with shear.

what does the inflammatory response do?

neutralizes and dilutes the inflammatory agent, removes necrotic materials, and establishes an environment suitable for healing and repair

Levine's technique

rotating a culture swab over a cleansed 1-cm2 area near the center of the wound. Use sufficient pressure to extract wound fluid from deep tissue layers

Pressure ulcers generally fall under the category of healing by

secondary intention.

A skin tear is a wound caused by

shear, friction, and/or blunt force resulting in separation of skin layers

what do you measure second with the wound

side to side

cellulitis

spreading of inflammation to subcutaneous or connective tissue

The inflammatory response can be divided into a

vascular response, cellular response, formation of exudate, and healing.

The purposes of wound management include

(1) protecting a clean wound from trauma so that it can heal normally, (2) cleaning a wound to remove any dirt and debris from the wound bed, and (3) treating infection to prepare the wound for healing.

Protein is needed to

171correct the negative nitrogen balance resulting from the increased metabolic rate

It is also important to use enough irrigation pressure to adequately clean the pressure ulcer (4 to 15 psi) without causing trauma or damage to the wound. To obtain this pressure, use

30-mL syringe and a 19-gauge needle.

A wound is

a break or opening into the skin.

For wounds that heal by primary intention, it is common to cover the wound or incision with

a dry, sterile dressing that is removed as soon as the drainage stops or in 2 to 3 days

The inflammatory response is

a sequential reaction to cell injury

Jackson-Pratt drain is

a suction drainage device consisting of a flexible plastic bulb connected to an internal plastic drainage tube

Wounds often occur because of

accidents or injuries.

Dryness is

an enemy of wound healing.

Topical antimicrobials and antibactericidals (hydrogen peroxide) should

be used with caution in wound care because they can damage the new epithelium of healing tissue and delay healing. Therefore they should never be used in a clean granulating wound.

when should a culture and sensitivity test be done

before the first dose of antibiotic is given

Vitamin C is needed for

capillary synthesis and collagen production by fibroblasts

Untreated ulcers may lead to

cellulitis, chronic infection, sepsis, and possibly death.

what do you record with drainage

consistency, color, and odor of any drainage.

If an infection develops what test should be done?

culture and sensitivity test to determine the organism and the most effective antibiotic for that specific organism

Local care of the pressure ulcer may involve

debridement, wound cleaning, application of a dressing, and relief of pressure.

Partial-thickness wounds

extend into the dermis

Full-thickness wounds

have the deepest layer of tissue destruction because they involve the subcutaneous tissue and sometimes even extend into the fascia and underlying structures such as the muscle, tendon, or bone

what do you measure first with the wound?

head to toe

inflammation can also be caused by

heat, radiation, trauma, chemicals, allergens, and an autoimmune reaction.

what kind of diet promotes healing?

high in protein, carbohydrate, and vitamins with moderate fat intake

Individuals at risk for wound healing problems are those with

malabsorption problems (e.g., Crohn's disease, gastrointestinal [GI] surgery, liver disease), deficient intake or high energy demands (e.g., malignancy, major trauma or surgery, sepsis, fever), and diabetes.

what dressing material is optimal to promote epithelialization?

material that keeps the wound surface clean and slightly moist

Thoroughly assess the wound

on admission (or first clinic visit) and on a regular basis thereafter.

A superficial wound involves

only the epidermis.

A skin tear can be

partial thickness or full thickness. This type of wound is common, especially in older adults and critically or chronically ill adults.

shearing force

pressure exerted on the skin when it adheres to the bed and the skin layers slide in the direction of body movement [e.g., when pulling patient up in bed

Protein is also necessary for

synthesis of immune factors, leukocytes, fibroblasts, and collagen, which are the building blocks for healing

To find the depth of the ulcer

take a sterile cotton-tipped applicator and soak it with saline. Gently place it into the deepest part of the ulcer, and then measure the length of the portion of the applicator that probed the ulcer.

Factors that influence the development of pressure ulcers include

the amount of pressure (intensity), length of time the pressure is exerted on the skin (duration), and ability of the patient's tissue to tolerate the externally applied pressure

Carbohydrate is needed for

the increased metabolic energy required in inflammation and healing

document the characteristics of the wound and surrounding area. This includes

the location, size, depth, undermining and tunneling, wound margin ,

when using NPWT monitor

the patient's serum protein levels and fluid and electrolyte balance because of losses from the wound. Additionally, monitor the patient's coagulation studies (platelet count, prothrombin time [PT], partial thromboplastin time [PTT]).

Vitamin A is also needed in healing because it aids in

the process of epithelialization. It increases collagen synthesis and tensile strength of the healing wound.

Chronic wounds are

those that do not heal within the normal time (approximately 3 months).

Negative-pressure wound therapy (NPWT) is used to

treat acute and chronic wounds. and remobe fluid

how long after a swab culture and sensitivity test should it be sent to the laboratory?

within one hour