Chapter 38 fundamentals review

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Prolonged cold can cause tissue damage due to inadequate circulation ( frostbite)

Fibrin ( pg 761)

Protein essential to clotting

What is fibrin formation?

Protein that helps clotting process.

Evisceration

Protrusion of an internal organ through an incision.

Sharp debridement?

Room or OR 1) May be performed with scissors and forceps-by doctor. 2) painful 3) Cut til bleeds 4) Sterile technique 5) Premedicate patient for pain.

SAFETY ALERT ( pg 773) Certain solutions are toxic to growing and normal cells and should not be used to cleanse granulating wounds. Never use Dakin solution (sodium hypochlorite), acetic acid, povidone-iodine, or hydrogen peroxide to clean an uninfected , granulating wound.

Scar tissue slowly thins and becomes paler

Serosanguineous (pg 766)

Serum and blood mixture

Integument ( pg 760)

Skin

Eschar ( 767)

Sloughing dead tissue, usually caused a thermal injury or gangrene.

Maceration (pg 781)

Softening of tissue from soaking in moisture.

Avulsion (table 38.1 pg 760)

Tearing away of a structure or a part, such as a fingertip, accidentally or surgically.

Telfa and other non adherent dressings - good absorption and less traumatic.

Dehiscense

The spontaneous opening of an incision

The type of wound indicates the type of dressing needed. ( pg 766)

The type of wound indicates the type of dressing needed (pg 766)

What do steroids do?

They mask the signs and symptoms of infection

The healing "intention" is known as delayed or secondary closure, sutures after granulation tissue has begun to form?

Third intention

When assessing for wound infection, you know that signs of wound infection may be: (Select all that apply) ( pg 768 DeWitt) 1) A rise in temperature 2) Pink granulation tissue 3) A WBC count greater than 10,000 4) Purulent drainage 5) Tenderness around the wound.

1) A rise in temperature 3) A WBC count greater than 10,000 4) Purulent drainage 5) Tenderness around the wound.

What is the Braden scale?

1) A scale for Predicting Pressure Ulcer Risk 2) The total score can range from 6 to 23 3) A lower score indicating a higher risk. SEVERE RISK- Total score < 9 HIGH RISK - Total score 10-12 MODERATE RISK - Total score 13-14 MILD RISK - Total score 15-18

What nursing diagnosis is applicable for the goal/expected outcome Pain will resolve when infection is cleared? ELSEVIER 1) Acute pain related to an infected wound 2) Anxiety related to the need to perform wound care 3) Acute pain related to a healed wound 4) Impaired skin integrity related to trauma

1) Acute pain related to an infected wound. Acute pain related to an infected wound is the most applicable to the stated goal/expected outcome.

What factors affect wound healing?

1) Age a) Children and adults heal more quickly than the elderly. b) Those with chronic health conditions. 2) Peripheral vascular disease ( PVD ) a) Impaired blood flow/ slows healing 3) Decreased Immune system function 4) Decreased production of antibodies and monocytes necessary for wound healing 5) Reduced liver function a) Impairs the synthesis of blood factors b) Liver biggest organ inside the body 6) Decreased lung function a) Reduces oxygen needed to synthesize collagen and new epthelium 7) Nutrition a) Protiens b) Carbohydrates c) Lipids d) Vitamins 8) Life style a) The person who does not smoke and who exercises regularly will heal more quickly. 9) Medications a) Steroids and other anti-inflammatories, heparin, and antineoplastic agents interfere with the healing process. 10) Infection 11) Chronic illness a) Diabetes b) Cardiovascular disease c) Immune system diseases May cause slow wound healing Wound healing s delayed due to decreased oxygen and nutrients at the cellular level

ADPI

1) Assess 2) Diagnosis 3) Plan 4) Implementation 5) Evaluation

What would be the nursing responsibilities concerning staples or a wound closure?

1) Assess the wound at every shift 2) Encourage the patient to use a pillow or folded blanket for splinting. (coughing , deep breathing) 3) Documenting wound appearance 4) Notify physician of problems.

Proliferation phase of wound healing

1) Begins on third ( 3rd ) or fourth (4th) day and lasts 2-3 weeks 2) Macrophages continue to clear the wound of debris, stimulating fibroblasts, which synthesize collagen ( Main ingredient of scar tissue.) 3) New capillary networks formed to provide oxygen and nutrients to support the collagen and for further synthesis of granulation tissue. 4) Granulation tissue is deep pink a) A full thickness wound begins to close by contraction as new tissue is grown 5) Scarring influenced by degree of stress on the wound. 6) AFTER 15 -20 DAYS - The risk of wound separation or rupture decreases.

A client who had abdominal surgery 24 hours ago suddenly reports a pulling sensation and pain in his surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? ( Select all that apply) ATI BOOK 1) Cover the area with saline soaked sterile dressings. 2) Apply an abdominal binder snugly around the abdomen. 3) Use sterile gauze to apply gentle pressure to the exposed tissues. 4) Position the client supine with hips and knees bent. 5) Offer the client a warm beverage , such as herbal tea.

1) Cover the area with saline soaked sterile dressings. The nurse should cover the wound with a sterile dressing soaked with sterile normal saline solution to keep the exposed organs and tissue moist until the surgeon can assess and intervene. 4) Position the client supine with hips and knees bent. This position minimizes pressure on the abdominal area.

Name a solution that damages granulation tissue?

1) Dakins 2) Acetic acid 3) H2O2 4) Povidone iodine

Main purposes of cold application?

1) Decrease swelling- Often immediately after injury to prevent or reduce swelling 2) Decrease pain

When caring for a pressure injury, you know that: ( pg 768 DeWitt) 1) Eschar must usually be removed before the wound will heal. 2) Pink granulation tissue should be cleansed with antiseptic solution. 3) Keeping the wound dry and covered will aid healing. 4) Heat treatments hurt new tissue and slow healing.

1) Eschar must usually be removed before the wound will heal. By allowing dead tissue to remain in the wound bed, it increases the risk of infection and minimizes the ability of the tissue to heal, because the nutrients needed for healing to take place can be significantly impaired if the wound bed is not kept clean.

Third Intention

1) Ex: Abdominal wound left open for drainage and later closed. ( Ruptured appendix )

Second Intention

1) Ex: Decubitus ulcer ( pressure ulcer) 2) A wound with tissue loss 3) Edges of wound do not approximate; a) Wound is left open and fills with scar tissue.

First Intention ( pg 762)

1) Ex: Surgical incision 2) A wound with little tissue loss 3) Edges of the wound approximate , and only a slight chance of infection.

Maturation phase of wound healing

1) Final phase begins about three (3) weeks after injury a) May take up to 2 years b) Scar maturation ( remodeling) is the process where collagen is lysed ( broken down) and resynthesized by macrophages, producing strong scar tissue. c) Scar tissue slowly thins and becomes paler. d) When process is complete- scar is FIRM and NONELASTIC.

Active drains?

1) Has suction Plastic drainage tubes can be connected to a closed drainage system. Example: a) Hemovac b) Jackson-Pratt

What are complications

1) Hemorrhage 2) Infection 3) Cellulitis

A nurse is collecting data from a client who is 5 days postoperative following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound and blood specimens for culture and sensitivity. Which of the following findings should the nurse expect? ( Select all that apply ) ATI BOOK 1) Increase in incisional pain 2) Fever and chills 3) Reddened wound edges 4) Increase in serosanguineous drainage 5) Decreased in thirst

1) Increase in incisional pain 2) Fever and chills 3) Reddened wound edges

What are signs that a wound is infected?

1) Increased pain 2) Redness 3) Warmth of surrounding tissues 4) Purulent exudate

Platelet aggregation, formation of fibrin, and phagocytosis occur during which phase? ELSEVIER 1) Inflammatory 2) Proliferation 3) Maturation 4) Healing

1) Inflammatory The inflammatory phase begins immediately after injury and lasts about 4 days. Hemostasis, clot formation, and phagocytosis occur during the inflammatory phase, not the proliferation or maturation phases. Healing is not a phase of wound healing.

Phase of wound healing?

1) Inflammatory phase 2) Proliferation phase 3) Maturation phase THESE PHASE OVERLAP

Assess

1) Inspect skin ( s/s )

What are signs and symptoms of hemorrhage?

1) Internal hemorrhage a) Swelling b) Disruption of wound c) Blood drainage- (Sanguinous) in drain- large amount 2) Extensive Hemorrhage a) Leads to s/s shock: 1) Decreased blood pressure 2) Increased pulse rate 3) Increased respiration's 4) Restlessness 5) Diaphoresis 6) Cold clammy skin

Cross sensitivity for CAT scan dye?

1) Iodine 2) Shellfish 3) Betadine 4) Sulfa

What are the steps to ensure appropriate wound healing? ( Box 38.1 pg 763 )

1) Keep surrounding skin and tissue clean and dry. 2) Ensure adequate oxygen and nutrient supply to the wound by maintaining appropriate body positioning to prevent undue or prolonged pressure. 3) Ensure dressings, compression stockings, NPWT, and wound VAC units , and drains are applies and positioned correctly so that circulation is not impaired and the risk of developing lymphedema is minimized. 4) Report any signs or symptoms of infection immediately to ensure appropriate therapies are quickly initiated. 5) Provide appropriate nutrition and optimize blood glucose levels to aid in the healing process.

A nurse is caring for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the clients skin? ( select all that apply ) 1) keep the head of the bed elevated 30 degrees. 2) Massage the clients bony prominence frequently. 3) Apply cornstarch liberally to the skin after bathing. 4) Have the client sit on a gel cushion when in a chair. 5) Reposition the client at least every 3 hours while in bed. ATI BOOK

1) Keep the head of the bed elevated 30 degrees. The nurse should slightly elevate the client head head of bed to reduce shearing forces that could tear sensitive skin on the sacrum, buttocks, and heals. 4) Have the client sit on a gel cushion when in a chair. The nurse should have the client sit on a gel , air, or foam cushion to redistribute weight away from ishial areas.

Cross sensitivity for latex allergies ( pg 234 )

1) Kiwis 2) Avocados 3) Bananas 4) History of reactions to other latex containing products.

Inflammatory phase of wound healing

1) Localized protective response 2) Begins immediately and lasts 1 - 4 days a) Vascular constriction Stops bleeding b) Platelet aggregation ( Clumping ) c) Fibrin formation ( Protein that helps clotting process.) d) Hemostasis e) Clot formation f) Chemical release ( histamine and prostaglandins g) Capillaries dilate/ permeable h) Serous fluid ( contains electrolytes) leaks into traumatized area. i) Phagocytosis begins/macrophages

Full thickness wounds

1) No dermal layer present except at margins of wounds. 2) All necrotic (dead) tissue must be removed , so granulation tissue can fill in. 3) Wound heals by contraction

Passive drains?

1) No suction and works by increased pressure in the wound. Example: Penrose drain which is a flat rubber tube.

What are the risk factors for dehiscence?

1) Obesity - Number one reason 2) Poor nutrition 3) Excessive coughing 4) Multiple trauma 5) Strong sneezing 6) Vomiting 7) Suture failure 8) Dehydration GREATEST RISK FOR DEHISCENCE IS POST OP DAY 4-5 BUT UP TO 2 WEEKS, BEFORE COLLAGE HAS BUILT UP

Which factors affect wound healing in the older adult? Select all that apply. ELSEVIER 1) Peripheral vascular disease (PVD) 2) Atherosclerosis 3) Improved immune function 4) Reduced liver function

1) Peripheral vascular disease (PVD) 2) Atherosclerosis 4) Reduced liver function PVD and atherosclerosis impair blood flow, which can impede healing. Reduced liver function impairs synthesis of blood factors, which can impede healing. Decline in immune function reduces formation of antibodies and monocytes necessary for wound healing; therefore improved immune function would actually assist in wound healing.

Suture removal requires?

1) Physician order to remove sutures and staples. 2)Sterile technique should be used 3) Sutures usually removed by physician at about 7-10 days

What do you do if evisceration / or dehiscence occurs

1) Place the patient in supine position 2) Place large sterile dressings over the viscera 3) Soak the dressings in sterile normal saline 4) Notify the surgeon immediately 5) Prepare the patient for return to surgery a) Keep NPO

What is the purpose of dressings?

1) Prevent microorganisms from entering the wound 2) Absorb drainage 3) Control bleeding 4) Support and stabilize tissues. 5) Reduce discomfort.

What abnormal findings does a nurse need to report to the physician about dressings?

1) Profuse drainage 2) Pain not being controlled by prescription medications. 3) Vital signs abnormal.

Implementation

1) Provide wound care 2) Use sterile gloves to touch a fresh surgical wound 3) Wound cleaning solutions a) NS b) Sterile water c) Wound cleaner- noncytotoxic

What is the first thing you do where there is a dehiscense?

1) Put the patient in a supine position

What are the two primary processes of wound healing?

1) Replacement 2)Regeneration

A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? ( select all that apply) 1) Stage III pressure ulcer 2) Sutured surgical incision 3) Casted bone fracture 4) Laceration sealed with adhesive 5) Open burn area

1) Stage III pressure ulcer Open pressure ulcers heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges. 5) Open burn area Open pressure ulcers heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges.

Acute phase of an infection is characterized by?

1) Sudden onset of symptoms r/t (related to) Vascular changes a) Fluid collects in tissue b) WBC's invade c) Skin becomes red/warm 2) Bacterial infections often cause wound drainage and should be assessed for color, consistency, and order 3) Purulent drainage contains pus- Dead phagocytes and bacteria

Partial-thickness wounds

1) Superficial wounds 2) Heal more quickly by producing new skin cells a) Remain in dermal layer 3) Fibrin clot forms framework for growing new cells.

What are the clinical signs of the inflammatory process?

1) Swelling or edema of the injured part. 2) Erythema (redness) resulting from the increased blood supply. 3) Heat or increased temperature at the site. 4) Pain stemming from pressure on nerve receptors. 5) A possible loss of function resulting from all these changes. SIGNS- YOU CAN SEE SYMPTOM- WHAT PATIENT STATES- Pain

What might be a sign of impending dehiscense?

1) The flow of serosanguineous drainage 2) Patient states "something has given way"

Stages of healing

1) The length of each phase is dependent on type of wound and if healed by; a) 1st intention b) 2nd Intention c) 3rd Intention 2) Stages of healing are interwoven a) Different part of the wound can be in different stages of healing. 3) Joint wound require special attention to maintain joint mobility, and prevent contractures( Abnormal shortening of the muscle) 4) Adhesion's are fibrous bands in the body, that hold tissue together. a) They can grow abnormally during wound healing and attach to organs. 5) Keloids- Overgrowth of collagen, causing a permanent raised scar.

An abdominal wound left open for drainage and then later closed is an example of healing by: ELSEVIER 1) Third intention. 2) Second intention. 3) Fourth intention. 4) First intention.

1) Third intention. Third intention is known as delayed or secondary closure and occurs when there is delayed suturing of a wound. Healing by second intention occurs when the wound is left open and fills with scar tissue. Fourth intention is not a type of wound closure. Healing by first intention occurs when a wound has little tissue loss.

Who can sign consent?

1) Under 18 with a child ( not pregnant ) 2) Under 18 and married 3)Under 18 in the military 4) Legally emancipated 5) In the event that someone is not there to sign consent; a) Second surgeon b) second physician

Treatment of wounds

1) wound cleaning should be performed with warm isotonic saline

Specific gravity ( sp gr )

1.003 - 1.030

Magnesium (Mg)

1.3 - 2.1 mg/dl

BUN ( Blood urea nitrogen )

11-23

Sodium (Na)

135-145 mEq/l

Platelets ( PLT )

150,000 - 400,000

Cold packs applied during the first 24 hours after an injury decreases swelling by: ( pg 768 DeWitt) 1) Increasing vasodilation so blood flow will carry away excess fluid. 2) Causing vasoconstriction and decreasing bleeding from damaged blood vessels. 3) Decreasing circulating blood volume so that swelling cannot occur. 4) Dulling pain and thereby reducing cellular enzyme release.

2) Causing vasoconstriction and decreasing bleeding from damaged blood vessels. If the blood and other fluids are restricted from being able to get to the injury, it can ad in minimizing pain and significant swelling and possible long-term complications.

When are sutures usually removed?

7-10 days

Calcium ( Ca )

8.4 - 10.6

Cloride ( Cl)

96-106 mEq/L

COLD THERAPY IS APPLIED FOR A MAXIMUM OF 20 MINUTES.

Your patient has had abdominal surgery for a ruptured appendix and requires postoperative care and dressing changes. The wound has been left open, and irrigation's are ordered. When irrigating a wound, it is MOST important to? ( pg 768 DeWitt) 1) Irrigate slowly to prevent discomfort. 2) Ensure the solution reaches the depths of the wound. 3) Prevent wetting of the bed and covers. 4) Use vigorous irrigation flow from the syringe.

2) Ensure the solution reaches the depths of the wound. If wound irrigation is not performed correctly, it increases the risk of severe peritonitis in this type of wound management because the exudate is not removed effectively.

A nurse is caring for an adolescent client who is 2 days postoperative following an appendectomy and has type I diabetes mellitus. The client is tolerating a regular diet. He has ambulated successfully around the unit with assistance. He requests pain medication every 6-8 hours while reporting pain at a 2 on a scale of 0-10 after receiving the medication. His incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing ( Select all that apply) ATI BOOK 1) Extremes in age 2) Impaired circulation 3) Impaired/ suppressed immune system 4) Malnutrition 5) Poor wound care

2) Impaired circulation 3) Impaired/ suppressed immune system The client who has type 1 diabetes mellitus is at risk for impaired circulation.

Which phase of healing begins about 3 weeks after injury? ELSEVIER 1) Proliferation 2) Maturation 3) Inflammatory 4) Reconstruction

2) Maturation The final stage of healing, maturation, begins about 3 weeks after injury. Scar maturation, or remodeling, is the process of collagen lysis and collagen synthesis by the macrophages to produce the strongest scar tissue possible. The proliferation phase begins on the third or fourth day after injury. The inflammatory phase begins immediately after injury. The reconstruction phase is the same as the proliferation phase.

If a wound appears infected, you should? ( pg 768 DeWitt) 1) Cleanse it with an antiseptic solution. 2) Obtain orders for a culture to be performed. 3) Apply an antibiotic ointment. 4) Change the dressing every two ( 2 ) hours.

2) Obtain orders for a culture to be performed. In order to ensure the correct treatment is prescribed, it is important to obtain a wound culture prior to the start of any type of antimicrobial agent. This also minimizes the risk of the patient developing a multi drug resistant organism.

Your patient with a leg wound asks about NPWT. You answer her question based on your knowledge that NPWT: 1) Decreases cellular proliferation. 2) Is contraindicated in infected wounds. 3) Can sometimes speed wound healing. 4) Minimize mechanical stretch of cells.

3) Can sometimes speed wound healing. NPWT has been shown to speed healing in some wounds. It increases cellular proliferation , is useful in infected wounds, and assists with mechanical stretch of cells, which promotes development of new granulation tissue.

A nurse finds an increased amount of serosanguineous drainage into the patient's abdominal wound dressing and the patient reports "something has given way." What has likely occurred? ELSEVIER 1) Evisceration 2) Fistula 3) Dehiscence 4) Abscess

3) Dehiscence Dehiscence is the spontaneous opening of an incision. Evisceration is the protrusion of an internal organ through the incision. Fistula is an abnormal passage that may form between two internal organs. Abscess is a localized infection with an accumulation of puss.

Which phase of the healing begins on the 3rd or 4th day after an injury and lasts 2 to 3 weeks? 1) First 2) Inflammatory 3) Proliferation 4) Maturation

3) Proliferation

Proper technique for removal of sutures is to: ( pg 768 DeWitt) 1) Clip the suture below the knot. 2) Assure the patient that the suture removal does not hurt. 3) Refrain from pulling an exposed suture through the wound. 4) Apply a steri-strip before removing suture.

3) Refrain from pulling an exposed suture through the wound. If the exposed sutures have not been cleansed prior to removal, and if poor technique is used to remove them, it can introduce pathogenic microorganisms into and along the suture line.

Potassium ( K)

3.5 -5.0 mEq/l

Which factor will promote wound healing? ELSEVIER 1) Steroids 2) Limitation of activity 3) Increased adipose tissue 4) Added protein

4) Added protein A diet rich in protein is needed for wound healing. Steroids inhibit the inflammatory response and can delay wound healing. Regular exercise contributes to enhanced blood circulation and promotes wound healing. Adipose tissue has less blood supply and predisposes the obese patient to risk of wound infection and slower healing.

Which type of debridement uses the body's enzymes to break down nonviable tissue in the uninfected wound? ELSEVIER 1) Sharp 2) Enzymatic 3) Chemical 4) Autolytic

4) Autolytic Enzymatic debridement is very useful for uninfected wounds. Autolytic debridement is a longer process that uses the body's enzymes to break down nonviable tissue in the wound. It is best used on small, uninfected wounds. Sharp debridement is done when there are signs of cellulitis or sepsis. Chemical debridement is occasionally used on a wound with necrotic tissue which is not responding to other treatments.

The assessment of the wound indicates healing is occurring when? ( pg 768 DeWitt) 1) The center tissue is white. 2) Bleeding has stopped. 3) There is no further drainage from the wound. 4) Pink granulation tissue is visible.

4) Pink granulation tissue is visible. Newly formed, healthy tissue is typically ink, regardless of skin tone; All other options are signs of infection.

The microorganism most frequently present in wound infections is: ELSEVIER 1) Escherichia coli. 2) Proteus vulgaris. 3) Pseudomonas aeruginosa. 4) Staphylococcus aureus.

4) Staphylococcus aureus. The microorganism most frequently present in wound infections is Staphylococcus aureus.

Which of the following is not a factor in wound healing? 1) Age 2) Medications 3) Lifestyle 4) Type of wound

4) Type of wound

White blood cells ( WBC)

4.5- 10 ( 6 - 8 ) thousand

Hematocrit

40%

Contusion (table 38.1 pg 760)

A bruise Tissue injury without breaking of skin

Sinus ( pg 766)

A fistula ( Canal or passageway) leading from an abscess to the outside of the body.

Abscess ( pg 765 )

A localized infection which is an accumulation of purulent exudate made up of debris from phagocytosis when microorganisms have been present. The fluid may be: 1) White 2) Yellow 3) Pink 4) Green

What type of dressing is used for infected pressure injuries or ulcers ? ( pg 772)

A non occlusive dressing is always used.

A sign of impending dehiscence may be an increase in the flow of serosanguineous ( serum and blood mixture) drainage into the wound dressing.

What is the most common cause of dehiscense?

A sneeze

Dermabond?

A synthetic , noninvasive glue- good seal, no dressing 7-10 days.

Laceration (pg 762)

A torn, ragged , or mangled wound

Mechanical stretch of cells causes ?

Cellular proliferation and tissue growth, by increasing blood flow which brings oxygen and nutrients to wound. Bacteria count in wound drops after 2-3 days.

When does the final stage of healing ( maturation) begin?

Approximately 3 weeks after injury

Apply a steri strip to support the incision after suture removal.

Approximate (pg 762)

Close together

Platelet aggregation (pg 761)

Clumping

What is platelet aggregation?

Clumping

ALL patients with fresh surgical wounds should be monitored for signs of hemorrhage.

Contractures

Abnormal shortening of the muscle

Traumic scrapping away of the skin - shearing is an example?

Abraision

Foam dressings

Absorb drainage Example: ABD

Jackson Pratt and hemorrhoids vacation are this type of post open drain?

Active

This type of tissue has less blood supply and predisposes the patient to slower healing andpotential for infection?

Adipose

When are cold applications used most effectively?

After surgeries such as total hip, knee or shoulder, facelifts, tonsillectomies, jaw surgery.

All necrotic (dead) tissue must be removed , so granulation tissue can fill in.

Plan

Allow time for wound and skin assessment Check orders for dressing change Set goals a) Wound well approximated b) wound clean and dry without redness c) Patient will learn to properly change dressing

Fistula ( pg 765)

An abnormal passage or communication usually formed between two internal organs or leading from an internal organ to the surface of the body. May result from an infection , or it may be present congenitally. Common postoperative fistulas are designated according to the organs or parts with which they communicate. A LITTLE TUNNEL

Enzymatic debridement?

An enzyme is used topically and is used to liquefy dead tissue Used for uninfected wounds.

Cellulitis ( pg 765)

An inflammation of the tissue surrounding the initial wound, with redness and induration ( skin hardening)

Assess drainage for color, consistency, odor, and amount , and document.

Tearing away a structure or part?

Avulsion

Wound made by a sharp pointed object through the skin?

Puncture

Erythema (pg 761)

Redness

Hemostasis ( 761)

Blood clotting or vessel compression

Sanguineous (pg 765)

Bloody

Lysis (pg 762)

Breakdown

Surgically made separation of the tissue?

Incision

Debridement (pg 767)

Removal of all foreign or unhealthy tissue from a wound.

Granulation tissue ( 774)

Connective tissue with multiple small vessels.

Purulent ( pg 765)

Containing thick typically white-yellow or yellow exudate, caused by infection. The drainage contains dead phagocytes, bacteria. As infection disappears the drainage lessens , has minimal or no odor, more serous or watery and lightens in color. All signs of inflammation subside as healing occurs.

Tissue injury without breaking the skin?

Contusion

Tissue significantly disturbed or compressed because of high level of force- damage may be internal?

Crush injury

The patient walking down the hall, felt something "give way" saw a large gush of serosanguinous blood- the nurse quickly does what?

Lie the patient flat, sterile towels, sterile saline, call the doctor, prepare patient for surgery

Place barrier between skin and actual ice bag to prevent frostbite.

What is pus?

Dead phagocytes or bacteria

Necrosis (pg 761)

Death or injury to cells.

This treatment can be mechanical, chemical, automatic or sharp?

Debridement

Black wounds?

Presence of eschar that hinders healing and requires removal. Need debridement of dead tissue, usually caused by thermal injury or ganegrene.

Approximation ( pg 772)

Degree of closure

Dressing changes require a medical order and wound irrigation's may be performed only with an order. ( pg 773)

Hydrocolloid dressing

DuoDerm- PROS 1) keep wound moist 2) water and air occlusive 3) self adhesive 4) promotes Autolytic debridement and provides thermal insulation. ( keep wound warm) 5) may leave on 3-5 days and as long as seal is maintained. CONS 1) Cannot see wound 2) Not recommended for wounds with heavy drainage USE 1) Clean, superficial wounds with granulation , mild to moderate exudate. MRSA - containment

Ear irrigation's are used to remove cerumen ( ear wax ) or foreign substances.

Phagocytosis (pg 761)

Engulfing of microorganisms or foreign particles.

Yellow wounds?

Presence of purulent drainage and slough 1) Have a layer of yellow fibrous debris and sloughing; 2) Need to be continually cleansed and have an absorbent dressing This type of wound often becomes infected

Ulceration (table 38.1 pg 760)

Excavation of skin and / or underlying tissue from injury or necrosis.

Adipose (pg 762 )

Fatty; composed of fat cells

Adhesion's ( pg 762 )

Fibrous bands that hold together tissues that are normally separated.

Replacement process of wound healing

Fibrous connective tissue forms. Does NOT have the same functional characteristics as the tissue lost.

Collagen (pg 762)

Fibrous structural protein of all connective tissue; The main ingredient of scar tissue.

Wound with little tissue loss heals by which intention?

First intention

Exudate ( pg 765)

Fluid accumulation containing cellular debris.

GREATEST RISK FOR DEHISCENCE IS POST OP DAY 4-5 BUT UP TO 2 WEEKS, BEFORE COLLAGE HAS BUILT UP

Heat applications are usually ordered for 15-30 minutes

Tissue injury that damages a blood vessel - pooling of blood under the skin?

Hematoma

The process of blood clotting or vessel compression?

Hemostasis

Hot and cold applications usually requires a physicians order and can dry or moist.

This type of dressing is both water and air occlusive; facilitates automatic deride mentioned, stays on 3-5 days?

Hydrochloride/ duoderm

If hemorrhage is internal, hypovolemic shock may occur.

Nursing diagnosis

Impaired skin integrity due to surgical incision Risk for infection

Perforation (table 38.1 pg 760)

Internal organ or body cavity tissue opened, usually because of infection or a penetrating wound.

Abnormal amount of collagen , resulting in a permanent raised scar?

Keloid

Traumatic separation of tissue, irregular torn edges?

Laceration

Large retention sutures may be used if risk of dehiscence.

The best way to prevent wound infection ?

Maintain strict asepsis when performing wound care.

PT/ INR

Measure drug response to warfarin ( Coumadin ) -Blood thinner.

PTT

Measures Heparin therapy

Macrophages (pg 762)

Monocytes that are phagocytic

Montgomery straps hold a dressing in place

NEVER PUSH TO PUT SOMETHING BACK IN AND SOAK IN STERILE SALINE.

NEVER USE A TRANSPARENT DRESSING OVER AN INFECTED WOUND.

Never exceed 105 degrees for water

Hemoglobin

Normal - 12.0 - 18.0 ( 14-15 )

What is NPO?

Nothing by mouth

When a wound infection is suspected?

Obtain a culture

What is an open wound?

Occurring though the skin.

Transparent film dressings

Op-Site 1) Assess wound without removing 2) Cover IV sites, Stage 1, Stage II ulcers 3) Used for superficial , partial thickness wounds 4)Nonabsorbent 5) Change dressing when loose, or every 3-7 days. Only used for stage 1

Keloid ( pg 762)

Overgrowth of collagen, causing a permanent raised scar.

The specialized white blood cells engulf debris and bacteria?

Phagocytes

Wrenching or twisting a joint with partial rupture of thromboembolism ligaments?

Sprain

What microorganism is the most frequently present in wound infections?

Staphylococcus Aureus

Ster-strips can be used if wound is small.

Superficial wounds heal faster when kept moist.

What is the best type of wound to have?

Surgery- Clean and controlled break in the skin.

Surgi pads or abdominal pads (outside has a blue stripe)

Incision (table 38.1 pg 760)

Surgical made separation of tissues with clean , smooth edges.

What is the ONLY wound that is considered clean?

Surgical wound

Surgical wounds and open wound dressing require sterile technique.

Hematoma (table 38.1 pg 760)

Tissue injury that damages a blood vessel. Pooling of blood under the unbroken skin.

Crush ( could cause open or closed wound ) (table 38.1 pg 760)

Tissue significantly disrupted or compressed because of high level of force being applied ( e.g., person pinned against a wall by a car hitting hm at a moderate speed); May or may not be visible lacerations or maceration of tissue.

What is the best way to prevent wound infection?

To maintain strict asepsis ( the absence of bacteria, viruses, and other microorganisms) when performing wound care.

What is the worse type of wound?

Trauma - Regular or irregular and partial or full thickness.

Abrasion (table 38.1 pg 760)

Traumatic scraping away of surface layers of skin.

Does smoking delay wound healing? True or false

True

Is oxygen a good killer of bacteria? True or false

True

Excavation of the skin and or underlying tissue from injury or necrosis?

Ulceration

WBC 19000 mm , blood culturesugar positive for gram positive concise in clusters T- 101.5 , P- 124, R- 24, BP- 130/86 The reason this patient has delayed wound healing is?

Underlying infection

Autolytic debridement?

Used on small uninfected wounds ( High risk for bacteria growth)

Using cold solution lowers the wound temperature , which slows healing. ( pg 773)

What does VAC stand for?

Vacuum assisted closure This applies negative pressure to wounds and draws edges together.

Penetrating (table 38.1 pg 760)

Variable - size open wound through skin and underlying tissues made by a bullet or metal or wood fragment; May extend deeply into body. DANGEROUS , BECAUSE NO FREE FLOW OF BLOOD OUT.

Cold causes what?

Vasoconstriction

Heat causes what?

Vasodilation, which increases blood supply to the area. Heat stimulates metabolism which increases WBC and antibodies to the site. Heat may stimulate pain. Water is a good conductor of heat.

What is a good conductor of heat?

Water

Wet to dry are more rarely used as they disrupt new growth.

Mechanical debridement?

Wet to dry dressing, (nurse), ultrasound mist (painless- 2-3 times a week, or whirlpool.

Regeneration process of wound healing

When blood supply is disrupted to a tissue and cells are damaged beyond recovery, new cells , similar n structure, and function to the original cells are produced. IF the damaged tissue is a type that can regenerate: 1) Skin 2) Muscle 3) Bone liver 4) Kidney 5) Lung Unable to regenerate: 1) Heart muscle 2) Nerve cells

Induration

When skn, which s normally soft, becomes hardened.

Binders ( pg 770)

Wide elasticized fabric bands.

Immunocompromised (pg 765)

With poorly functioning immune system

Evaluation

Wound edges are well approximated

Wound infections slow the healing process

Puncture (table 38.1 pg 760)

Wound made by sharp , pointed object through skin or mucous membranes and underlying tissue. DANGEROUS , BECAUSE NO FREE FLOW OF BLOOD OUT.

What is a closed wound?

Wound without a break in the skin.

Red wounds?

Wounds that are clean and ready to heal. A protective dressing should be used

Wound vac used ?

Wounds that are difficult to heal

Sprain (table 38.1 pg 760)

Wrenching or twisting of a joint with partial rupture of its ligaments; causing swelling.

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