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