Wound care

skin appearing black in color

"That is necrotic tissue, which must be removed to promote healing

4 phases of healing

1. hemostasis 2. inflammation 3. proliferation 4. maturation

gunshot wound cleaning

Clean the wound from the top to the bottom and from the center to outside

What is true about the dermis?

It is responsible for producing the proteins collagen and elastin. It is the thickest skin layer

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?

Rotate the swab several times over the wound surface to obtain an adequate specimen

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn

Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown

negative-pressure wound therapy for a client with a pressure injury, I should implement which nursing assessment?

assessing the wound for active bleeding

yellow wound

cleans, drainage and slough might be present, exudate & yellow fibrous debris; treat with moist-to-moist dressing,

Maturation

collagen is remodeled and the scaring is formed

Hemostasis phase

constricting blood vessels, blood clotting begins.

black

debridement, must be removed

Dehydrated tissue with crusty wound

desiccation

Jackson-Pratt drain removes

foul-smelling drainage that is grayish in color

proliferation phase

granulation tissue is formed

undermining

normally one or more directions, hard to manage, cause is infection, dehydration, poor care

tunneling

one or more directions, from tissue to tissue or organ.

typically exits a client's skin through a stab wound created by the surgeon

penrose

remodeling phase of wound repair

period during which the wound undergoes changes and maturation

Red wound

protect & cover, using gentle cleansing

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage

serosanguineous

Coccyx wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound, 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound?

stage III

purpose for a T-tube drain is

to provide drainage for bile

Inflammatory phase

white blood cells move to the wound