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