Fundamentals of Nursing Wound Care lecture notes – Flashcards
Unlock all answers in this set
Unlock answersquestion
functions of skin
answer
protection prevent water loss excretion of waste protection from pathogens temperature regulation sensation production of vitamin B folates metabolism -vitamin D synthesis
question
closed wounds
answer
contusions
question
open wounds
answer
risk for infection
question
full thickness wounds (develop scar tissue)
answer
1) hemostasis 2) inflammatory phase 3) proliferative phase 4) maturation phase
question
hemostasis
answer
stop bleeding -vasoconstrictions + platelets stop bleeding -release growth factor -inflam. cells attracted to site
question
inflammation phase
answer
-3 days, clean wound (vasodiliate) - laukocytes (neutrophils) and macrophages -^ growth factor released, fibroblasts and other cells attracted to wound site. collagen --> by day 2 (helps scar tissue form) redness, swelling
question
proliferative phase
answer
- 3-21 days -angiogenesis -fibroblasts, myofibroblasts, keratinocyte
question
angiogenesis
answer
formation of BV, granulation tissue formation and contraction of wound d
question
maturation phase
answer
- 21 days - 1 1/2 years -collagen fibers of scar tissue reorganized (collagen synthesis)shrink in size -wound becomes stronger over time -scar tissue is fragile in beginning - never as strong
question
partial thickness wounds (brush burn)
answer
inflam response epithelial proliferation and migration reestablishment of epidermal layers * keep them moist *
question
inflam response
answer
-redness, edema, serous clean drainage -24 hrs -releases histamine -> red
question
epithelial proliferation and migration
answer
reproduction of epithelial cells
question
reestablishment of epidermal layers
answer
normal thickness occurs slowly
question
types of wounds
answer
incision abrasions lascerations punctures
question
incision
answer
clean, intentional, sterile technique
question
abrasions
answer
superficial, partial thickness
question
lascerations
answer
traumatic injury
question
punctures
answer
deep wound, step on nail/cut knife
question
wound healing process
answer
clean v dirty acute v chronic (doesn't heal over 3 mon) tissue loss v no tissue loss partial v full thickness
question
partial thickness wound healing process
answer
epidermis (small amount dermal tissue)
question
full- thickness wound healing process
answer
goes to subcutaneous layer -reepitheliazation
question
wound healing
answer
primary intention secondary intention tertiary intention
question
primary intention
answer
surgical incision, suture, approximated (reepithelization occurs within hours) thin scar
question
secondary intention
answer
left open (pressure ulcer) full thickness, skin loss that can't bring together ^ scar tissue leaves individual susceptible to infection
question
tertiary intention
answer
wound left open for a while need to get necrotic tissue out before covering with a skin graph
question
types of draingage
answer
serous sanguineous serosanguineous purulent
question
serous
answer
light pint/yellow drainage
question
sanguinous s
answer
bloody drainage
question
serosanguineous
answer
* most common inbetween serous and sanguineous
question
purulent
answer
thick, creamy, green, brown, tan, odor, pus microorganixms and microphages and leukocytes
question
fun fact: if you were to skin yourself and weigh it
answer
it'd be about 8 lbs
question
factors affecting wound healing
answer
infection smoking medication altered health status age nutrition weight tissue perfusion/oxygenation status psychosocial impact
question
infection
answer
prolongs inflam. phase
question
smoking
answer
vasoconstriction
question
medication
answer
steriods -> impairment of skin
question
altered health status
answer
diabetes, CHF, peripheral vascular disease decrease BF
question
age
answer
older - longer to heal
question
nutrition
answer
protein for healing, vitamins (nutritional needs ^) prealbunmin
question
psychosocial impact
answer
wound -> stress maladaptive symptons stress on whole body and not heal as well
question
hematoma
answer
collection of blod under tissue
question
complications of healing
answer
eschar infection keloid hemorrhbage prolonged hemostasis/bleeding anticoaggulant
question
keloid
answer
overgrowth of scar tissue
question
dihescence
answer
partial or total separation of wound layers -usually abdominal wounds 3-11 days after surgery at risk pts : obese, malnutrition, infection warning ^ inserosangineous drainage prevention: pillow to splint incision when coughing
question
*evisceration*
answer
protrusion of abdominal organs assess pt vital signs cover organ w/ sterile saline cloth NPO- call surgeon
question
diabetics are more at risk for
answer
wound healing
question
granulation tissue
answer
beefy - red
question
wound assessment
answer
color presence of edema approximation of edges presence of sutures /s taples (intact?) presence of drains exudate- amount, color, consistency, odor, thick/thin?
question
what is a peri wound assessment
answer
skin around wound (4 cm around)
question
peri wound assessment
answer
connected / not connected rolled under (epiboly) pink thick, white
question
masceration
answer
moisture, not controlled exudate dressing overlapped skin softens skin, delays healing and ^ chance of skin breakdown
question
chronic wound assessment
answer
-wound location size and type - be accurate, measurements/ drawings -characteristics of wound bed - signs of infection -odor and exudate -conditions of surrounding skin -clinical signs of colonization / localized infection -pain
question
purpose of dressings
answer
-protection -absorption of drainage and contain -aid in hemostasis (bleeding->pressure dressing) -debridement of wound -provide and maintain humidity -splint or immobilize -protect pt from seeing - distressing
question
common types of dressings
answer
-2x2 -4x4, 4x3 -kerlex -ABD pad -tefla -drain sponge -transparent film -impregnated non-adherent -hydrocolloids -hydrogels -polyurethane foams -exudate absorbers -iodaform absorbers
question
wound V.A.C.
answer
-neg pressure to wound bed -stim gran tissue -decrease edema-improve wound healing -arteriole dilation (^ circulation) -enhance proliferation of granulation tissue -enhance lymphatic flow -remove excess fluid -decrease wound edema -decrease bacterial load at wound bed
question
hydrocolloids
answer
provide structure (adhesive) support healing and granulating and debridement (dissolve/get soft)
question
hydrogels
answer
water and glycerin based, soothing dec wound pain debridement moist don't adhere to wound bed
question
impregnated non-adherent
answer
vaseline doesn't allow air - seal
question
penrose drains
answer
advance = pull out rubber band w/ safety pin
question
JP jackson pratt
answer
thinner drainage grenade clamp
question
UNNA boots
answer
roll compression bandages impregnated with zinc oxide, calamine lotion, glycerin, and gelatin to treat ulcers due to chronic venous insufficiency -chronic venous insufficiency / venoustasis ulcer
question
types of drains
answer
hemovac - spring loaded -> blood (surgical site ie knee replacements) if not maintaining suction- let physician know
question
Nursing Diagnosis and Planning impaired skin integrity
answer
risk for infection acute / chronic pain imbalanced nutrition : less than body requirements
question
Nursing Diagnosis and Planning impaired tissue integrity
answer
impaired physical mobility ineffective peripheral tissue perfusion risk for impaired skin integrity
question
securing dressings
answer
adhesive removers - tape elastic, micropore, plastic, silk, paper size montgomery straps - frequent dressing changes kerlex tubular mesh or surgical netting
question
1 in
answer
2.5 cm
question
preparing
answer
check phys orders assessment document
question
what to document about wound
answer
location of dressing appearance of dressing drainage/exudate/amount patient response type of dressing applied allergies
question
binders purpose
answer
help hold dressings in place (obese, prevent tension on sutures) -limit motion to promote healing -dec trauma, edema and discomfort- stabilization
question
ace wraps
answer
bandages should be firm but not too tight secure with pins or tape stump dressing -reshape *distal and work way up * VENOUS RETURN
question
simple dressing change
answer
-MD order -Prepare -clean v sterile technique -reinforce dressing v change dressing -explain to pt what doing
question
heat and cold
answer
a) skin and nerve receptors adapt to temp b) transferred by conduction c) tolerance varies between people and body parts d) tolerate greater extremes when for shorter periods
question
HEAT application
answer
IMMEDIATE effect is VASODILATION PROLONGED effect is VASOCONSTRICTION
question
purpose of heat application
answer
-promote circulation -promote exudation -decrease muscle spasms -decrease chills
question
methods of heat application
answer
electric heating pad hot water bottle k-pad sitz bath soaks heat/cradle lamp (drying inhibits healing)
question
diabetics -sensations
answer
not too hot or cold of a temperature with a diabetic neuropathy
question
application of COLD
answer
IMMEDIATE effect is VASOCONSTRICTION PROLONGED effect is VASODILATION
question
purpose of cold application
answer
-vasoconstriction -reduce exudate and edema -control bleeding -relieve pain -decrease body temp
question
methods of cold application
answer
-ice bag -cold compresses -k-pad -cryo-cuff (knee surgery) -hypothermia blanket
question
wound cleansing
answer
-least contaminated (incision) to most contaminated (outer edges) -gentle friction (get debris off) -same for irrigation - least contaminated to most -drains - clean from drain outward (circular motion) -drains are dirtier than an incision
question
wound irrigation
answer
clean get rid of debris loosen eschar normal saline
question
wound packing
answer
healing from inside out help with debridement pack with what physical orders
question
staples and remover
answer
scissors orders may be to remove every other and to use steri-strips
question
debridement
answer
removal of dead tissue debris and bacteria from a wound
question
why use/do debridement
answer
dead tissue, slough and debris in a wound may : -delay or prevent healing -mimic or hide infection -attract bacteria and increase risk of infection -diminish ability to assess wound -increase odor
question
types of debridement
answer
-autolytic -surgical/sharp -biosurgical/chemical -mechanical -ultrasound
question
autolytic debridement
answer
-use body moisture to shed dead/devitalized tissue -dressings used to add moisture / absorb excess exudate -slower than other debridement methods
question
dressing types
answer
hydrogels transparent films hydrocolloid alginates or hydrofibres - used for deep or very wet wounds
question
surgical debridement
answer
-quickest method for debridement -scalpel or scissors used
question
bio-surgical / chemical debridement
answer
-enzymes or maggots used to breakdown necrotic tissue -MD order required
question
mechanical debridement
answer
-wet to dry dressings -whirlpool -jet lavage -irrigation
question
mechanical debridement wet to dry dressings
answer
moist dressings allowed to dry in wound then removed- pulls out tissue, both necrotic and viable non-selective debridement pull out good tissue and necrotic tissue
