Nursing Interventions Wound Care – Flashcards
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wound healing
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a process of tissue response to injury
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phases of healing depend on
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thickness of wound
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partial thickness wound-epidermis and dermis
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inflammation regeneration
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full thickness wounds phases of wound helaing
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hemostasis inflammation proliferation maturation
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promotes wound healing
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Well balanced diet Protein Vitamin A & C Hydration: 8-10 glasses fluid daily Rest periods Activity modification Prevent pressure and tension on wound
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local wound healing factors
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depth of wound nature of injury wound environment moisture pressure internal external trauma edema
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systemic factors
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- age (inflammatory response) (collagen synthesis) - pain and stress - nutrition (protein, vitamins, A,C,K,B, minerals Zinc Fe - nitrogen balance - body build (obesity, emaciation) - smoking - tissue perfusion and oxygenation - co morbid conditions
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nicotine characteristics
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vasoconstrictor increases platelet adhesion
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tissue perfusion and oxygenation effects
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collagen synthesis neutrophil function macrophage funstion
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co morbid conditions
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chronic diseases medications
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surgical wounds can be
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clean clean/contaminated contaminated
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abrasion
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scuff
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laceration
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deeper wounds
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puncture
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hole in skin
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contusion or hematoma
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bruise
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skin tears
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traumatic separation of epidermis form dermis
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pressure ulcers causes
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unequal distribution of pressure shearing force
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stage 1
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pressure injury - lightly pigmented
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blanchable vs non-blanchable
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blanchable means pressure fades with pressure
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unstageable pressure injury
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slough and eschar
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eschar
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dry or leathery gray to black
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slough
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yello/white to gray stringy or thick
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pressure ulcer scales
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braden and norton scale
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braden scale
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Sensory perception Moisture Activity Mobility Nutrition Friction & shear
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norton scale
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Physical condition Mental condition Activity Mobility Incontinent (1-4)
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pressure relief measures
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- reposition every 2 hours - use of pillows - maintain funcitonal alignment - hell/elbow protectors - lambswool/padding - bed crad;es - support surfaces (static overlay, foam, dynamic overlay) -specialty beds
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some speciailty beds
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kinar and clinitron bed
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primary intention wound observe for
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edge approximation
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primary intention wound closure
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-sutures -staples -steristips -wound glue
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secondary intention wound observe
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for granulation tissue
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secondary ointention wound complications
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- hemorrhage - hematoma (solid swelling of clotted blood within the tissues) - dehiscence (wound ruptures along a surgical incision) - evisceration (organs coming out of wounds) -tunneling/fistula (n abnormal or surgically made passage between a hollow or tubular organ and the body surface, or between two hollow or tubular organs) - infection
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dehiscence and evisceration risk factors
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Obesity Inadequate nutrition Stress on wound Infection Smoking tobacco Anticoagulation use
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infection signs
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- edema at site - increased pain - erythema (superficial reddenign) - warmth - increased drainage w/ odor - febrile (fever)
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wound assessment
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- full assessment weekly - wound photography w/ consent - mesurement, centimeters. length, width, depth - exudate/drainage - wound bed appearance wound bed integrity - wound margins and surrounding skin - presence of pain
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exudate/drainage observations
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Amount Consistency Odor Color
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serous
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clear
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serosanguinous
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clear and bloody
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sanguinous
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bloody
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perulent
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yellow-green
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wound bed appearance
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RYB classification
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red
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granulation tissue
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tellow
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slough
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black
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necrotic tissue
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wound bed integrity
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tunneling
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wound cultures
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- culture and sensitivity - gram stain
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obtaining a wound culture
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- clean wound before culturing - roll swab to maximize contact - use different swab for different sites
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purposes of wound dressings
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- Provide physical and aesthetic comfort - Protect from further injury - Prevent or control infection - Absorb drainage - Protect skin surrounding wound - Maintain moist wound environment - Remove necrotic tissue
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types of primary dressings
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- non adhesive dsg telfa - gauze 2x2 gauze 4x4 gauze - transparent dsg tegaderm - ABD pad
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keeping dressings in place
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tape - adhesive - paper - stretch self-adhesive dressings
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secondary dresings
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montgomery straps (lace up) wrap cling gauze adhesive wrap stockinette
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aseptic technique always face
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sterile field
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aseptic techique
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- Sterile items must always be above waist - Edges of field are considered contaminated - sterile only comes in contact with sterile - keep movements controlled to prevent airborne pathogen contamination - moisture causes contamination
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external heating devices
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Aquathermia pad Hot water bottle Crushable microwavable packs
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cold application devices
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Cooling blanket Ice bag Ice collar, glove Crushable pack
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pruritis relief
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- lotions - limit bathing - use tepid water - cool baths or compresses - medication
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edema relief
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- elevation - sodium restriction - compression stockings wraps
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NANDA nursing diagnoses
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Impaired skin integrity (or risk for) Impaired tissue integrity Risk for infection Ineffective tissue perfusion: peripheral
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associated diagnoses
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Self-care deficit Activity intolerance Risk for trauma Acute/chronic pain Deficient knowledge r/t wound care Disturbed body image Impaired physical mobility
