Surgical Asepsis: Risk For Dehiscence/evisceration Nanda

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Risk for Dehiscence/Evisceration
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Anyone w/ poor wound healing Poor nutritional status/malnourished, obese Infections, increased stress Can occur w/ exaggerated coughing, vomiting, straining
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NANDA Diagnoses
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Impaired skin/tissue integrity Risk for infection/trauma/imbalanced nutrition Alteration in comfort Body image disturbance
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Nursing Interventions
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Multidisciplinary care planning needed Encourage patient independence and patient accomplishments Educate patients/families about how to minimize factors that impair wound healing
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WOCN
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Wound, Ostomy, and Continence Nurses
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Debridement
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Removal of foreign material/dead tissue to discourage microogranism growth
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Surgical debridement
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Using a scalpel/scissors
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Enzymatic debridement
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Placing chemical products like collagenase into wound
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Autolytic debridement
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Occlusive/hydrocolloid dressing
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Mechanical debridement
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Wet-to-dry saline gauze dressing
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Type of Dressing to use depends on…
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Assessment of wound, location, drainage and phase of healing
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Transparent Film dressing
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Semipermeable Remains in place 3-5 days
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Polyurethane foams used for what kind of wounds?
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Partial/full wounds with small to moderate amount of drainage
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What do polyurethane foams provide?
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Absorption and protection and moist wound surface
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Hydrocolloid/Hydrogels Dressing encourages…
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Granulation and assists with autolytic debridement (3-5 days)
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Alginate Dressing used for what amount of drainage?
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Moderate to heavy drainage
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What does Alginate Dressing to?
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Forms gel when in contact with exudate and absorbs 20x its weight
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Wound Vac System
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Negative pressure therapy for open wounds/hard to heal wounds
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What does a Wound Vac System do?
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Removes and quantifies wound drainage and aids in formation of granulation tissue

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