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infection and wounds
infection, wounds, and pressure ulcers
| Questions | Answers |
|---|---|
| Medical asepsis | a sterile techique includes all practices intended to confine a specific microorganism to a specific area, limiting the number growth and transmission of microorganisms |
| Vehicle | any substance that serves as an intermediate means to transport and introduces an infectious agent into a susceptible host through a suitable portal of entry |
| Iatrogenic infections | are the direct result of diagnostic or therapeutic procedures |
| compromised host | a person at increased risk an individual who for one or more reasons is more likely than others to acquire an infection |
| colonization | the process by which strains of microorganisms become resident flora |
| nonspecific defenses | protect the person against all microorganisms regardless of prior exposure |
| parasites | live on other living organisms |
| vector | an animal or flying or crawling insect that serves as an intermediate means of transporting the infectious agent |
| fungi | include yeast and molds |
| Carrier | a person or animal reservoir of a specific infectious agent that usually does not manifest any clinical signs of disease |
| Viruses | consist primarily of nucleic acid and therefore must enter living cells in order to reproduce |
| antigens | part of bodys plasma protein |
| regeneration | is renewal of tissue |
| Hemostasis | is the cessation of bleeding that results from vasoconstriction of the larger blood vessels in the affected area, retraction (draw back) of injured blood vessels the depostion of fibrin (connective tissue) and the formation of blood clots in the area. |
| exudate | a material such as fluid and cells that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces |
| Bandage | a strip of cloth used to wrap some part of the body |
| Ischemia | is a deficiency in the blood supply to the tissue |
| irrigation (lavage) | the washing or flushing out of an area |
| pressure ulser | any lesion caused by unrelieved pressure (a compressing downward force on a body area) that results in damage to underlying tissue as defined by the U.S. Public Health Services Panel for the prediction and prevention of pressure Ulcers in adult |
| Collagen | a whitish protein substance that adds tensile strength to the wound |
| reactive hyperemia | when pressure is relieved from compressing the skin and then takes on a bright red flush |
| shearing force | is a combination of friction and pressure |
| Risk assessment tools | braden scale, 4 stages of pressure sores including unstageable |
| primary intention healing | occurs where the tissue surfaces have been approximated (closed)and there is minimal or no tissue loss |
| secondary intention healing | a wound that is extensive and involves considerable tissue loss and in which the edges connot or should not be approximated |
| tertiary intention or delayed primary intention | that are left open for 3 to 5 days to allow edema or infection to resolve or exudate to drain and are then closed with sutures staples or adhesive skin closure heal |
| serous exudate | consists chiefly of serum (the clear portion of the blood) derived from blood and the serous membranes of the body such as the peritoneum |
| purulent exudate | is thcker than serous exudate because of the presence of pus which consists of leukocytes liquefied dead tissue debris and dead and living bacteria |
| purulent exudates very in what color | vary in color some acquiring tinges of blue, green or yellow the color may depend on the causative organism |
| sanguineous exudate | consists of large amounts of red blood cells indicating damage to capillaries that is severe enough to allow the escape of red blood cells from plasma. |
| serosanguineous | (consisting of clear and blood-tinged drainage) exudate is commonly seen in surgical incisions |
| purosanguineous | discharge (consisting of pus and blood) is often seen in a new wound that is infected |
| dehiscence | is the partial or total rupturing of a sutured wound |
| evisceration | is the protrusion of the internal viscera through an incision |
| what may precede dehiscence | sudden straining such as coughing or sneezing |
| your patient has a Braden scale of 17 what is the appropriate nursing action | implement a turning schedule the cleint is at increased risk of skin breakdown |
| proper technique for performing a wound culture is | cleansing the wound prior to obtaining the specimen |
| why do we leave heat on for only 30 min | heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the one desired (dilation) |
| what items are used to perform wound irrigation | clean gloves to remove the old dressing and to hold the basin collecting the irrigating fluid plus sterile gloves to apply new dressing and a 60-mL syringe |
| Stage I care | Skin prep, granulex Hydrocolloid dressing Transparent dressing (only on unbroken skin) |
| Stage II care | Transparent dressing (preferably over hydrocolloid, but not actually touching wound) Hydrocolloid dressing |
| Stage III care | Wet to dry gauze dressing with sterile NS Hydrocolloid dressing Proteolytic enzymes |
| Stage IV care | Wet to dry gauze dressing with sterile NS Vacuum-assisted closure (VAC) |
| incision wound | open wound caused by a sharp instrument (eg knife scalpel) |
| contusion wound | closed wound skin appearing ecchymotic (bruising) because of damaged blood vessels caused by blow from a blunt instrument |
| abrasion wound | open wound involving the skin caused by surface scrape with unitentional or intentional |
| puncture wound | open wound caused by penetration of the skin and often the underlying tissues by a sharp instrument either intentional or unintentional |
| laceration wound | open wound caused by open wound edges often jagged caused by tisssues torn apart often from accident (eg with machinery) |
| penetrating wound | open wound caused by penetration of the skin and the underlying tissues usually unitentional (eg from a bullet or metal fragment) |
| Gauze | Retain dressings on wounds Bandage hands and feet (Kerlix) |
| Elasticized | Provide pressure to an area Improve venous circulation in legs |
| Binders | Support large areas of body Triangular arm sling; straight abd binder |
| Types of bandages | Transparent Film Hydrocolloids Impregnated Nonadherent Hydrogels Polyurethane Foams Hydrophilic Hydrophobic Alginates |
| Nutrition | Need Protein, Carbs, Lipids, Vitamins A and C, |
| Minerals | Iron, zinc, and copper. |
| Medications | Steroids, ASA, Antineoplastics (chemo) inhibit healing |
| Prolonged or repeated antibiotic use can lead | resistant organisms & superinfections (MRSA, VRE) |
| Friction | is a force acting parallel to the skin surface |
| immobility | refers to a reduction in the amount and control of movement a person has |
| Local infection | limited to the specific part of the body where the microorganism remain |
| inflammation | a local and nonspecific defensive response of the tissues to an injurious or infestious agent |
| communicable | if the infectious agent can be transmitted to an individual by direct or indirect contact or as an airborne infection the resulting condition is called a ________ disease |
| opportunistic pathogen | causes disease only in a susceptible individual |
| opportunistic | the freedon from disease only in a susceptible individual |
| bacteria | by far the most common infection-causing microorganisms |
| free from infection | in medical asepsis objects are considered clean or _______ |
| sepsis | the state of infection and can take many forms including septic shock |
| Virulence | the ability to produce disease |
| Nosocomial | infections that are associated with the delivery of health care services in a health care facility |
| Regeneration | the replacement of destroyed tissue cells by cells that are identical or similar in structure and function |
| Antiseptices | agents that inhibit the growth of some microorganism |
| Asepsis | freedon from disease causing microorganisms |
| proliferative phase | the second phase in healing extends from day 3 or 4 to about day 21 post injury |
| 1.inflammation 2. Reconstruction (Proliferative) 3. Maturation 4. remodeling | the four phases in healing in order |
| Vasodilation | the process in which extra blood floods to the area to compensate from the preceeding period of impeded blood flow |
| eschar | If the wound does not close by epithelialization the area become covered with dried plasma proteins and dead cells |
| 48 hours | the greatest time period for the risk of hemmorrhage right after surgery |
| dihiscence | the partial or total rupturing of a sutured wound |
| clean wounds | unfected wounds in which there is minimal inflammation and the respiratory gastrointestinal genital and urinary tracts |
| clean - contaminated wounds | surgical wounds in which the respiratory gastrointestinal genital or urinary tract has been entered such show no evidence of infection |
| contaminated wounds | include open fresh accidental wounds and surgical wounds involving a major break in sterile technique or a large amount of spillage from the gastointestinal tract contaminated wounds show evidence of inflammation |
| Dirty or infected wounds | include wounds containing dead tissue and wounds with evidence of a clinical infection such as purulent drainage |
| decubitus ulcers | ulcers were previously called |
| maceration | moisture from incontinence promotes skin (tissue softened by prolonged wetting or soaking) and makes the epidermis more easily eroded and susceptible to injury |
| excoriation | Digestive enzymes in feces and gastric tube drainage and urea in urine also contribute to skin _____ (area of loss of the superficial layers of the skin: also known as denuded area) |
| suppuration | the process of pus formation |
| primary intention healing and secondary intention healing | the two types of healing, influenced by the amount of tissue loss |
| 3.5 g/dL | an Albumin value below ____ indicates poor nutrition and may increase the risk of poor healing and infection |
| aerobic | growing only in the presence of oxygen |
| anaerobics | growing only in the absence oxygen |
| hydrocolloid | a client has a pressure ulcer with a shallow partial skin thickness eroded area but no necrotic area the nurse would treat it with what kind of dressing |
| Heels, sacrum. elbows, scapulae, back of head | areas are being pressured in the supine postion |
| malleolus, knee, greater trochanter, llium, shoulder, ear side of head | areas are being pressured in the lateral postion |
| toes, knees, genitalia, breasts, shoulder, cheek and ear | areas are being pressured in the prone postion |
| Heels, pelvis, sacrum, vertebrae | areas are being pressured in the fowlers postion |
| DERMABOND ADVANCED | is a liquid bonding agent that holds many cuts, wounds, and incisions together as effectively as stitches do.1,2 |
| Phagocytosis | essential to healing |
| Leukocytes (neutrophils) | move into interstitial space. Replaced ~ 24 hours after injury by macrophages that engulf |
| Angiogenesis factor | secreted to stimulate new blood vessel formation to ↑ circulation in wound to aid with healing process |
| Anti-inflammatory meds (steroids) | may inhibit this process and delay healing |
| Reconstruction (Proliferative) Phase of Wound Healing | post-injury day 3 or 4 until day 21 |
| Maturation Phase of Wound Healing | Day 21 until 1-2 years after injury Collagen re-organization Remodeling or contraction of wound |
| Inflammatory Phase of Wound Healing | Immediately after injury; lasts 3-6 days |
| Keloid | can form if abnormal amount of collagen is laid down. Hypertrophic scar, or “proud tissue”. More common in darker-skinned persons |
| Allergic contact dermatitis | Erythema (redness) Edema Pruritis Vesicles Bullae |
| Irritant contact dermatitis | Discrete area of redness at exposure location |
| <18 | Braden Scale at risk |
| 23 point score | Braden Scale possible total points |
| 15-16 | Braden Scale mild risk |
| 12-14 | Braden Scale mod risk |
| 11 or less | Braden Scale severe risk |
| Infection signs | redness/edema/exudate/odor |
| For mod to lg amt drainage: | Foam |
| For scanty to sm amt drainage: | Hydrogel or Hydrogel or Hydrocolloid impregnated gauz |
| Transparent adhesives | Debride +A/ absorb N/A / Fill N/A / sheild from bacteria + / insulate + / Moisten + / Guildlines for use change 1X WK |
| Hydrocolloids | Debride +A/ absorb + / Fill N/A / sheild from bacteria + / insulate + / Moisten + / Guildlines for use change 2X WK |
| absorption or filler dressing | Debride +A / absorb + / Fill + / sheild from bacteria N/A / insulate N/A / Moisten + / Guildlines for use change QD |
| Semipermeable / polyurethane form | Debride N/A / absorb + / Fill N/A / sheild from bacteria + / insulate + / Moisten + / Guildlines for use change depending on drainage |
| Hydrogels | Debride +A/ absorb + / Fill + / sheild from bacteria N/A / insulate + / Moisten + / Guildlines for use change QD |
| opsite, Tegaderm | Transparent adhesives |
| Tegasorb, comfeel Duoderm, restore | Hydrocolloids |
| Bard absorption Sorbsan, Curasorb (calcium alignate) DuoDerm paste Iobosorb, aguacel | absorption or filler dressing |
| polymem, flexan allevyn, Lyoform optifoam | Semipermeable / polyurethane form |
| solosite, flexigel strands safgel | Hydrogels |
| Function of inflammation | allows repair of injured area to proceed at faster pace. Always present with infection, but also can occur in absence of infection. --Contains injury --Destroys microorganisms |
Created by:
ED.
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