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Lisa Luiz
wound care, fluid and electrolytes
| Question | Answer |
|---|---|
| wounds | damaged skin or soft tissue resulting from trauma |
| open wound | incision, lac, abrasion, avulsion, ulceration, puncture |
| closed | contusion |
| three phases of wound repair | inflammation, proliferation, remodeling |
| purpose of inflamation | limit local damage, remove injured cells and debris, prepare wound for healing |
| characteristics of proliferation | appearance of granulation tissue |
| process of proliferation phase | new cells fill and seal wound, fibroplasts produce collagen, skin integrity restored by resolution, regeneration, scar formation |
| when does proliferation occur? | 2 days to three weeks AFTER inflammatory phase |
| remodeling phase | Contraction of wound and shrinkage of scar |
| how long does remodoling last? | 6 months to 2 years |
| what are the factors affecting wound healing? | Type of injury, Expanse or depth of wound, quality of circulation, amount of debris, presence of infection, health status, age, mobility |
| first inention wound healing | wound edges approximated |
| Second intention wound healing | wound edges widely spaced |
| third intention wound healing | wound edges widely spacd, later closed by device |
| What is the purpose of a dressing? | keep wound clean, absorb drainage, control bleeding, protect from further injury, hold med in place, maintain moist environment |
| Gauze dressing | woven, cloth fibers, highly absorbant |
| transparent dressing | allow wound assesment without removal, non absorbant |
| hydrocolloid | self adhesive, air and water occlusive, opague |
| what is a wound drain? and why do we use them? | Tubes that remove blood and drainage from wound to promate healing |
| what is an open drain? | flat, flexible tube that provides pathway for drainage to dressing |
| what is a closed drain? | pulls fluid by vacuum, has neg pressure, terminates into receptacle |
| suture | knotted ties from silk or nylon |
| staples | wide metal clips |
| debridement | removal of dead tissue |
| complications of wound healing | hemmorage, infection, dehiscence, evisceration |
| serous | inflammatory material composed of serum (clear portion of blood) derived from the blood and serous membranes of the body such as the peritoneum, pleura, pericardium, and men-inges; watery in appearance and has few cells |
| purulent | an exudate consisting of leukocytes, liquefied dead tissue debris, and dead and living bacteria |
| sanguineous | an exudate containing large amounts of red blood cells |
| dehiscence | the partial or total rupturing of a sutured wound; usually involves an abdominal wound in which the layers below the skin also separate |
| evisceration | extrusion of the internal organs |
| stage 1 pressure ulcer | skin intact, reddened |
| stage ll pressure ulcer | partial thickness, red blistering or skin tear |
| stage lll pressure ulcer | full thickness, tissue loss to subcutaneous tissue |
| stage lv pressure ulcer | full thickness, to muscle or bone |
| risk factors/pressure uclers | decreased mobility, edema, incontinence, decreased mental status,, decreased sensation, increased body heat, increased age |
| keloid. | a hypertrophic scar containing an abnormal amount of collagen |
| Serous exudatev | inflammatory material composed of serum (clear portion of blood) derived from the blood and serous membranes of the body such as the peritoneum, pleura, pericardium, and men-inges; watery in appearance and has few cells |
| Suppuration | the formation of pus |
| Shearing force | a combination of friction and pressure which when applied to the skin results in damage to the blood vessels and tissues |
| Irrigation (lavage) | flushing or washing-out of a body cavity, organ, or wound with a specified solution |
| Hemostasis | cessation of bleeding |
| Granulation tissue | young connective tissue with new capillaries formed in the wound healing process |
| Hypoproteinemia | small amounts of protein in the blood plasma |
| Collagen | a protein found in connective tissue; a whitish protein substance that adds tensile strength to a wound |
| Hematoma | a collection of blood in a tissue, organ, or space due to a break in the wall of a blood vessel |
| An open wound with jagged edges and the tissue torn apart is called a(n): | laceration |
| A client’s open wound is described as clean-contaminated. What does this mean? | The wound is surgical and without inflammation. |
| Which of the following actions would place a client at the greatest risk for a shearing force injury to the skin? | sitting in Fowler’s position |
| Why is a client with fever predisposed to pressure ulcers? | Metabolism increases, and the cells need more oxygen. |
| A client has a pressure ulcer that is healing by secondary intention. Which of the following findings would be unexpected? | rapid healing |
| A client’s wound is covered with ____________, or dried plasma proteins and dead cells. | eschar |
| A client’s wound is draining thick yellow material. The nurse correctly describes the drainage as: | purulent. |
| The nurse needs to keep a client’s wound covered with a thin layer of petrolatum. Which type of dressing would be most effective? | impregnated nonadherent dressing |
| A client has an open wound with healthy granulation tissue and scant drainage. The wound is being cleaned bid. The nurse should write an order to: | clean the wound once a day |
| When bandaging a client’s foot the nurse should: | work from distal to proximal. |
| normal blood osmularity | 290 |
| Fluid volume deficit (hypovolemia) | an abnormal reduction in blood volume |
| Fluid volume excess (hypervolemia) | an abnormal increase in the body's blood volume; circulatory overload |
| Hypercalcemia | an excess of calcium in the blood plasma |
| Hyperchloremia | an excess of chloride in the blood plasma |
| Hyperkalemia | an excess of potassium in the blood plasma |
| Hypernatremia | an excess of sodium in the blood plasma |
| Hypokalemia | deficiency of potassium in the blood plasma |
| Metabolic acidosis | a condition characterized by a deficiency of bicarbonate ions in the body in relation to the amount of carbonic acid in the body, in which the pH falls to less than 7.35 |
| Obligatory loss | the essential fluid loss required to maintain body functioning |
| Respiratory alkalosis | a state of excessive loss of carbon dioxide from the body |
| ph | a measure of the relative alkalinity or acidity of a solution; a measure of the concentration of hydrogen ions |
| Oncotic pressure | pulling force exerted by colloids that help maintain the water content of blood |
| Intravascular fluid | plasma |
| Intracellular fluid (ICF) | fluid found within the body cells, also called cellular fluid |
| Interstitial fluid | fluid that surrounds the cells, includes lymph |
| Anion | ion which carries a negative charge; chloride, bicarbonate, phosphate, sulfate |
| Active transport | movement of substances across cell membranes against the concentration gradient |
| Transcellular fluid includes fluid: | in the cerebrospinal, pleural, and peritoneal spaces. |
| What are two principal electrolytes found in intracellular fluid? | potassium and phosphate |
| body fluids | all liquids contained within the body |
| homeostasis of fluids | required for optimal functing of the body, balance between fluids and electrolytes |
| percentage of body fluids at age 1 | male 64%, female 64% |
| Percentage of body fluids at age 13-39 | Male 60% Female 55% |
| Percentage of body fluids at age 40-60 | Male 55% Female 47% |
| Percentage of body fluids over age 61 | Male52 % Female 46% |
| Why do men have more water in their body? | They have less adipose |
| effect of resp rate on fluid loss | 22-26 rpm causes fluid loss to go up by 200 cc |
| insensible fluid loss | Comes from breathing, talking, and sweat |
| sensible fluid loss | Fluids that can be measured and include urine, vomit, and stools. Fluid can be measured |
| Non-electrolytes | Substances that DO NOT break down. |
| cations | positively charged electrolytes including Potassium, Sodium, calcium and magnesium |
| Anions | Neg charged electrolytes including chloride, phosphate and bicarbonate |
| main compartments | Intracellular fluids, extracellular, and transcellular |
| Intracellular fluid | Fluid found within the cells and makes up 2/3 the bodys fluid |
| Extracellular fluid | divided into 2 groups, Intercistitial and intravascular. |
| Percentage of extracellular fluid | 20% |
| Intercistial fluids | found between cells, includes lymph and cerebrospinal fluids-found in blood |
| Intravascular fluid | makes up 5% volume and is found within plasma |
| what is the only fluid volume directly affected by fluid intake and excretion | intravascular |
| Chem 7 | CO2, Sodium, Glucose, Phosphate, and magnesium |
| Mild fluid loss | Deficit of 5% loss |
| Moderate fluid loss | 10% loss |
| Severe Fluid loss | 15% fluid loss |
| signs of fluid loss deficits | Thirst, Vertigo, syncope, disorientation, weak pulse, nausea, vomiting, cardiac output, weight loss |
| causes of fluid loss deficits | GI disfunction, diarrhea, renal disfunction, poor oral intake, diabetes insipidus, endocrine dysfunction, neurological dysfunction, fever |
| signs of fluid loss | dry skin, sunken eyes, postural hypertension, elevated BUN,Creat, Dry mucos membranes, prolong tugor, |
| Where should you assess turgor | over forehead or sternum |
Created by:
lisaluiz
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