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68WM6 Phase II Ch13
Surgical Wound Care
| Question | Answer |
|---|---|
| incision stress | nausea, vomitting, abdominal destention, coughing, respiratory efforts |
| wound healing stress | age, nutritional status, physical condition, preexisting health problems, medication habits, properative skin prep, surgical procedure, surgical environment, post op wound care |
| incision | a cut produced surgically by a sharp instrument creating an opening into an organ or space in the body |
| puncture | stab wound for a drainage system |
| 4 classifications of wounds | 1. clean 2. clean-contamintated 3. contaminated 4. dirty or infected |
| clean wound | uninfected surgical wound, chance of infected 5% |
| clean-contaminated wound | surgical wound into the respiratory, gastrointestinal, genitourinary tract, chance of infection 3%-11% |
| contaminated wound | wound with presence of GI products, resulting from acute non purulent inflammation, or when aseptic technique is broken during surgery, chance of infection 10%-17% |
| dirty wound | wound infection prior to surgery (gangrenous toe), chance of infection 27% |
| 4 phases of wound healing | 1. hemostasis 2. inflammatory 3. reconstruction 4. maturation |
| hemostasis phase | fist phase of wound healing: termination of bleeding begins as soon as the injury occurs, clot begins to form |
| fibrin | holds the wound together |
| inflammatory phase | second phase of wound healing, increase in blood elements (antibodies, electrolytes, plasma proteins) and water flow out of bvs and into vasxular space, cells migrate and divide, clot dissolves, redness, heat, swelling, pain, leukocyte appearance |
| wound seal time frame | 24-48 hrs withing inflammatory phase |
| erythema | redness |
| edema | swelling |
| leukocytes | bodys vacuum cleaner, engulf bacteria, fungi, toxic proteins, and viruses...during inflammation phase |
| reconstruction phase | third phase of healing, fibroblasts procuce collagen, formation begins 3rd or 4th day of injury lasts for 2-3 weeks |
| collagen | a gluelike protein substance that adds tensile stength to the wound and tissue |
| maturation phase | final phase of wound healing, collagen production increases from day 5 to 25, wound's appearance changes to irregular, raised, purplish, immature scar, wound dehiscence most frequently occurs, keloid may form |
| keloid | an overgrowth of collagenous scar tissue at the site of the wound, color ranges from red to pink to white, elevated, rounded, and firm, most common in African-American, dark complexion caucasions, and young women |
| 3 types of wound healing | 1. primary intention 2. seconodary intention 3. tertiary intention |
| primary intention | primary union, skin edges are close together (usually an insicion) begins during inflammatory phase of healing, leaves fine scar |
| secondary intention | occurs when skin edges are not close together or when pus has formed, granulation tissue fills in the wound, leaves a large scar |
| granulation | soft pink fleshy projection consisting of capillaries surrounded by fibrous collagen |
| tertiary intention | delayed primary intention, occurs when a contaminated wound is left open and sutured closed after the infection is contolled occurs when a primary wound becomes infected, is opened, is allowed to granulate, and then is suture, causes deep scar |
| factors in wound healing | nutritonal needs, fluid intake of 2000-2400mL in 24 hours until patient hydration is stabe (usually 24 to 72 hrs, movement and preexisting conditions |
| coughing precautions | apply a pillow, rolled bath blanket, or palms of the hand to the incisional area to lessen intraabdominal pressure |
| surgical incision site selection | may be selected based on drain placement, and organ involved, disease process, inflammation, infection, strength of site |
| common closures | sutures staples steri-strips butterfly strips transparent sprays films bandages to support incision |
| dressing inspection | 2-4hrs for the first 24hrs |
| sanguineous | day of surgery exudate pertaining to blood |
| serosanguineous | day of surgery exudate, thin and red, composed of serum and blood |
| serous | a later exudate, thin and watery composed of blood serum |
| inflammatory response | a tissue reaction to injury depends on the level of damage inflicted, size of the area, and physical condition of the patient |
| phagocytosis | process by which certain cells engulf and dispose of microorganisms and debris |
| infectious process | condition caused by the invasion of the body by pathogenic micobes, changes can be measured in the WBC count |
| process: before wound care | 1. medical record 2. introduce 3. identify pt 4. explain procedure (layman's terms) 5. advise patient of unpleasantness 6. pt teaching 7. asess pt: baseline info 8. wash hands, don gloves 9. assemble equip. 10. prep: pull curtain, raise bed, drape |
| process: during wound care | 1. promote pt involvement 2. assess pt tolerance |
| process: completion of wound care | 1. assist pt to POC 2. raise side rails 3. remove gloves, gown, goggles 4. wash hands 5. document pt response 6. report any unexpcted outcomes |
| gauze | used until epithelialization occurs, permits air to reach the wound |
| semiocclusive | dressing that permits oxygen but not air impurities to pass, keep wound moist yet sterile |
| occlusive | dressing that permits neither air nor oxygen to pass, keeps wound moist yet sterile |
| anchoring | use of tape ties, bandages, cloth binders to secure dressing, type used is based on wound size, location, drainage presence, frequency of dressing changes, and pt activity level |
| 30 minutes prior | When should an analgesic be given in dressing changes? |
| 24 hours post op | when is a dressing change done on a closed surgical wound? |
| pathogenic | any microbes capable of producing disease |
| sterile asepsis | absense of germs, when used reduces risk of aquiring a nosocomial infection |
| nosocomial infection | hospital aquired infection |
| gown, mask, goggles | what do you wear if wound exudate is expected? |
| dry dressing | what type of dressign is used for a wound with little drainage, and abbrasion, or nondraining post-op incisions? |
| use sterile saline, or water | what do you do if a dry dressing has adhered to a wound? |
| wet-to-dry dressing | dressing whos primary purpose is to mechanically debride wound |
| wet-to-dry dressings | what type of dressing is used used for wounds with large amounts of necrotic tissue or large amounts of exudate? |
| commonly used wetting agents | saline, LRs, acetic acid, sodium hypochlorite, povidone-iodine |
| every 24 hours to prevent harboring of microbes | when should wetting solutions be discarded? |
| transparent dressings | self adhesive, acts as a temporary second skin, adheres to undamaged skin to contain exudate, amd serve as a barrier, allowing wound to breathe and promote a moist environment that speeds up cell growth |
| process: irrigation | 1. sterile or clean technique 2. tip should remain 1in above the wound 3. 35ml syringe with 19 gauge needle 4. position pt so fluid flows away from wound |
| soft catheter | used in irrigation if it is a deep wound with a narrow opening |
| handheld shower | may be used in home irrigation, should be held 12 inches from wound and a washcloth over if pressure is not well tolerated |
| whirlpool | used for irrigation if everything else has not been tolerated by pt |
| wound irrigation | promotes wound healing, removes debris from wound surface, loosens eschar |
| eschar | black leathery crust on a wound |
| solutions for irrigation | water, saline, mild detergents |
| basic wound cleansing | applying antiseptic solutions with sterile gauze or by irrigation |
| irrigation | gentle washing of an area with a stream of solution delivered through a syringe |
| from the area being cleansed to an area that is both distal to and lower than the wound area: from healthy tissue to infected tissue | which way does irrigation move? |
| medicate your pt if necessary!!! | what do you do before an irrigation procedure? |
| a slipped suture, dislodged clot, coagulation problem, or trauma to a bv or tissue | what may wound bleeding indicate? |
| hemorrhage | pt with s/s of increased thirst, restlessness, rapid, thready pulse, decreased bp, decrease urinary output, cool, clammy skin |
| serosanguineous drainage | what precedes dehiscence? |
| dehiscence may have occured | what may have happend if a pt say something has "given way" post sneezing, couching, vommitting? |
| steri-strip or butterfly closures | what is used to close a dehiscence? |
| postop day 5-12 | what day range does dehiscence usually occur? |
| evisceration | medical emergency following a dehiscence when an abdominal organ protrudes through an opened inscision. |
| pt is to stay in bed, wound covered with warm sterile dressign, surgeon should be notified immediatley | protocol for pt with eviserated dehiscence? |
| wound sepsis | classified by the CDC as a wound with pus (purulence), usually occurs in fourth or fifth post op day |
| fever, tenderness, pain at the wound, edema, and elevated wbc count | s/s of a wound with infection? |
| institutional policy followed by a physicians writtien orders | who authorizes the removal of staples or sutures/staples? |
| usually 7-10 days post op or sooner based on wound healing | when are sutures/staples removed? |
| method based on physician preference to remove every staples, every other, or ever other and replace with steri-strips | how do we determine how to remove sutures/staples? |
| sutures | wire, silk, cotton, linen, nylon, or dacron used to sew body tissues together, placed withing tissue layers deep in wounds, and superficially as the final mean s for closure |
| deep sutures | usually made of an absorbable material and disappear in several days |
| types of sutures | interrupted, separate, blanket, or retention with rubber tubing |
| staples | made of stainless steel wire, are quick and provide ample strenght. popular for skin closure of abdominal incisions and orthopedic incision when appearance is not critical |
| retention sutures | sutures left in place 14 days or longer |
| the remaining sutures/staples are left in place, document, and tell the physician. | what is done if the incision line begins to seperate during suture/staple removal? |
| exudate | material that fluid/cells discharge through their cell membrane |
| drainage | removal of fluids from a body cavity or wound |
| 300ml in the first 24 hours | what amount of exudate or drainage is considered a cause for concern? |
| ambulation | may increase exudate/ drainage |
| color amount consistency odor | what about the drainage/exudate do we chart? |
| infection is likley | what does a pungent strong odor ususally mean? |
| only with the physicians orders! | when should soiled dressing be removed? |
| stab wound | puncture made deliberately for surgical drainage |
| closed drainage | system of tubing attatched to the body to remove fluid in an airtight circuit that prevents environmental contaminants from entering the wound or cavity |
| open drainage | drainage that passes through an open-ended tube into a receptacle or out onto a dressing |
| suction drainage | uses a pump or other mechanical device to help extract a fluid |
| penrose drain | exaple of open drainage |
| Hemovac, RediVacettemSnyder | example of closed drainage |
| Jackson-Pratt, Davol | example of closed drainage systems that use a bulb to provide needed vacuum |
| T-Tube drainage | closed surgical drainage system usually post colecystectomy, where a tube is inserted into a duct to maintain a free flow of bile until edema subsides |
| woundVAC | a device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together, accelerates wound healing by promoting formation of granulation tissue, collagin, fibroblasts, and inflammatory cells |
| 3 or 4 days | how long before a bacterial cell count drops once you apply a woundVAC? |
| every 24 hrs | how often do woundVAC dressing get changed on an infected wound? |
| three times per week | how often do woundVAC dressing get changed on a clean wound? |
| bandage | strip or roll of cloth or other material that may be wound around a part of the body in a variety of ways for multiple purposes |
| binder | bandage that is made of large pieces of material to fit a specific body part, made of elastic, cotton, muslin, or flannel |
| first 2 to 3 days | when is wound inflammation normal? |
| 7 to 10 days | when should normal healing of a wound, including filling with epithelial cells, and edges closing? |
| 1. malnutrition 2. hypernutrition 3. improper perfusion | 3 things that do not support tissue repair? |
Created by:
ahughes0919
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