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wound damaged skin or soft tissue
trauma injury
open wound the surface of the skin or mucous membrane is no longer intact
What are some types of open wounds? incision, laceration, abrasion, avulsion, ulceration, puncture
closed wound no opening in the skin or mucous membrane
What are examples of a closed wound? contusion
incision clean separation of skin and tissue with smooth even edges
laceration a separation of skin and tissue in which the edges are torn and irregular
abrasion a wound in which the surface layers of skin are scraped away
avulsion stripping away of large areas of skin and underlying tissue, leaving cartilage and bone exposed
ulceration a shallow crater in which the skin or mucous membrane is missing
puncture an opening of skin, underlying tissue or mucous membrane caused by a narrow, sharp pointed object
contusion injury to soft tissue underlying the skin from the force of contact with a hard object
What is a contusion sometimes called? bruise
What are the sequential phases of wound repair? inflammation, proliferation, and remodeling
inflammation the physiologic process immediately after tissue injury that lasts about 2-5 days
What is the purpose of inflammation? to limit local damage, to remove injured cells and debris, and to prepare wound for healing
Which phase usually last about 2 to 5 days? inflammation phase
What happens immediately following an injury? blood vessels constrict to control blood loss and confines the damage, then the blood vessels dilate to deliver platelets to form loose clot
The local response produces the characteristic signs and symptoms of inflammation. What are the signs and symptoms? swelling, redness, warmth, pain, and decreased function
leukocytes or macrophages types of white blood cells that migrate to the site of injury
leukocytosis an increased production of white blood cells
What is the lab test used to determine leukocytosis? white blood cell count and differential count
What does an increased production of white blood cells, particularly neutrophils and monocytes usually indicate? inflammatory and/or infectious process
phagocytosis process by which these cells consume pathogens, coagulated blood, and cellular debris
What are primarily responsible for phagocytosis? neutrophils and monocytes
What generally cleans the injured area and prepares the site for wound healing? neutrophils and monocytes
proliferation when new cells fill and seal a wound
What process of wound repair occurs from 2 days to 3 weeks after the inflammatory phase? proliferation
proliferation is characterized by the appearance of what? granulation tissue
granulation tissue a combination of new blood vessels, fibroblasts and epithelial cells
What does granulation tissue look like? Why? bright pink to red because of extensive projections of capillaries in the area
collagen a tough and inelastic protein substance
In what ways are the integrity of skin and damaged tissue restored? resolution, regeneration adn scar formation
resolution when damaged cells recover and reestablish their normal function
regeneration cell duplication
scar formation replacement of damaged cells with fibrous scar tissue
remodeling when wound undergoes changes and maturation
How long may the remodeling phase last? 6 months to 2 years
during what phase of wound repair does the wound contract and the scar shrink? remodeling
What are some factors that can affect wound healing? type of wound injury, expanse or depth of wound, quality of circulation, amount of wound debris, presence of infection, status of clients health, purulent or bloody or serous fluid accumulation
What does the speed of wound repair and the extent of scar tissue that forms depend on? whether the wound heals by first, second or third intention
First intention healing or healing by primary intention wound edges are directly next to each other
second intention healing wound edges are widely separated
Why may healing by second intention be prolonged? if the wound contains body fluid or other wound debris
third intention healing wound edges are intentionally left widely separated and later brought together with closure material
which type of healing results in a broad, deep scar? third intention healing
In what way can healing be sped up with third intension healing? drainage devices may be used or packing the wound with absorbent gauze
what are some age related changes which can affect the wound healing in older adults? diminished collagen and blood supply and decreased quality of elastin
what factors can interfere with adequate nutrition in older adults which may impair wound healing? depression, poor appetite, cognitive impairments, physical and economic barriers
What nutrients play important roles in tissue repair? vitamin C and zinc
What is the key to wound healing? adequate blood flow to the injured tissue
what predisposes older adults to wound infections? diminished immune responses from reduced T-lymphocyte cells
what does the nurse assess for on a client with a wound? determine if wound is intact, presence of any unusual swelling, redness, warmth, drainage, increasing discomfort, undermining, slough, necrotic tissue, dehiscence or evisceration
undermining erosion of tissue from underneath intact skin at wound edge
slough dead tissue on wound surface that is moise, stringy, yellow, tan, gray or green
necrotic tissue dry, brown or black devitalized tissue
what are two potentially serious surgical wound complications? dehiscence and evisceration
dehiscence the separation of wound edges
evisceration wound separation with protruding organs
Within how many days after surgery may dehiscence or evisceration occur? within 7 to 10 days after surgery
What are some things that can cause dehiscence or evisceration? insufficient dietary intake of protein & sources of vitamin C, premature removal of sutures or staples, unusual strain on incision, weak tissue or muscular support secondary to obesity, distention of abdomen from intestinal gas, impaired tissue integrity
What should the nurse do if wound disruption or dehiscence occurs? nurse positions client to put the least strain on operated area(supine)
what should the nurse do if evisceration occurs? the nurse places sterile dressings moistened with normal saline over the protruding organs and tissues
what signs should the nurse be alert for if dehiscence or evisceration occurs? impaired blood flow (swelling, localized pallor or mottled appearance, or coolness of tissue in area around wound)
what is the primary goal of surgical or open wound management? to repproximate the tissue to restore its integrity
pressure ulcer wound caused by prolonged capillary compression that is sufficient to impair circulation to skin and underlying tissue
what is the primary goal in managing pressure ulcers? prevention
once a pressure ulcer forms, what is the nurses responsibility? to implement measures to reduce the size of the ulcer and to restore skin and tissue integrity
what is the medical term for pressure ulcers? decubitus ulcers
when lying in a supine position, what area are at risk for developing pressure ulcers? occiput(back of head), dorsal thoracic area, sacrum, coccyx, rim of ear, elbow, and heel
when in a side lying position, what areas are at risk for developing pressure ulcers? side of head, shoulder, perineum, malleus, ischium, trochanter, anterior knee
if in a wheelchair, what area are at risk for developing pressure ulcers? shoulder blade, sacrum, coccyx, ischial tuberosity, foot, and posterior knee
explain stage 1 pressure ulcer. skin is intact but reddened and skin remains red and fails to resume normal color when pressure is relieved
explain stage II pressure ulcer. red with blistering or skin tear without slough
skin tear a shallow break in the skin
at a stage II pressure ulcer, what is a risk factor due to impairment of the skin? colonization and infection of a wound
explain stage III pressure ulcer. shallow skin crater which extends to the subcutaneous tissue, may be accompanied by serous or purulent drainage, and usually is painless despite severity of ulcer
serous drainage leaking plasma
purulent drainage white or greenish fluid
explain stage IV pressure ulcer. life threatening, tissue is deeply ulcerated thus exposing muscle and bone, slough and necrotic tissue may be evident, and foul odor may be present
if an infection is present in a stage IV pressure ulcer, what is the client at risk for? going septic
sepsis a potentially fatal systemic infection
what are the steps in preventing pressure ulcers? identifying clients at risk for developing pressure ulcers and to implement measures which reduce conditions in which pressure ulcers are likely to form
which clients are at risk for developing pressure ulcers? clients who are inactive, immobile, malnourished, emaciated, diaphoretic, incontinent, have vascular disease, have localized edema, are dehydrated or are sedated
in order to prevent pressure ulcers, how often should a client shift his or her weight when in a wheelchair? every 15 minutes
which position is better to put a client in lateral oblique or lateral side lying position? Why? lateral oblique position becuase it reduces the potential for pressure on vulnerable bony prominences
when preventing pressure ulcers, how far should the head of the bed be elevated and why? no more than 30 degrees because sliding down in the bed can produce a shearing force
shearing force the effect that moves layers of tissues in opposite directions
dressing to cover a wound
what are the purposes of dressings? to keep wound clean, absorb drainage, control bleeding, protect wound from further injury, to hold medication in place, and maintain moist environment
what are the types of dressings? gauze, transparent, and hydrocolloid
what type of dressing are made of woven cloth fibers, and are ideal for covering fresh wounds that are likely to bleed? gauze dressing
why should an ointment be used on the wound or gauze dressing? because when removing the gauze dressing, granulation tissue may adhere to the gauze fibers which disrupts the wound when removed
montgomery straps strips of tape with eyelets
why may montgomery straps be used? if gauze dressings need frequent changing or if client is allergic to tape
what is an example of a transparent dressing? op-site
what dressings are clear wound coverings that alows the nurse to assess the wound without removing the dressing? transparent dressing
what are transparent dressings most commonly used for? covering peripheral and central intravenous insertion sites
what is an example of hydrocolloid dressings? DuoDerm
what type of dressing are self adhesive, opaque, air and water occlusive wound coverings? hydrocolloid dressings
which type of dressing keeps wounds moist? hydrocolloid dressings
why do moist wounds heal more quickly? because new cells grow more rapidly in a wet environment
if the hydrocolloid dressing remains intact, how long can it be left in place? up to 1 week
if a client urinates and/or defecates on themselves and has a wound near the peri area, what type of dressing is recommended? hydrocolloid dressing
a physician may want to change all dressings himself. In this case, if the wound saturates through that dressing, does the nurse remove that dressing or just add more? What is this called? add more dressings on top of the old or saturated dressing...called reinforcing dressing
drains tubes that provide a means for removing blood and drainage from a wound
open drains flat, flexible tubes that provide a pathway for drainage toward the dressing
In what ways can drainage occur? by gravity and capillary action
Capillary action the movement of a liquid at the point of contact with a solid
In an open drain, why is a safety pin or long clip attached to the drain? to prevent the drain from slipping within the tissue
Why may a physican instruct the nurse to shorten the drain? because drainage has decreased
How does the nurse shorten the drain for an open wound? the nurse pulls it from the wound for a specified length and then repositions safety pin or clip near the wound to prevent drain from sliding back internally within the wound
closed drain tubes that terminate in a receptacle
what are some examples of closed drains? hemovac and jackson pratt drain
why are closed drains more eficient than open drains? because closed drains pull fluid by creating a vacuum or by negative pressure
how do you create a vacuum or negative pressure for closed drains? open the vent on receptacle, compress drainage collection chamber, then cap vent
when caring for a wound with a drain, how does the nurse cleanse the insertion site? in a circular manner from the center outward
sutures knotted ties that hold an incision together
staples wide metal clips
How long may sutures or staples remain in place? few days to 2 weeks
what can be used instead of sutures or staples? steri-strips of butterflies
bandage a strip or roll of cloth wrapped around a body part
what are some purposes of bandages and binders? to hold dressing in place, to support the area around the wound or injury to reduce pain, and to limit movement in wound area to promote healing
what are some general rules to follow when applying a roller bandage? elevate & support limb, wrap distal to proximal, avoid gaps between each turn, exert equal but not excessive tension with each turn, keep bandage free of wrinkles, secure with metal clips, check color & sensation of expose finger/toes, do hygiene 2x/day
In what way does the nurse wrap a roller bandage? from distal to proximal
what are the 6 basic techniques used to wrap a roller bandage? circular turn, spiral turn, spiral reverse turn, figure of eight turn, spica turn, recurrent turn
circular turn used to anchor and secure a bandage where it starts and ends
what involves holding the free end of the rolled material in one hand and wrapping it around the area, bringing it back to the starting point? circular turn
spiral turn partly overlapping a previous turn
when are spiral turns used? when wrapping cylindrical parts of the body like the arms and legs
spiral reverse turn a modification of a spiral turn in which the roll is reversed or turned downward halfway through the turn
Which is the best technique used when bandaging a joint like the elbow or knee? figure of eight turn
How is the figure of eight turn made? by making oblique turns that alternately ascend and descend simulating the number eight
spica turn a variation of the figure of eight pattern but differs by the wrap which includes a portion of the trunk or chest
how is the recurrent turn made? by passing the roll back and forth over the tip of a body part
in which client are a recurrent turn beneficial? when wrapping the stump of an amputated limb or the head
binder type of cloth cover generally applied to a particular body part
what type of binder is used to secure a dressing to the anus or perineum or within the groin? T binders
debridement removal of dead tissue
what are the 4 methods of debridement? sharp, enzymatic, autolytic, and mechanical
sharp debridement the removal of necrotic nonliving tissue from healthy areas of a wound with sterile scissors, forceps or other instruments
which method of debridement is preferred if the wound is infected? sharp debridement
is sharp debridement painful? yes
what can be expected after sharp debridement? bleeding
enzymatic debridement involves the use of topically applied chemical substances which break down and liquefy wound debris
what are used to keep the enzyme in contact with the wound and to help absorb the drainage? dressing
what method of debridement is appropriate for uninfected wounds or for clients who can't tolerate sharp debridement? enzymatic debridement
autolytic debridement or self dissolution painless, natural physiologic process that allows the body's enzymes to soften, liquefy and release devitalized tissue
which method of debridement is used when a wound is small and free of infection? autolytic debridement
what is the main disadvantage of autolytic debridement? the prolonged time it takes to achieve desired results
what does the nurse monitor the client closely for with autolytic debridement? signs of wound infection
mechanical debridement the physical removal of debris from a deep wound
what are some methods for mechanical debridement? wet to dry dressing or calcium alginate, hydrotherapy, or irrigation
if a client's wound is packed with a wet to dry dressing for mechanical debridement, when does the dressing need to be removed? 4 to 6 hours later when the gauze is dry
what is an alternative to wet to dry dressing? a calcium alginate dressing like Algiderm
hydrotherapy the therapeutic use of water in which the body part with the wound is submerged in a whirlpool tank
what does hydrotherapy do to the wound? softens dead tissue in which loose debris remains attached and is removed afterward by sharp debridement
irrigation technique for flushing debris
when is irrigation used for mechanical debridement? when caring for a wound and when cleaning an area of the body like eyes, ears, or vagina
when is wound irrigation generally carried out? just before applying a new dressing
when is wound irrigation best used? when granulation tissue has formed
eye irrigation flushes a toxic chemical from one or both eyes and displaces dried mucus or other drainage that accumulates form inflamed or infected eye structures
when perfoming eye irrigation, how should the nurse position the clients head? tilt head slightly toward side
ear irrigation remvoes debris from ear
when might an ear irrigation be contraindicated? if the tympanic membrane is perforated
when performing ear irrigation, if the nurse occludes the ear canal with tip of syringe, what can happen? the pressure of the trapped solution could rupture the eardrum
after ear irrigation, what is place within the clients ear and why? cottonball is placed loosely to absorb drainage
douche a procedure for cleansing the vaginal canal
when teaching how to douche, what is the location of the bag? above the hips about 18-24 in
in which clients are hot/cold packs used very cautiously? children younger than 2 eyars, older adults, clients with diabetes, clients who are comatose or neurologically impaired
why are heat packs used? to provide warmth, promote circulation, speed up healing, relieve muscle spasms, reduce pain
why are cold packs used? to reduce fever, prevent swelling, control bleeding, releive pain, numbs sensation
what may be applied to a cleint who has just had a tonsilectomy? ice collars
what are applied to any small injury in the process of swelling? ice bags
compresses moist, warm or cool cloths
before applying a compress, what does the nurse do? soak it in tap water or medicated solution at appropriate temperature and then wring out excess
when using an ice bag, how far do you fill the bags with ice? 1/2 to 2/3 full
how long do you leave the ice in place at one time? no more than 20-30 minutes
how long do you wait before reapplying the ice pack? at least 30 minutes
when an ice pack has been applied, how do you know if the pack is too cold? if the skin becomes mottled or numb
aquathermia pad or K pad an electrical heating or cooling device
soak when a body part is submerged in fluid to provide warmth or to apply a medicated solution
pack a commercial device for applying moist heat
how long does soak usually lasts? 15-20 minutes
in which clients are packs never used on? clients who are unresponsive or paralyzed
therapeutic baths those performed for other than hygiene purposes
what helps to reduce a high fever or apply medicated substances to skin to treat disorders or discomfort? therapeutic baths
what are some examples of baths? cornstarch, oatmeal paste, or sodium bicarbonate baths
what are the most common types of therapeutic baths? sitz bath
sitz bath a soak of the perianal area
what is the purpose of sitz baths? to reduce swelling and inflammation and to promote healing of wounds
Created by: 1115060100