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NP Ch 38 CCC 105
NP Ch 38 CCC PN105
| Question | Answer |
|---|---|
| types of wounds | closed, open, partial thickness and full thickness |
| partial thickness wound | heal quickly by production of new skin cells by epithelial cells remaining in dermal skin layer |
| full thickness wound | dermal layer is no longer present except at wound margins, all necrotic tissue must be removed prior to healing, wound heals by contraction |
| clean wound | wound free of microorganisms |
| dirty wound | wound containing microorganisms |
| infected wound | wound containing large number of microorganisms |
| tissue necrosis heals by | regeneration (new cells similar in structure and function to the dead ones is produced) |
| tissues that can regenerate | skin, mucous membranes, bone marrow, muscle, bone, liver, kidney, lung |
| tissues that cannot regenerate | heart and nerve cells |
| heart and nerve tissues heals by | replacement (form of fibrous connective tissue without same functional characteristics as wound tissue) |
| phases of wound healing | inflammation, proliferation (reconstruction), maturation (remodeling) |
| inflammation time frame | begins immediately, lasts 1-4 days |
| characteristics of inflammation | swelling or edema at injury, erythema from increased blood supply, heat at injury, pain, possible loss of function |
| proliferation time frame | begins on day 3-4 and lasts 2-3 weeks |
| characteristics of prolliferation | granulation tissue forms (deep pink), macrophages clear wound of debris, scarring appears |
| main ingredient in scar tissue | collagen |
| scarring is caused by | degree of stress on the wound |
| maturation time frame | begins 3 weeks after injury, can take up to 2 years - length dependent upon type of injury |
| characteristics of maturation | collagen breakdown to produce strongest scar tissue possible |
| special attention for joint wound | maintain joint mobility and prevent contracture (abnormal shortening of muscle tissue) that restricts extension |
| collagen overgrowth results in | keloids and adhesion |
| first intention wounds | surgical incisions, no tissue loss |
| second intention wounds | tear, no tissue loss |
| third intention wounds | abdominal wound left open for drainage, tissue loss |
| ages of healing | children and adults heal faster than elderly |
| elderly healing issues | slower metabolism, chronic disease, peripheral vascular disease, immune function decline, reduced liver function, decreased lung function, thinner more fragile skin |
| common healing complications in elderly | dehiscence and evisceration due to prolonged healing process |
| effect of diet on healing | malnourished patients at risk for delayed healing; need protein, carbs, fat, vitamins A/C, thiamine, pyridoxine, riboflavin, zinc, iron, anc copper for proper healing |
| chronic wounds require what increase in diet | protein and fluids |
| effect of lifestyle on healing | regular exercise enhances blood circluation and promotes faster healing; smoking reduces functional hemoglobin in blood and slows healing |
| effect of steroid medication on healing | may mask signs of wound infection because they inhibit the inflammatory response |
| effect of infection on healing | slows healing process |
| bacterial infection causes | purulent fluid drainage from wound or damaged tissue (pus) |
| what to assess for regarding drainage | color, consistence, odor, and amount of fluid - serous (clear) drainage is ok; purulent drainage shows infection |
| effect of chronic illness on healing | diabetes, cardiovascular disease, or immune disorders cay cause slower healing |
| types of closed wounds | bruise (contusion), hematoma, sprain |
| types of open wounds | incision, laceration, abrasion, puncture (knife), penetrating (gun shot), avulsion (torn off), ulceration |
| wounds complications | hemorrhage, infection, cellulitis, fistula, sinus, dehiscence, evisceration |
| hemorrhage complications | decreased BP, increased pulse, increased RR, restless, diaphoresis, cold/clammy skin; potential for hypovolemic shock |
| all post op patients should be monitored for | hemorrhage |
| highest risk of hemorrhage occures ___________ after surgery | 48 hrs |
| nursiing steps for possible internal hemorrhage | notify physician immediately |
| nursing steps for external hemorrhage | apply sterile pressure and call for help |
| infection complications | abcess, cellulitis, sinus |
| most frequent types of infection | staph, e.coli, strept |
| how to test for infection | culture and sensitivity |
| best way to prevent infection | maintain strict asepsis when performing wound care |
| signs on dihiscence or evisceration | increase in flow of serosanguineous fluid into dressing; patient stating "something has given way" |
| risks for dehiscence | obesity, poor nutrition, multiple trauma, excessive coughing, vomiting, strong sneezing, suture failure, dehydration |
| when is greatest risk for dehiscence | fourth or fifth post op day |
| nursing steps for dehiscence or evisceration | place patient in supine position, sterile dressice soaked in saline over incision, notify physician immediately |
| types of wound closure | sutures/staples, silver wire clips, dermabond (glue), steristrips for small wounds |
| open wound classification | red, yellow, black |
| red open wound | clean and ready to heal |
| yellow open wound | layer of yellow fibrous debris, may have drainage, needs to be continually cleansed and dressing to absorb drainage - often becomes infected |
| black open wound | reqire debridement to heal |
| reason for drainage device | to provide an exit for blood and fluids that accumulate during the inflammatory phase |
| types of drainage | active and passive |
| active draining | drain attached to wound suction device |
| passive draining | drain has no suction device, works by gravity and capillary action |
| penrose drain | flat rubber tube that is shortened over time |
| plastic drainage tube | connected to closed drainage system that is compressed thus applying slight suction to help evacuate fluids within wound |
| hemovac / jackson pratt drains | emptied at end of each shift, fluid measured, helps prevent formation of abcess or fistula |
| to activate JP drain | compress bulb after emptying |
| debridement types | sharp, enzymatic, chemical, autolytic, mechanical |
| sharp debridement | for signs of cellulitis or sepsis; done at bedside or OR using sterile scissors, forceps, and scalpel; painful; surgeon usually performs |
| enzymatic debridement | topical substances used to break down and liquefy dead tissue; useful for uninfected wounds; nurses perform |
| chemical debridement | Dakins solution or sterile maggots for necrotic tissue not responding to other treatments; never used on healthy tissue |
| autolytic debridement | long process using body enzymes to break down nonviable wound tissue; best for small, uninfected wounds; must monitor closely for infection |
| mechanical debridement | physical removal of debris by irrigation or hydrotherapy; wet to dry dressings; performed by physical therapist or nurse |
| only necrotic wound not recommended for debridement | pressure ulcer on heel |
| purpose of wound dressing | prevent microorganisms from entering or excaping freely from wound; pressure to control bleeding; support and stabilize tissues; reduce discomfort |
| how to choose dressing | physician order based upon location, size, and type of wound; debridement and frequency of change are also by physician order |
| tegaderm | transparent film dressing allowing wound assessment without removing dressing; less tape and less bulky; does not absorb drainage; good for superficial patrial thickness wounds; NEVER for infected wound |
| tegaderm uses | cover IV sites, stage I or II pressure ulcers |
| duoDERM | hydrocolloid dressing to keep wound moist; water and air occlusive and self adhesive; cannot see through; facilitates autolytic debridement and provides thermal insulation; not recommended for heavy drainage |
| types of dressings | dry sterile gauze, tefla (nonadherent), surgi-pads (abdominal pads), foam, transparent, hydrocolloid |
| transparent dressings can help elderly by | preventing skin breakdown on reddened area of possible pressure ulcer |
| clean wounds with _____ | warm, isotonic saline solution or lactate Ringers solution |
| cleaning wound with cold saline causes | decreased temperature, slowing healing |
| antibiotic wound treatment must be ____ | ordered prior to application |
| sterile wound treatment is required for ___ | surgical wounds and open wounds |
| tape application | place opposite to body action along wound location; never across joint or crease; turn end under for easy removal |
| before applying tape | check with patient for possible allergies |
| suture removal | sterile technique, requires use of suture scissors, physician ordered, special staple remover required |
| after suture removal | steri strips can be applied |
| if leave sutures under skin ____ | may cause inflammation |
| eye irrigations | may be performed for injury with debris or caustic substance in eye |
| ear irrigations | used ot remove cerumen or foreign substance |
| vaginal irrigations | may be ordered for infections or surgical preparation |
| vascular ulcer cleaning | only during dressing changes; use normal saline; recover with dressing |
| stage I vascular ucler | thin film dressing to protect from shear |
| stage II vascular ulcer (non infected) | hydrocolloid dressing used |
| stage III vascular ulcer (draining) | absorbent dressing used |
| stage IV vascular ucler | chemical enzyme to help debridement; wet to dry dressing |
| infected vascular ulcer | nonocclusive dressing always used |
| hot/cold applications | physicians order required; can be dry or moist |
| heat applications | general comfort and speeds healing process; relives pain; reduces congestion; relieves muscle spasms; reduces inflammation; reduces swelling; elevates body temperature; joint strains and low back pain |
| cold applications | decreases swelling decreases blood flow in joint injuries AND decreases pain; decreasees cellular activity due to numbing |
| types of cold applications | compresses, ice bags, collars, hypothermia blanket |
| types of heat applications | water bottle, electric pad, aquathermia pad, disposable pack, soaks, sitz bath |
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