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NP Ch 38 CCC 105

NP Ch 38 CCC PN105

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
Created by: cmp12345