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infection and wounds

infection, wounds, and pressure ulcers

Medical asepsis a sterile techique includes all practices intended to confine a specific microorganism to a specific area, limiting the number growth and transmission of microorganisms
Vehicle any substance that serves as an intermediate means to transport and introduces an infectious agent into a susceptible host through a suitable portal of entry
Iatrogenic infections are the direct result of diagnostic or therapeutic procedures
compromised host a person at increased risk an individual who for one or more reasons is more likely than others to acquire an infection
colonization the process by which strains of microorganisms become resident flora
nonspecific defenses protect the person against all microorganisms regardless of prior exposure
parasites live on other living organisms
vector an animal or flying or crawling insect that serves as an intermediate means of transporting the infectious agent
fungi include yeast and molds
Carrier a person or animal reservoir of a specific infectious agent that usually does not manifest any clinical signs of disease
Viruses consist primarily of nucleic acid and therefore must enter living cells in order to reproduce
antigens part of bodys plasma protein
regeneration is renewal of tissue
Hemostasis is the cessation of bleeding that results from vasoconstriction of the larger blood vessels in the affected area, retraction (draw back) of injured blood vessels the depostion of fibrin (connective tissue) and the formation of blood clots in the area.
exudate a material such as fluid and cells that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces
Bandage a strip of cloth used to wrap some part of the body
Ischemia is a deficiency in the blood supply to the tissue
irrigation (lavage) the washing or flushing out of an area
pressure ulser any lesion caused by unrelieved pressure (a compressing downward force on a body area) that results in damage to underlying tissue as defined by the U.S. Public Health Services Panel for the prediction and prevention of pressure Ulcers in adult
Collagen a whitish protein substance that adds tensile strength to the wound
reactive hyperemia when pressure is relieved from compressing the skin and then takes on a bright red flush
shearing force is a combination of friction and pressure
Risk assessment tools braden scale, 4 stages of pressure sores including unstageable
primary intention healing occurs where the tissue surfaces have been approximated (closed)and there is minimal or no tissue loss
secondary intention healing a wound that is extensive and involves considerable tissue loss and in which the edges connot or should not be approximated
tertiary intention or delayed primary intention that are left open for 3 to 5 days to allow edema or infection to resolve or exudate to drain and are then closed with sutures staples or adhesive skin closure heal
serous exudate consists chiefly of serum (the clear portion of the blood) derived from blood and the serous membranes of the body such as the peritoneum
purulent exudate is thcker than serous exudate because of the presence of pus which consists of leukocytes liquefied dead tissue debris and dead and living bacteria
purulent exudates very in what color vary in color some acquiring tinges of blue, green or yellow the color may depend on the causative organism
sanguineous exudate consists of large amounts of red blood cells indicating damage to capillaries that is severe enough to allow the escape of red blood cells from plasma.
serosanguineous (consisting of clear and blood-tinged drainage) exudate is commonly seen in surgical incisions
purosanguineous discharge (consisting of pus and blood) is often seen in a new wound that is infected
dehiscence is the partial or total rupturing of a sutured wound
evisceration is the protrusion of the internal viscera through an incision
what may precede dehiscence sudden straining such as coughing or sneezing
your patient has a Braden scale of 17 what is the appropriate nursing action implement a turning schedule the cleint is at increased risk of skin breakdown
proper technique for performing a wound culture is cleansing the wound prior to obtaining the specimen
why do we leave heat on for only 30 min heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the one desired (dilation)
what items are used to perform wound irrigation clean gloves to remove the old dressing and to hold the basin collecting the irrigating fluid plus sterile gloves to apply new dressing and a 60-mL syringe
Stage I care Skin prep, granulex Hydrocolloid dressing Transparent dressing (only on unbroken skin)
Stage II care Transparent dressing (preferably over hydrocolloid, but not actually touching wound) Hydrocolloid dressing
Stage III care Wet to dry gauze dressing with sterile NS Hydrocolloid dressing Proteolytic enzymes
Stage IV care Wet to dry gauze dressing with sterile NS Vacuum-assisted closure (VAC)
incision wound open wound caused by a sharp instrument (eg knife scalpel)
contusion wound closed wound skin appearing ecchymotic (bruising) because of damaged blood vessels caused by blow from a blunt instrument
abrasion wound open wound involving the skin caused by surface scrape with unitentional or intentional
puncture wound open wound caused by penetration of the skin and often the underlying tissues by a sharp instrument either intentional or unintentional
laceration wound open wound caused by open wound edges often jagged caused by tisssues torn apart often from accident (eg with machinery)
penetrating wound open wound caused by penetration of the skin and the underlying tissues usually unitentional (eg from a bullet or metal fragment)
Gauze Retain dressings on wounds Bandage hands and feet (Kerlix)
Elasticized Provide pressure to an area Improve venous circulation in legs
Binders Support large areas of body Triangular arm sling; straight abd binder
Types of bandages Transparent Film Hydrocolloids Impregnated Nonadherent Hydrogels Polyurethane Foams Hydrophilic Hydrophobic Alginates
Nutrition Need Protein, Carbs, Lipids, Vitamins A and C,
Minerals Iron, zinc, and copper.
Medications Steroids, ASA, Antineoplastics (chemo) inhibit healing
Prolonged or repeated antibiotic use can lead resistant organisms & superinfections (MRSA, VRE)
Friction is a force acting parallel to the skin surface
immobility refers to a reduction in the amount and control of movement a person has
Local infection limited to the specific part of the body where the microorganism remain
inflammation a local and nonspecific defensive response of the tissues to an injurious or infestious agent
communicable if the infectious agent can be transmitted to an individual by direct or indirect contact or as an airborne infection the resulting condition is called a ________ disease
opportunistic pathogen causes disease only in a susceptible individual
opportunistic the freedon from disease only in a susceptible individual
bacteria by far the most common infection-causing microorganisms
free from infection in medical asepsis objects are considered clean or _______
sepsis the state of infection and can take many forms including septic shock
Virulence the ability to produce disease
Nosocomial infections that are associated with the delivery of health care services in a health care facility
Regeneration the replacement of destroyed tissue cells by cells that are identical or similar in structure and function
Antiseptices agents that inhibit the growth of some microorganism
Asepsis freedon from disease causing microorganisms
proliferative phase the second phase in healing extends from day 3 or 4 to about day 21 post injury
1.inflammation 2. Reconstruction (Proliferative) 3. Maturation 4. remodeling the four phases in healing in order
Vasodilation the process in which extra blood floods to the area to compensate from the preceeding period of impeded blood flow
eschar If the wound does not close by epithelialization the area become covered with dried plasma proteins and dead cells
48 hours the greatest time period for the risk of hemmorrhage right after surgery
dihiscence the partial or total rupturing of a sutured wound
clean wounds unfected wounds in which there is minimal inflammation and the respiratory gastrointestinal genital and urinary tracts
clean - contaminated wounds surgical wounds in which the respiratory gastrointestinal genital or urinary tract has been entered such show no evidence of infection
contaminated wounds include open fresh accidental wounds and surgical wounds involving a major break in sterile technique or a large amount of spillage from the gastointestinal tract contaminated wounds show evidence of inflammation
Dirty or infected wounds include wounds containing dead tissue and wounds with evidence of a clinical infection such as purulent drainage
decubitus ulcers ulcers were previously called
maceration moisture from incontinence promotes skin (tissue softened by prolonged wetting or soaking) and makes the epidermis more easily eroded and susceptible to injury
excoriation Digestive enzymes in feces and gastric tube drainage and urea in urine also contribute to skin _____ (area of loss of the superficial layers of the skin: also known as denuded area)
suppuration the process of pus formation
primary intention healing and secondary intention healing the two types of healing, influenced by the amount of tissue loss
3.5 g/dL an Albumin value below ____ indicates poor nutrition and may increase the risk of poor healing and infection
aerobic growing only in the presence of oxygen
anaerobics growing only in the absence oxygen
hydrocolloid a client has a pressure ulcer with a shallow partial skin thickness eroded area but no necrotic area the nurse would treat it with what kind of dressing
Heels, sacrum. elbows, scapulae, back of head areas are being pressured in the supine postion
malleolus, knee, greater trochanter, llium, shoulder, ear side of head areas are being pressured in the lateral postion
toes, knees, genitalia, breasts, shoulder, cheek and ear areas are being pressured in the prone postion
Heels, pelvis, sacrum, vertebrae areas are being pressured in the fowlers postion
DERMABOND ADVANCED is a liquid bonding agent that holds many cuts, wounds, and incisions together as effectively as stitches do.1,2
Phagocytosis essential to healing
Leukocytes (neutrophils) move into interstitial space. Replaced ~ 24 hours after injury by macrophages that engulf
Angiogenesis factor secreted to stimulate new blood vessel formation to ↑ circulation in wound to aid with healing process
Anti-inflammatory meds (steroids) may inhibit this process and delay healing
Reconstruction (Proliferative) Phase of Wound Healing post-injury day 3 or 4 until day 21
Maturation Phase of Wound Healing Day 21 until 1-2 years after injury Collagen re-organization Remodeling or contraction of wound
Inflammatory Phase of Wound Healing Immediately after injury; lasts 3-6 days
Keloid can form if abnormal amount of collagen is laid down. Hypertrophic scar, or “proud tissue”. More common in darker-skinned persons
Allergic contact dermatitis Erythema (redness) Edema Pruritis Vesicles Bullae
Irritant contact dermatitis Discrete area of redness at exposure location
<18 Braden Scale at risk
23 point score Braden Scale possible total points
15-16 Braden Scale mild risk
12-14 Braden Scale mod risk
11 or less Braden Scale severe risk
Infection signs redness/edema/exudate/odor
For mod to lg amt drainage: Foam
For scanty to sm amt drainage: Hydrogel or Hydrogel or Hydrocolloid impregnated gauz
Transparent adhesives Debride +A/ absorb N/A / Fill N/A / sheild from bacteria + / insulate + / Moisten + / Guildlines for use change 1X WK
Hydrocolloids Debride +A/ absorb + / Fill N/A / sheild from bacteria + / insulate + / Moisten + / Guildlines for use change 2X WK
absorption or filler dressing Debride +A / absorb + / Fill + / sheild from bacteria N/A / insulate N/A / Moisten + / Guildlines for use change QD
Semipermeable / polyurethane form Debride N/A / absorb + / Fill N/A / sheild from bacteria + / insulate + / Moisten + / Guildlines for use change depending on drainage
Hydrogels Debride +A/ absorb + / Fill + / sheild from bacteria N/A / insulate + / Moisten + / Guildlines for use change QD
opsite, Tegaderm Transparent adhesives
Tegasorb, comfeel Duoderm, restore Hydrocolloids
Bard absorption Sorbsan, Curasorb (calcium alignate) DuoDerm paste Iobosorb, aguacel absorption or filler dressing
polymem, flexan allevyn, Lyoform optifoam Semipermeable / polyurethane form
solosite, flexigel strands safgel Hydrogels
Function of inflammation allows repair of injured area to proceed at faster pace. Always present with infection, but also can occur in absence of infection. --Contains injury --Destroys microorganisms
Created by: ED.