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wound care

Animal Tech VI

QuestionAnswer
2 types of wounds open & closed wounds
Incision a clean separation of skin & tissue wit smooth, even edges
Laceration separation of skin & tissue in which the edges are torn & irregular
Abrasion a wound in which the surface layers of skin are scraped away.
Avulsion Stripping away of large areas of skin & underlying tissue, leaving cartilage & bone exposed.
Ulceration shallow crater in which skin or mucous membrane is missing
Puncture an opening of skin, underlying tissue, or mucous membrane caused by a narrow sharp, pointed object.
Contusion Also called a BRUISE, Injury to soft tissue underlying the skin from the force of contact w/ a hard object.
Wound damaged skin or soft tissue results from trauma.
Trauma general term referring to injury.
Open wound the surface of the skin or mucous membrane is no longer intact.
Closed wound there is no opening in the skin or mucous membrane occur from blunt trauma or pressure.
Granulation tissue combination of new blood vessels, fibroblast & epithelial cells.
Dehiscence the parting of the sutured lips of a surgical wound.
Evisceration protrusion of wound contents.
Three sequential phases Inflammation, proliferation, remodeling.
Inflammation Starts immediately after injury, last 2-5 days, limit local damage, prepares wound for healing.
Stages of Inflammation 1st stage-local changes, inflammation (edema), 2nd stage-phagocytosis, redness & warmth, cleaning of the injured area, 3rd pain 4th decrease function.
Normal saline 0.9% sodium chloride.
Measure wounds use sterile qtip (does no hurt pt).
Proliferation New cells fill & seal the wound, 2 days-3 wks after inflammatory phase, Granulation tissue appear.
Remodeling follows proliferation phase, may last 6mths to 2yrs, wound contracts, scar shrinks.
Factors affecting wound healing type of wound injury, expanse or depth of wound, quality of circulation, amt of wound debris, presence of infection, status of the pt’s health.
1st intention/Primary intention healing wound edges are directly next to each other, small amt of scar tissue, surgical wound closely approx. ex:paper cut.
2nd intention healing1 wound edges are widely separated, margins are not in direct contact, a scar generally forms, presence of body fluid.
2nd intention healing2 wound debris w/in the wound will prolong the healing; disrupted granulation tissue will retard the healing process.
3rd intention/tertiary intention Widely separated margins, closure material to bring edges 2gether,broad deep scar formation, wounds usually deep, extensive drainage & tissue debris, may contain drains, may pack w/ absorbent gauze.
Wound management promotes healing, goal is to reapproximate the tissue to restore integrity.
Serous clear watery fluid (ex. Blister)
Serosanguineous pink, composed of serum & blood drainage.
Sanguineous Red, relating to blood.
Purulent Pus
Dressing keep wound clean, absorb drainage, controls bleeding, protection from further injury, holds medication in place, maintains a moist environment.
Npo pain meds take 45 mins to work in body.
Sq pain meds take 30-35 mins to work in body.
Intramuscular pain meds take 15-30 mins to work in body.
IV pain meds take 5-10 mins to work in body.
Pain meds Most analgesics have a 4-6 hr window to work.
Gauze dressings woven fibers, highly absorbent, wound assessment can be difficult, granulation tissue may adhere (stick), secured w/tape.
Montgomery straps strips of tape w/eye lids that have a shoe lace through it.
Purpose of gauze dressings for debriment, to address wound drainage.
Reason for uncovered wound to prevent irritation.
Transparent dressing clear wound covering (opsite), assessment w/o removal, less bulky, no tape, non absorbent dressing, common use: IV site.
Hydrocolloid dressing self adhering, Opaque, air & water occlusive (duoderm), Keep wounds moist, leave intact for up to 1 wk, size generously.
Dressing changes wound nds assessment, requires care, dressing is loose, saturation, physician may assume responsibility for 1st change
Drains means for removing blood & drainage, promotes healing, placement direct insertion, separate location besides the wound.
Open drains flat, flexible tubes, pathway for drainage toward the dressing, drains passively by gravity & capillary action secured w/ safety pin or clip, may shorten drainage decrease.
Closed drains tubes terminate into a receptacle (ie: Hemovac & Jackson-Pratt (jp) drain, more efficient than open drains, vacuum or negative pressure.
Drains2 clean using circular motions, precut drain sponge or gauze.
Types of closures Sutures, staples, steri-strips/butterflies.
Sutures hold an incision 2gether, silk or synthetic material (nylon), encircles the wound.
Staples wide metal clips, form a bridge holding 2 wound margins 2gether.
Steri-strips/butterflies closure of superficial lacerations, holds weak incisions 2gether temporarily.
Advantage of staples over sutures sutures will not compress the tissue if it swells, & it does not encircle the wound.
Bandages strip or roll of cloth wrapped around a body part (ex: ace wrap).
Binders type of bandage applied to a particular body part (ex: abd or breast).
Bandages/binders1 hold dressings in place especially when tape cannot be used or the dressing is extremely large.
Bandages/binders2 Support the area around a wound or injury to reduce pain.
Bandages/binders3 Limit movement in the wound area to promote healing.
Principles of roller bandages1 elevate/support the limb, wrap from closet (distal) to farthest (proximal), avoid gaps between each turn of the bandages, Exert equal but not excessive, tension w/each turn.
Principles of roller bandages2 keep bandage free of wrinkles, secure end of roller bandage w/metal clips, check the color/sensation of exposed fingers or toes often, remove bandage for hygiene/replace twice a day.
Styles of bandage application circular turn-wrap, spiral turn-cylindrical, spiral reverse turn, figure 8 turn-joints, spica turn-variation, Recurrent turn-beneficial.
Binder application not commonly used, replaced by commercial devices, T-binder, used to secure a dressing to anus or perineum or w/in the groin.
Debridement removal of dead tissue, promotes healing, 4 methods: sharp, enzymatic, autolytic, mechanical.
Sharp debridement removal or necrotic tissue, sterile scissors, forceps or other instruments, preferred for infected wound, preformed @ bedside or in surgery, Painful, Bleeding may occur.
Euchar hard necrotic tissue (black) depending on location & Dr.’s order may be removed.
Enzymatic debridement topically applied chemical substances; wound debris is broken down & liquefied, dressing keeps enzyme in contact w/ wound, uninfected wounds, poor tolerance to sharp debridement.
Autolytic debridement small wound, infection free, prolonged time to achieve results, painless, natural physiological process, occlusive or semi-occlusive dressing, monitor for s/s of infection.
Mechanical debridement1 Wet to dry dressing, remove after 4-6 hrs, dead tissue adheres to gauze mesh work, painful, disrupts or removes healthy tissue.
Mechanical debridement2 Hydrotherapy, submerged in a whirl pool tank, antiseptic solution, agitation softens dead tissue, sharp debridement for loose debris.
Mechanical debridement3 Irrigation (uses normal saline to clean out area), flushing debris, wound care, cleaning eyes, ears & vaginal.
Wound irrigation used before applying new dressing, granulation tissue has formed.
Vaginal irrigation also know as douche, sometimes necessary to treat an infection.
Eye irrigation flushes toxic chemical from one or both eyes, displaces dried mucous or other drainage, warm solution to body temp.
Ear irrigation Removes debris, perform gross inspection 1st, contraindicated w/ a perforated ear drum, avoid occluding ear canal w/ syringe, trapped pressure can cause rupture of ear drum, loose cotton ball to absorb drainage.
Heat uses Provides warmth, promotes circulation, speeds healing, relieves muscle spasm, reduced pain.
Cold uses Reduces fevers, prevents swelling, controls bleeding, relieves pain, numbs sensation.
Cold application Ice bag/ice collar: containers for holding ice, improvised version, reduce swelling, applied after tonsil removal, small injures.
Chemical packs strike or crush to activate, included in 1st aid kits, commercial cold packs 1 time use, gel packs for hot or cold are reusable, store in freezer/heat in microwave.
Compresses moist, warm, or cool cloth, appropriate temp, plastic wrap, remove excess moisture, gloves if applied to draining wound, aseptic surgical technique if open wound.
Aquathermia Pad (k-pad) 1 electrical heating or cooling device, use alone or cover over a compress, temp controlled by thermostat, altered body temps.
Aquathermia Pad (k-pad) 2 Nurse responsibility, assess skin freq, remove device periodically, cover pad to prevent thermal skin damage, monitor Vs closely pt w/ altered body temp.
Soaks & moist packs submerge body part to warm or apply medication, keep temp constant, never use pack on unresponsive or paralyzed pt, potential for burn, freq assessment, remove park periodically.
Therapeutic baths Non hygienic purpose, fever reducer, application of medicated substances, reduce discomfort, baking soda, cornstarch or oatmeal paste bath, most common is sitz bath.
Therapeutic baths2 Nurse responsibility: assess temp of application freq, monitor skin condition, avoid direct contact between skin & heating device, exposure of skin to extremes of temp can result in injures, use cautiously in children younger than 2 & older adults, pt w/
Pressure ulcers(decubitus ulcers)/bedsores caused by prolonged capillary compression, resulting in impaired circulation to skin & underlying tissue, reddened area over bony prominence that doesn’t go back to normal color when pressure is released.
Pressure ulcer risk factors1 Inactivity, immobility, malnutrition, emaciation, diaphoresis, excessive sweating, really thin.
Pressure ulcer risk factors2 Incontinence, vascular disease, localized edema, dehydration sedation.
Pressure ulcers May also develop over elbows, shoulder blades, back of head, & places of unrelieved pressure d/t infreq movement, primary goal: prevention, nursing measure: reduce size & restore integrity.
Prevention of pressure ulcers identify pt w/ risk factors. Reduce condition under which pressure ulcers are likely to form.
Pressure ulcers stage 1 intact but red skin.
Pressure ulcers stage2 red, blistering.
Pressure ulcers stage3 shallow skin crater extends sq tissue, yellowing color of cells called slough.
Pressure ulcers stage 4 life threatening, deeply ulcerated, bone & muscle exposure, dead infected tissue may cause sepsis.
Nursing diagnosis r/t wounds Acute pain, impaired skin integrity, ineffective tissue perfusion, impaired tissue integrity, risk for infection.
Gerontologic considerations1 wound healing delayed in older adults d/t diminished collagen, blood supply, decreased quality of elastin, dermal layer becomes thinner, decreased amt of sq tissue.
Gerontologic considerations 2 diminished immune response increases risk for infection, absorbent under garments may contribute to skin break down, co morbidities may delay wound healing diminished mobility.
Created by: posiniv