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Wound Care

wound notes

__ is the largest organ of the body, weighing about 40 pounds in the adults. The unbroken skin is considered the body's first defense against bacterial invasion. Skin
The active__include interpreting environmental temperature,helping to regulate body temperature, and functioning as an organ of excretion and secretion. Function of skin
What is the wound healing process? wounds can heal by primary intention or secondary intention.
In__ there is little or no tissue loss, such as clean surgical incision. The skin edges approximate,or close together, and the risk of infection developing is slight Primary Intention
_Is a would involving loss of tissue such as a severe laceration or chronic wound such as a pressure ulcer. The edges do not close, increasing the risk for infection and loss of tissue function. Potter and Perry pg.1062 Secondary Intention
With_, the wound is usually left open and allowed to heal by granulation. Tissue defects are filled with fragile granulation tissue(connective tissue with more abundant blood supply than collagen.) Secondary Intention
During___Scarring is usually extensive with the prolonged healing. Secondary Intention
Wounds that heal by primary intention and shallow wounds that only involve loss of the epidermis and perhaps some of the dermis are repaired by the resurfacing of the wound with new epidermal cells is called what? Partial-Thickness Wound Repair
During Partial-thickness wound repair__________ is immediately post injury. This stage lasts for approximately 24 hours.__and__ are the first response,bringing white blood cells to the site. The wounded area appears red and swollen. Inflammatory response, erythema, edema
During Epidermal Repair, epithelial cells begin migration across the wound,originating from the epidermal cells at the wound edges or the epidermal appendages._____________occurs within 24 to 72 hours after injury. peak epithelial proliferation
During epidermal repair, Blood clotting requires___. This entire process lasts approximately 3-4 days. Hemostasis occurs, the vessels pull together.Throbin joins with fibrinogen to form fibrin and a scab consisting of clotted blood and dead tissue forms Calcium
During _____. After about 48 hours, a thin layer of epithelial tissue forms to exclude infectious organisms. Redness in a wound and on the edges is a positive sign during the first 1-4 days. To promote healing the doctor would order___ Epidermal repair, ascorbic acid
Differentiation The epidermis thickens,anchors to adjacent cells, and resumes normal function. The new epidermis is __,__,and __ pink,dry,frafile
Differentiation If dermal repair is necessary, dermal repair occurs concurrently with_______ epidermal repair
____ involves tissue loss and extend to at least the subcutaneous layer.____may be either acute(a surgical wound) or chronic(a pressure ulcer) Full-Thickness wounds
The first event in the ____ ___ involving a full-thickness wound healing by primary intention is___, the control of bleeding. Platelets cause coagulation and vasoconstriction. Hemostasis phase, hemostasis
Bleeding and hemostasis do not occur in wounds healing by secondary intention,thus___________ compromising the repair process
The goal of the ___ phase is to establish a clean wound bed and to obtain bacterial balance. The ____ ____ brings white blood cells to the area, cleaning up the site and releasing additional growth factor. Inflammation, inflammatory response
The inflammation phase lasts approximately 3 day in an acute clean wound, such as a __ __. However, in a chronic wound healing by secondary intention this phase is prolonged and may lasts longer than 3 days. Surgical incision
The key events in the proliferative phase are production of new tissue, epithelialization, and contraction. The wound begins to close with new tissue. Epithelialization occurs faster in a___ ___,. This stage last from the 3rd or 4th day to 2-3weeks Moist environment
The remodeling phase which can last up to 1 year,reorganizes the collagen to produce a more elastic,stronger collagen for the scar tissue. The __ of the scar tissue is never more than80% of the____ in nonwounded tissue. tensile strength
The remodeling phase process is the same for wounds healing ___ and __ intention. * A scar is not as strong as unbroken epidermis primary and secondary
wound healing is not without complications. When caring for clients with wounds, you must observe the ___ while observing for ____. healing process, complications
With internal bleeding, you will see hypovolemic shock and swelling of the affected body part. The symptoms of hypovolemic shock are? paleness of the skin,cynosis,expressionless facial appearance,starring of the eyes with loss of characteristic luster,dilated pupils,weak and rapid pulse,increased breathing rate and shallow breathing rate,restlessness,extreme thirst, and very little pain
_____is a collection of clotted blood, is a localized collection of blood underneath the tissues. It appears as a bluish swelling or mass. External bleeding will be more obvious. The dressings are saturated. Hematoma
_____ ______ are draining bright red blood. Observe closely particularly surgical wounds in the first 24 to 48 hours. Surgical drains
____ wound infection inhibits healing by increasing tissue damage and altering the healing process. Chances are greater when dead or necrotic tissue is present, foreign bodies are in or near the wound, and the blood supply and local tissue defense is redu bacterial
On a contaminated or traumatic wound, infection would usually occur in ___days. With a surgical wound the infection will occur in about 4-5 days. When an infection is present,a culture is usually taken of the exudate. 2-3
The __ __ will appear tense,swollen,and painful, with redness extending beyond the immediate wound edge. wound edges
When dealing with infections, exudate may be nnpurulent(containing pus), yellow green,or brown and odorous depending on the causative organism. Systemic signs include_,_,_,_ fever,general malaise, and elevated wbc count
__is the partial or total separation of layers of skin and tissue above the fascia in a wound that is not healing properly.__ clients have a high risk of _ because of constant strain on their wounds and the poor vascularity of fatty tissue. Dehiscence, obese, dihiscence
Dehiscence occurs most often in __ __ __ after a sudden strain such as coughing,vomiting, or sitting up in bed. When Serosanguineous drainage increases from a wound, be alert for dihiscence. abdominal surgical wounds
__ occurs when the wound layers separate below the fascial layer, and ___may protrude through the wound opening. Evisceration, visceral organs
If evisceration occurs. It is a medical emergency requiring placement of sterile towels soaked in sterile ___ over the extruding tissues to reduce chances of bacterial invasion and drying before surgical repair occurs saline
__ is an abnormal opening between two organs or between an organ and the outside body.__ can result from wound-healing problems associated with trauma, infection,radiation exposure,or disease such as cancer Fistula
Fistulas increases the risk of ___, ___, and___ ___, and skin breakdown from chronic drainage. infection, fluid, and electrolyte imbalances
clear, watery plasma serous
fresh bleeding sanguineous
pale,more watery, a combination of plasma and red cells, may be watery blood streaked serosanguineous
what are the three types of wound drainage serosanguineous, serous, sanguineous
___ is indicated for deeper infections, or for the evaluation of current treatment. __ is an excision of a small piece of tissue for microscopic assessment. skin biopsy, biopsy
Factors influencing wound healing are age, nutrition,infection,obesity,extent of the wound, tissue perfusion,smoking,immunosuppression,diabetes mellitus, radiation, and wound stress.>>>protein1. tofu and lean meat 2. fresh fruit (vit C) 3.leafy green vegetables
what are the risk for malnutrition Age(younger that 18 or older than 64), Weight(5%to19% loss in 1 to 6 months), Albumin(less than 2.1 mg/dl*SEVERE RISK),Transferrin(less than 100mg/dl(SEVERE RISK), Prealbumin(less than 7mg/dl(SEVERE RISK)
Do not clean wounds with ___ or ___. These chemicals kill the cells. use only normal saline for the cleansing wounds. Peroxide or betadine
Dressing may be use to_________________________ enhance absorption of topical medications,encourage retention of moisture, prevent evaporation of medication, and reduce pain and itching
_____dressings are clear sheets coated on one side with an adhesive. The film is impermeable to fluid but semipermeable to oxygen. this is a clear film that allows the wound to be viewed. You change the dressing when the seal is broken Transparent film
____ is the most common dressing type. It does not interact with wound tissues and thus causes little wound irritation. __ is available in different textures and in squares, rectangles, and rolls of various lengths and widths Gauze
_______ ______ are made of gelling agents and have an adhesive wound surface. They extend at least 11/2 inches beyond the wound margin. Hydrocolloid dressing
Hydrocolloid form as a gel as they interact with the wound surface.When removed you will note a gel over the wound base, the gel maintains a ____ ___ to support healing and washes away during wound cleaning moist environment
Hydrogel dressings are available in sheets or in a gel in a tube(amorphous). They contain a high percentage of water and are indicated for wounds that requires ____, ____,___ moisture, wound with granulation, or wound that has a high percentage of necrotic tissue
____is used to assist wound healing by evacuating wound fluids, stimulating granulation tissue formation, reducing the bacterial burden of a wound and maintaining a moist wound environment. Negative pressure wound therapy vac
____ dressings may be ordered for acute,weeping ,crusted,inflammatory,or ulcerative lesions._____ dressings are used to decrease inflammation,cleanse and dry the wound, and continue drainage of infected areas. Open wet dressing
The solutions commonly used for open wet dressings consist of normal saline,__________, or magnesium sulfate aluminum acetate solution(Burow's solution)
open wet dressings The dressing is saturated with the solution before it is applied. Wet dressings are usually applied___ for 15 to 30 min. The client should be kept warm during treatment. 3 to 4 hours
The purpose of dressings includes providing a barrier to microorganism. What other reasons might dressing be used for? Dressings also promotes hemostasis,absorbs drainage , prevents drying debriding, immobilization of the body part,protects the client from seeing wound, and promotes thermal insulation and protection from the dehydrating effect of air
The nurse is legally responsible for safe administration of heat and cold packs. Do not apply heat over active bleeding because it causes_______._______ improves blood flow and can cause hemmorage. A Dr's order is always needed for the application of heat vasodilation
Check staples,sutures, or wound closures for irritation and note whether the closures are intact. Swelling should subside after the first few days. Cont. swelling causes an overly tight closure and can cause ___or___. eviseration or dehiscence
early suture removal decreases the risk of____ scarring
a__ is used if the dr expects a large amount of drainage and if keeping wound layers closed is especially important,because accumulated fluid under the tissues prevent closure. A pin or clip through a___ prevents it from slipping farther into the wound penrose drain
____ is a drain and reservoir for wound fluid. ___ carefully measure the amount of wound fluid removed from the_____reservoir.Leave the stopper to the_reservoir open and gently depress the reserv. then put the stopper back in the reserv. Jackson-Pratt
Created by: Ash_21121