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Wound Care 1 & 2

3802 test III

Formation of fibrous scar tissue around the incision as a result of surgical intervention. Can cause obstruction or malfunciont by distorting the organ.What term is this describing? Adhesions
The number of contaminating bacteria present on an object bacterial biodurden
one or more than 100 distinct proteins produced primarily by WBC's. They regulate immunological aspects of cell growth and function during inflammation and immune response. Cytokines
A bursting open, as a graadian follicle or wound, especially abdominal wounds. Dehiscense
Protrusion of the viscera; removal of the viscera Evisceration
Scabs or dry crust that result from trauma or infection Eschar
Redness of the skin due to congesion of capillaries. Erythema
Scarlike growth of collagen that results in a rounded, hard, shiny, white benign tumor. Keloid
the closure or state of being closed, of a passage Occulsion
An atypical fibroblast with features of a fibroblast and a smooth muscle cell myofibroblast
To shed or cast off dead tissue Slough
Containing pus, or caused by pus Purulent
What is the first phase of wound healing? Inflammation (Reaction)
When does the inflammatory phase begin during wound healing? Occurs immediately after an injury and lasts 2-5 days.
What happends physiologically in the body during the inflammatory phase? Small blood vessels dilate and become more permeable and serous fluid leaks into the traumatized tissue as a result of histamine and prostaglandin release. Plasma and electrolytes leak into the interstitial spaces causing edema.
When does neutrophils reach the injured site during the inflammatory phase? About 6 hours
What has to be necessary for neutrophils to destroy the bacteria? Oxygen
When do monocytes enter the wound during the inflammatory phase? By the fourth day
By the fourth day the monocytes will enter the inflammed injured site and differentiate into...what? Macrophages
What do macrophages do? Digest necrotic tissue, remove, debris, and inhibit microbial growth.
When does the proliferative or graulation phase (regeneration) begin? After the inflammatory phase and between about 2 days to 3 weeks (after the injury).
When does the proliferative or granulation phase (regeneration) end? 14-24 days later after the 2 days - 3 weeks. Pg 877 in skills lab bk
What happens during the proliferation phase? There is a rapid growth of epithelial cells to produce a protective covering for the wound.
How is the granulation tissue formed during the proliferation phase? From rebuilding of the rebuilding of vascular capillary network-collagen tissue
During the proliferation/granulation phase when is the scar 10% of the tensile strength normal skin? in 6 wks
What color does healthy granulation tissue look like? Reddish-pink color
What is the last phase of wound healing? Maturation, or would-remodeling phase
when does wound contraction begin and how long can it lasst? Which phase does this happen in? Begins between 14-21 days after the injury and can last up to two years. This happens during the maturation/wound re-modeling phase.
What happens during the maturation/wound re-modeling phase with the scar? The scar shrinks and thins. It becomes less red because the capillaries regress.
Once scar tissue in complete during wound-remodeling, what percent achieves tensile strength of normal skin? 70-80%
why is scar tissue a lighter color than our normal skin? B/c scar tissue has fewer melanocytes
Primary vrs Secondary intention: Which is the simplest form of healing? Primary
How is the primary intention during wound healing managed? How do these wounds occur? The skin experiences a surgical incision or a traumatic laceration. The would can be closed with sutures or stables, which pulls the wound edges together.
What are the positive and negative sides to using primary intentions during wound healing? Positive: these wounds close rapidly b/c there are no gaps in tissue. Negative: the tensile strength of the wound is very weak at this stage of healing
How do secondary intention wounds heal? By granulation
what types of wounds are healed by the secondary intentions? Burns, pressure ulcers, and wounds with lg pieces of skin that are missing.
How much should calories be increased to promote wound healing? 30-35 cal/kg/day
What delays wound healing r/t nutrition? Low serum albumin, low oxygen, and Zinc deficiancy.
Which vitamins play a major role in wound healing? Vitamins A, C, iron, copper, zinc
What levels of blood glucose reduces the body's ability to heal? Over 200 mg/dL
hemoglobin levels have to be what to indicate poor wound healing --> a delay in the healing process? below 10 g/dL
Which types of medicatins delay wound healing? anti-inflammatories, steriods, nonsteriod meds used to treat arthritis or respiratory conditions.
which vitamin can be given to reverse the process associated with steriod use (steriods delay wound healing)? vitamin A
Pt's who have atherosclerosis and DM are more likely to get which type of ulcer? A) venous ulcers B)arterial ulcers C) pressure ulcers B)Arterial ulcers
What is unique about venous ulcers r/t how a Pt gets a venous ulcer? they are NOT due to a lack a venous return but rather a diminished ability of nutrients to diffuse through the interstial space from capillaries.
What are the etiologies of venous ulcers? Calf pump failure, pregnancy, obesity, tumor, or deep vein thrombosis.
What two conditions can lead to venous ulcers as a result of calf muscle disuse? Peripheral neuropathy and musculoskeletal disorders.
What type of therapy is used to treat venous ulcers? Compression therapy
Compressino therapy is containdicated with clients experiencing which conditions? Phlebitis, diminished sensation, and arterial insufficiency.
Clients with a hx of smoking and who sustain mechanical trauma to the extremity are prone to which type of ulcers? Arterial ulcers
How are pt's treated for arterial ulcers? drug therapy with vasodilators, anticoagulants, or thrombolytic agents.
when is surgical treatment for an arterial ulcer necessary? if drug therapy is insufficient
When packing a wound with sterile 4 x 4 gauze, should the wound be moistened or completely dry when put in wound? Should be moistened with sterile saline solution
When are clean gloves worn and when are sterile gloves worn when packing a wound? Clean gloves are put on after hand hygiene and before tape is removed. Clean gloves will be worn during the removal of the dressing and assessment of wound site. Sterile gloves will be worn after wound site assessment and before wound is ready to clean.
T/F when setting up sterile field, sterile gloves must be worn at all times. False. When opening gloves package after everything else is set up is when gloves must be put on to clean wound.
T/F It is NOT okay to spill sterile solution on sterile field even if by accident. TRUE
Which area is considered contaminated when opening a package? One inch around edges
Describe the wound site assessment. Identify location of wound, observe wound bed and appearance; check wound for size, shape, depth, and margins. Observe exudates or drainage, evaluate presence of pain.
Which type of dressing does NOT support healing or prevent entry to exogenous bacteria? Gauze dressings
When changing a dry sterile dressing, what is the appropriate way to remove the tape? Slowly, by pulling tape TOWARD the wound.
What is the rationale behind pulling the tape toward the wound when removing an old dressing? To decrease the pain of tape removed by not putting pressure on the incision line.
When changing a dressing the nurse is trying to decide what indicates a complication is occuring. If there is a complication 2 days post op,what will the nurse more likely see? persistent drainage,edema, or temp above 100.4
What is the proper way to clean a wound around the incision line? Clean from least contaminated to most contaminated which means: clean incision line first then move away from incision line. Clean from top to bottom, using the swab only once.
What type of dressing is used when applying a wet-moist dressing? A sterile 4 x 8 ABD pad
During a wet to moist dressing application the gauze is already packed into wound, covering all exposed surfaces. The gauze is pressedd lightly into depressions or cracks. How are the moist, wet, and dry dressings applied next? Unfold a moist, sterile 4 x 8 dressing into a single layer and place on top of wet dressing covering the wound (NOT on skin). Then place dry 4 x 8 pad over the dressing to hold it in place. Tape only edges of dressing.
When caring for a wound with a penrose drain, where should cleansing start and what is the proper technique? Start cleansing at drain site, moving in a circular motion toward the periphery. Hold drain erect while cleaning around it. Dry surrounding skin with gauze swab.
When removing sutures, describe the proper way to cut off suture. Grasp suture at the knot with forceps and lift away from skin. Place the curved end of the scissors under the suture next to the knot and cut. Then pull suture through skin with one movement. After removal clean incision site.
Describe the process of removing staples. Lift staple remover upward and away from incision site when both ends of staple are visible.
what foods should a Pt eat if staples are removed? Eat foods high in protein, carbs, vitamins, and minerals to promote wound healing.
What should a Pt do to prevent separation of wound edges when coughing or moving? Splint wound
What if a Pt asks questions about showering after staples have been removed, what is the correct Pt teaching a nurse can provide? Encourage daily use of showering; water may run over wound. Instruct Pt not to use soap, lotions, or vitamin creams on incision.
How much wt can a Pt lift who just had their staples removed? 10 lbs or less.
What is the first thing a nurse should do before obtaining a wound culture? Rinse wound thoroughly w/ sterile saline.
Describe technique of obtaining culture swab after wound has been cleaned. Rotate swab while obtaining specimen. Swab edges starting at top, crisscross wound to bottom. Do NOT take specimen from exudate or eschar. Culture medium sends to be sent to lab immediately.
Created by: jalvarez1210