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Lisa Luiz

wound care, fluid and electrolytes

wounds damaged skin or soft tissue resulting from trauma
open wound incision, lac, abrasion, avulsion, ulceration, puncture
closed contusion
three phases of wound repair inflammation, proliferation, remodeling
purpose of inflamation limit local damage, remove injured cells and debris, prepare wound for healing
characteristics of proliferation appearance of granulation tissue
process of proliferation phase new cells fill and seal wound, fibroplasts produce collagen, skin integrity restored by resolution, regeneration, scar formation
when does proliferation occur? 2 days to three weeks AFTER inflammatory phase
remodeling phase Contraction of wound and shrinkage of scar
how long does remodoling last? 6 months to 2 years
what are the factors affecting wound healing? Type of injury, Expanse or depth of wound, quality of circulation, amount of debris, presence of infection, health status, age, mobility
first inention wound healing wound edges approximated
Second intention wound healing wound edges widely spaced
third intention wound healing wound edges widely spacd, later closed by device
What is the purpose of a dressing? keep wound clean, absorb drainage, control bleeding, protect from further injury, hold med in place, maintain moist environment
Gauze dressing woven, cloth fibers, highly absorbant
transparent dressing allow wound assesment without removal, non absorbant
hydrocolloid self adhesive, air and water occlusive, opague
what is a wound drain? and why do we use them? Tubes that remove blood and drainage from wound to promate healing
what is an open drain? flat, flexible tube that provides pathway for drainage to dressing
what is a closed drain? pulls fluid by vacuum, has neg pressure, terminates into receptacle
suture knotted ties from silk or nylon
staples wide metal clips
debridement removal of dead tissue
complications of wound healing hemmorage, infection, dehiscence, evisceration
serous inflammatory material composed of serum (clear portion of blood) derived from the blood and serous membranes of the body such as the peritoneum, pleura, pericardium, and men-inges; watery in appearance and has few cells
purulent an exudate consisting of leukocytes, liquefied dead tissue debris, and dead and living bacteria
sanguineous an exudate containing large amounts of red blood cells
dehiscence the partial or total rupturing of a sutured wound; usually involves an abdominal wound in which the layers below the skin also separate
evisceration extrusion of the internal organs
stage 1 pressure ulcer skin intact, reddened
stage ll pressure ulcer partial thickness, red blistering or skin tear
stage lll pressure ulcer full thickness, tissue loss to subcutaneous tissue
stage lv pressure ulcer full thickness, to muscle or bone
risk factors/pressure uclers decreased mobility, edema, incontinence, decreased mental status,, decreased sensation, increased body heat, increased age
keloid. a hypertrophic scar containing an abnormal amount of collagen
Serous exudatev inflammatory material composed of serum (clear portion of blood) derived from the blood and serous membranes of the body such as the peritoneum, pleura, pericardium, and men-inges; watery in appearance and has few cells
Suppuration the formation of pus
Shearing force a combination of friction and pressure which when applied to the skin results in damage to the blood vessels and tissues
Irrigation (lavage) flushing or washing-out of a body cavity, organ, or wound with a specified solution
Hemostasis cessation of bleeding
Granulation tissue young connective tissue with new capillaries formed in the wound healing process
Hypoproteinemia small amounts of protein in the blood plasma
Collagen a protein found in connective tissue; a whitish protein substance that adds tensile strength to a wound
Hematoma a collection of blood in a tissue, organ, or space due to a break in the wall of a blood vessel
An open wound with jagged edges and the tissue torn apart is called a(n): laceration
A client’s open wound is described as clean-contaminated. What does this mean? The wound is surgical and without inflammation.
Which of the following actions would place a client at the greatest risk for a shearing force injury to the skin? sitting in Fowler’s position
Why is a client with fever predisposed to pressure ulcers? Metabolism increases, and the cells need more oxygen.
A client has a pressure ulcer that is healing by secondary intention. Which of the following findings would be unexpected? rapid healing
A client’s wound is covered with ____________, or dried plasma proteins and dead cells. eschar
A client’s wound is draining thick yellow material. The nurse correctly describes the drainage as: purulent.
The nurse needs to keep a client’s wound covered with a thin layer of petrolatum. Which type of dressing would be most effective? impregnated nonadherent dressing
A client has an open wound with healthy granulation tissue and scant drainage. The wound is being cleaned bid. The nurse should write an order to: clean the wound once a day
When bandaging a client’s foot the nurse should: work from distal to proximal.
normal blood osmularity 290
Fluid volume deficit (hypovolemia) an abnormal reduction in blood volume
Fluid volume excess (hypervolemia) an abnormal increase in the body's blood volume; circulatory overload
Hypercalcemia an excess of calcium in the blood plasma
Hyperchloremia an excess of chloride in the blood plasma
Hyperkalemia an excess of potassium in the blood plasma
Hypernatremia an excess of sodium in the blood plasma
Hypokalemia deficiency of potassium in the blood plasma
Metabolic acidosis a condition characterized by a deficiency of bicarbonate ions in the body in relation to the amount of carbonic acid in the body, in which the pH falls to less than 7.35
Obligatory loss the essential fluid loss required to maintain body functioning
Respiratory alkalosis a state of excessive loss of carbon dioxide from the body
ph a measure of the relative alkalinity or acidity of a solution; a measure of the concentration of hydrogen ions
Oncotic pressure pulling force exerted by colloids that help maintain the water content of blood
Intravascular fluid plasma
Intracellular fluid (ICF) fluid found within the body cells, also called cellular fluid
Interstitial fluid fluid that surrounds the cells, includes lymph
Anion ion which carries a negative charge; chloride, bicarbonate, phosphate, sulfate
Active transport movement of substances across cell membranes against the concentration gradient
Transcellular fluid includes fluid: in the cerebrospinal, pleural, and peritoneal spaces.
What are two principal electrolytes found in intracellular fluid? potassium and phosphate
body fluids all liquids contained within the body
homeostasis of fluids required for optimal functing of the body, balance between fluids and electrolytes
percentage of body fluids at age 1 male 64%, female 64%
Percentage of body fluids at age 13-39 Male 60% Female 55%
Percentage of body fluids at age 40-60 Male 55% Female 47%
Percentage of body fluids over age 61 Male52 % Female 46%
Why do men have more water in their body? They have less adipose
effect of resp rate on fluid loss 22-26 rpm causes fluid loss to go up by 200 cc
insensible fluid loss Comes from breathing, talking, and sweat
sensible fluid loss Fluids that can be measured and include urine, vomit, and stools. Fluid can be measured
Non-electrolytes Substances that DO NOT break down.
cations positively charged electrolytes including Potassium, Sodium, calcium and magnesium
Anions Neg charged electrolytes including chloride, phosphate and bicarbonate
main compartments Intracellular fluids, extracellular, and transcellular
Intracellular fluid Fluid found within the cells and makes up 2/3 the bodys fluid
Extracellular fluid divided into 2 groups, Intercistitial and intravascular.
Percentage of extracellular fluid 20%
Intercistial fluids found between cells, includes lymph and cerebrospinal fluids-found in blood
Intravascular fluid makes up 5% volume and is found within plasma
what is the only fluid volume directly affected by fluid intake and excretion intravascular
Chem 7 CO2, Sodium, Glucose, Phosphate, and magnesium
Mild fluid loss Deficit of 5% loss
Moderate fluid loss 10% loss
Severe Fluid loss 15% fluid loss
signs of fluid loss deficits Thirst, Vertigo, syncope, disorientation, weak pulse, nausea, vomiting, cardiac output, weight loss
causes of fluid loss deficits GI disfunction, diarrhea, renal disfunction, poor oral intake, diabetes insipidus, endocrine dysfunction, neurological dysfunction, fever
signs of fluid loss dry skin, sunken eyes, postural hypertension, elevated BUN,Creat, Dry mucos membranes, prolong tugor,
Where should you assess turgor over forehead or sternum
Created by: lisaluiz