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Nursing 101

Safety/Infection Control, Comfort/Sleep,Integumentary: wound care/healing

Types of Cultures Aerobic-Growing only in the presence of oxygen Anaerobic-Growing only in the absence of oxygen
Types of wound healing primary, secondary, tertiary
Primary Wounds with minimal tissue loss, Edges are approximated, Wound healing occurs with minimal granulation tissue and scaring
Secondary Wounds with extensive tissue loss Edges are not approximated Tissue replacement and scarring is greater Increased risk of infection
Tertiary Wounds that are left for 3-5 days Then are closed aka “delayed primary intention
Assessing a wound wound edges: together, color, smell, location, sizes,
Wound edges Red inflammation
Wound edges White arterial insufficiency
Wound edges Blue Severe arterial insufficiency
Wound edges Black necrosis
Wound edges Brown venous insufficiency
Serous Clear
Purulent Thick, Yellow, Blue, Green
Sanguineous Bloody
SeroSanguineous Pink Clear with streaks Phases of Wound Healing
Factors that affect wound healing lifestyle: smoking and, nutrients, movement, incon. Meds, infection and other disease
Caring for a client with a wound drain Nursing Responsibilities *Keep linen to a minimum *Assess skin very often *Use the right product * Therapeutic Beds * turn q hour
Diabetic Foot Care *Inspection *Nail care *Client Education
Wound culture Purpose *Determine the presence of infection *Identify the causative organism
Stage 1 Nonblanchable erythema of intact skin
Stage 2 Partial-thickness skin loss involving epidermis and possibly dermis
Stage 3 Full-thickness skin loss involving damage or necrosis or subcutaneous tissue that may extend down to, but not through,the underlying fascia.
Stage 4 Full-Thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures such as a tendon or joint capsule
Created by: aanderson14