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68wm6 p2 wound manag

Wound management

QuestionAnswer
What are the phases of wound healing? *Hemostasis *Inflammatory Phase *Reconstruction Phase *Maturation Phase
What happens during the hemostasis phase? termination of bleeding
What happens during the inflammatory phase? initial increase in blood elements and water flow from the vessels to the vascular space.
What happens during the reconstruction phase? collagen formation from fibroblasts at wound site. Begins the 3rd or 4th day after injury.
What happens during the maturation phase? roughly 3 weeks after surgery fibroblasts begin to exit the wound. Scar developes.
In which phase is collagen formed from fibroblasts to promote healing? Reconstruction phase
What is the primary intention wound healing method? *When wound edges are directly next to one another *Little tissue loss *MINIMAL SCARRING *Most surgical wounds heal by first intention healing *Wound closure is performed with sutures *staples, or adhesive at the time of initial evaluation
What is the secondary intention wound healing method? *The wound is allowed to granulate *May be packed a wound with gauze or use a drainage system *Results in a broader scar *Healing process is slow *Wound care must be performed daily
What is the delayed primary closure (Tertiary) healing method? *The wound is initially cleaned, debrided and observed, typically 4 or 5 days) before closure *The wound is purposely left open
What are the three types of wound healing? *Primary *Secondary *Tertiary (Delayed Primary)
Define Granulation: tissue and capillaries must extend from the edges inside the wound toward the center, this results in a broader scar
Define Compartment Syndrome: a painful condition resulting from the expansion or overgrowth of enclosed tissue (as of a leg muscle) within its anatomical enclosure producing pressure that interferes with circulation and adversely affects the function and health of the tissue itself.
Define Extravasations: Passage or escape into the tissues, usually blood, serum, or lymph fluid.
Define Dhiscence: the parting of the sutured lips of a surgical wound.
What are the S&S of compartment syndrome? *Pain with pressure *Diminished sensation distal to the compartment area. *Diminished to absent extremity pulses distal to the injury
List 3 S&S of internal bleeding *Increase thirst *Restlessness *Rapid, thready pulse *Decreased blood pressure *Decreased urinary output *Cool clammy skin *Abdomen rigid and distended *Hypovolemic shock
True or False: A patient suffering Dehiscence should be kept NPO True
Which wound complication is a surgical emergency? Evisceration
What are the steps for a dry dressing change? 1)Assemble supplies 2)Wash hands, don gloves 3)Remove old dressing, note drainage 4)Change gloves, clean wound per physician orders/protocol 5)Apply ointment if ordered 6)Apply new dressing 7)Secure with tape, initial and date
What supplies do you need to do a dry sterile dressing change? Gloves, gauze, tape, basin, NSS, 30-60 ml syringe, pad
How often do you change a wet to dry dressing? Every 12 hours
True or False: You change a wet to dry dressing every 12 or once the dressing becomes dry. False. You do change the dressing at least every 12 hours, but you must NEVER let the dressing become dry before you change it.
At what temperature does wound healing happen? Body temperature
List the steps for removing sutures *Grasp elevated knotted end with hemostat or forceps *Snip suture at skin level on opposite side proximal to knot *Repeat for all sutures
What sre the types of wound drainage (exudate)? *Serous *Sanguineous *Serosanguineous *Purulence
What volume of exudate drainage w/in a 24 hour period is considered abnormal? 300ml
What may cause a slight increase in drainage? Ambulation
What type of wound drain prevents environmental contaminants? Closed/Suction drain
What drain is used when small amounts (100-200 ml) of drainage anticipated Jackson-Pratt drain
What drain is used for larger amounts (up to 500 ml)of drainage Hemovac drainage system
Give two examples of a closed drainage system Hackson-pratt, Hemovac drainage system
When is wound healing evaluated? *Each dressing change *Application of heat and cold therapies *Wound Irrigation *Stress to the wound site
How often should the condition of dressings be inspected? At least every shift
Make potential nursing diagnosis for a patient requiring wound care (or memorize pre-existing ones listed here from slides) *Potential for infection related to alteration in skin integrity *Alteration in comfort related to injury *Knowledge deficit related wound care
How do you evaluate wound healing? *Reduced Size/Depth *Increase in granulation tissue *Free of signs and symptoms *Relief of pain
Created by: Shanejqb