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NUR 317 wounds

Ch. 13: Wounds and the healing process

What is primary intention? well approximated. ex: surgical incision/paper cut. 3 phases: initial=inflammatory (3-5 days). granulation phase=reconstructive (5 days-3 weeks). maturation phase/scar contraction=overlaps with granulation phase. may begin at 7 days and last months-yrs
What is secondary intention? secondary intention is a wound with wide, irregular margins with extensive tissue loss. these wounds would not be approximated
what is tertiary intention? a tertiary intention wound is a primary intention wound that is kept open so that it can heal from the bottom up. Suturing is delayed.
tell me about protein and wound healing. A protein deficiency gives you a NEGATIVE nitrogen balance. A normal person has a NEUTRAL nitrogen balance, however A PT WHO IS HEALING A WOUND NEEDS A POSITIVE NITROGEN BALANCE. kick up the protein intake!
how should the caloric/protein intake be changed in a pt healing a wound? in a patient who is healing a wound, their caloric intake should be elevated to 30-35 kcal/kg/day OR 1.25-1.50 g protein/kg/day
How are wounds classified? CAUSE (surgical/nonsurgical....acute/chronic) DEPTH OF TISSUE AFFECTED (superficial=epidermis, partial thickness=dermis, full thickness=subQ&potentially bone.) COLOR (red=clean/pink granulating tissue. yellow=exudate pus. Black=eschar/necrotic tissue)
Tell me about a red wound. a red wound is clean, pink/red. it is GRANULATING tissue. it may have serosanguneous drainage.
Tell me about a yellow wound yellow wounds may have exudate pus. there may be an odor, it is not normal tissue. The goal in a yellow wound is debridement/cleaning. wet to dry dressing is applied.
Tell me about a black wound. Another name for a black wound is eschar. It is necrotic tissue. the goal in a black wound is debridement. if eschar is present, the wound will not heal properly. A wet to dry dressing may be applied as a psssive debridement of the wound.
how often should you assess a wound? wounds should be assessed on a regular basis (q8hr or qshift)
name 11 things that may delay wound healing: nutritional deficiencies (PROTEIN, zinc, vitamin C). Inadequate blood supply. corticosteroid drugs (depress immune healing). infection. smoking. friction on wound. advanced age (Decreased immune system). obesity. diabetes. poor general health. anemia
What nutrient deficiencies are you especially concerned in a patient healing a wound? PROTEIN! zinc and vitamin C
why might corticosteroid drugs delay the healing process? Corticosteroid drugs are administered to patients who need a depressed immune system. These drugs may delay the healing of a patient with a wound.
What should you look for when assessing for infection? When assessing a patients wound for infection, assess for odor, pain around the site, heat around the site, increased WBC [ESPECIALLY NEUTROPHILS -> called "shift to the left"], increased bands
what is the WBC range? 4,000-10,000
why would smoking delay healing of a wound? smoking vasoconstricts which decreases blood supply to the site.
why would anemia delay healing of a wound? anemia decreases the oxygen that gets to the site.
What is an adhesion? scar tissue between organs (especially abdominal)
what are contractures? who are the common in? shortening of muscle or tissue (common in burn patients)
what is evisceration? dishesience with organ protrusion
What 8 things should you assess when evaluating a wound? length (head to toe). width (side to side). depth. tunneling. undermining. odor. color. drainage.
what is the purpose of negative pressure wound therapy? a wound vac removes drainage through suction and speeds the healing process. it is very helpful because it helps pull the wound together.
what is important to monitor when a pt has a wound vac? monitor serum protein, F&E, and coagulation status (PT/PTT)
what is hyperbaric O2? hyperbaric O2 delivers O2 at increased atmospheric pressure allowing O2 to diffuse into serum. It lasts 90-120 minutes with 10-60 treatments
risk factors for pressure ulcers: age, ANEMIA, contracutres, DIABETES(NEUROPATHY/ELEVATED BG), ELEVATED TEMP, immobility, impaired circulation, incontinence, LOW DIASTOLIC BP, mental deterioration, SPINAL CORD INJURY (loss of sensation), pain, surgery, obesity, vascular disease
T/F: you stage an ulcer based on what stage the majority of the pressure ulcer is at. False. Ulcers are staged according to the deepest level of tissue damage
Describe Stage 1 pressure ulcer INTACT skin. NONBLANCHABLE redness. area may be painful, firm, soft, warmer or cooler. The area may appear red, blue, purple in darker skinned tones
Describe Stage II pressure ulcers partial thickness (loss of dermis). shallow open ulcer with red-pink wound bed without slough. a second stage pressure ulcer may manifest as intact or open serum filled blister
Describe stage III pressure ulcer A stage III pressure ulcer is full thickness. It may extend to but NOT THROUGH the fascia (there is NO BONE, TENDON OR MUSCLE)slough may be present, but it does not obstruct depth of tissue loss. there may be undermining/tunneling.
Describe stage IV pressure ulcer in a stage IV pressure ulcer, there is exposed bone, tendon or muslce. slough or eschar may be present. there is often tunneling or undermining.
Describe an unstageable ulcer. an ulcer is unstageable when the base of the ulcer is covered by slough (yellow, gray, tan, green or brown) and/or eschar is in the wound.
What is the most common complication of a pressure ulcer? recurrence
what are some complications associated with pressure ulcers? the most common complication is recurrence. Cellulitis, chronic infection and osteomyelitis are other complications associated with pressure ulcers.
what is cellulitis? infection of the skin
what is the risk assessment tool used for pressure ulcers? The Braden Scale is used to assess someone's risk for getting a pressure ulcer.
what is the Braden Scale based on? nutrition, mobility, moisture etc.
what does boggy mean? squishy
Created by: 1398660434
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