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