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