Wound management
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| What are the phases of wound healing? | *Hemostasis *Inflammatory Phase *Reconstruction Phase *Maturation Phase
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| What happens during the hemostasis phase? | termination of bleeding
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| What happens during the inflammatory phase? | initial increase in blood elements and water flow from the vessels to the vascular space.
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| What happens during the reconstruction phase? | collagen formation from fibroblasts at wound site. Begins the 3rd or 4th day after injury.
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| What happens during the maturation phase? | roughly 3 weeks after surgery fibroblasts begin to exit the wound. Scar developes.
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| In which phase is collagen formed from fibroblasts to promote healing? | Reconstruction phase
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| 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
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| 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
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| 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
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| What are the three types of wound healing? | *Primary *Secondary *Tertiary (Delayed Primary)
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| Define Granulation: | tissue and capillaries must extend from the edges inside the wound toward the center, this results in a broader scar
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| 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.
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| Define Extravasations: | Passage or escape into the tissues, usually blood, serum, or lymph fluid.
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| Define Dhiscence: | the parting of the sutured lips of a surgical wound.
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| 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
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| 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
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| True or False: A patient suffering Dehiscence should be kept NPO | True
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| Which wound complication is a surgical emergency? | Evisceration
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| 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
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| What supplies do you need to do a dry sterile dressing change? | Gloves, gauze, tape, basin, NSS, 30-60 ml syringe, pad
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| How often do you change a wet to dry dressing? | Every 12 hours
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| 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.
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| At what temperature does wound healing happen? | Body temperature
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| 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
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| What sre the types of wound drainage (exudate)? | *Serous *Sanguineous *Serosanguineous *Purulence
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| What volume of exudate drainage w/in a 24 hour period is considered abnormal? | 300ml
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| What may cause a slight increase in drainage? | Ambulation
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| What type of wound drain prevents environmental contaminants? | Closed/Suction drain
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| What drain is used when small amounts (100-200 ml) of drainage anticipated | Jackson-Pratt drain
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| What drain is used for larger amounts (up to 500 ml)of drainage | Hemovac drainage system
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| Give two examples of a closed drainage system | Hackson-pratt, Hemovac drainage system
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| When is wound healing evaluated? | *Each dressing change *Application of heat and cold therapies *Wound Irrigation *Stress to the wound site
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| How often should the condition of dressings be inspected? | At least every shift
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| 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
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| How do you evaluate wound healing? | *Reduced Size/Depth *Increase in granulation tissue *Free of signs and symptoms *Relief of pain
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