wound care
Terms
undefined, object
copy deck
- What precautions are used when implementing wound care?
- standard precautions
- What would a nurse avoid when caring for a healing wound?
- avoid frequent cleaning.
- Risk factors that contribute to pressure ulcers ?
-
immobility
inadequate nutrition
fecal and urinary incontinence
decreased mental status
diminished sensations
excessive body heat
advanced age
chronic medical conditions
hard support surfaces, repeated injury, incorrect application of protective devices - Partial thickness
-
confined to the dermis and epidermis
heals by regeneration - full thickness
-
involving the epidermis, dermis, subcutaneous tissue, and possibly bone and muscle.
require connective tissue repair - incision
-
cause= sharp instrument
characteristics= open, deep or shallow - contusion
-
causes= blow from a blunt instrument
characteristics= closed wound, skin appears ecchymotic d/t damaged blood vessels - abrasion
-
causes= surface scrape, intentional or unintentional
characteristics= open wound involving the skin - puncture
-
causes= penetration of the skin and often the underlying tissue by a shape instrument, intentional or unintentional.
characteristics= open wound - laceration
-
causes= tissues torn apart, often from an accident
characteristics= open wound, rough edges - penetrating wound
-
penetration of the skin and the underlying tissues, usually unintentional
characteristics= open wound - reactive hyperemia
- body mechanism. extra blood floods an area to compensate for the preceding period of impeded blood flow results in a bright red flush appearance
- reactive hyperemia is caused by ?
- vasodilation
- How long does reactive hyperemia last?
- 1/2 to 3/4 as long as the duration of blood impeded blood flow.
- If reactive hyperemia is relieved in 1/2 to 3/4 the time as blood impediment, will there be tissue damage to the area ?
- NO.
- An example of shearing force.
- sitting in the Fowler's position for extended periods of time.
- An example of friction.
- sheets rubbing against skin.
-
Primary intention healing
AKA
primary union or first intention healing -
tissue surfaces have been approximated.
minimal or no tissue loss.
formation of minimal granulation tissue and scarring. - An example of primary intention healing
- surgical incision
- Secondary intention healing
-
extensive
considerable tissue loss
edges cannot be approximated - An example of secondary intention healing .
- pressure ulcers
- How does secondary intention healing differ from primary intention healing?
-
repair time is longer
the scarring is greater
the susceptibility to infection is
greater - Phases of wound healing ?
-
inflammatory phase
proliferative phase
maturation phase - inflammatory phase
-
initiated immediately
last 3-6 days
two major processes= hemostasis and phagocytosis -
Proliferative phase
second phase -
day 3 or 4 to day 21 postinjury
collagen= strength to the wound
sutures collagen= healing ridge
unsutures= invisible
granulation tissue- bleeds easily
eschar=dried plasma protein and dead cells -
Maturation Phase
third phase -
from day 21 to 2 years after injury
collagen fibers are more organized
wound is remodeled and contracted
never as strong as original
keloid development is some individuals -
Pressure Ulcer Scale for Healing
or
National Pressure Ulcer Advisory Panel -
measures length, depth, width, and amount of drainage, and tissue type.
the score is used as an indicator of healing. - Three types of exudate
-
serous exudate
pyogenic exudate
sanguineous (hemorrhagic) exudate - serous exudate consists of ?
- serum from the serous membrane of the body
- purulent exudate consists of?
-
thicker than serous and contains pus
which is composed of leukocytes, liquefied dead tissue debris.
purulent exudate can vary in color of green, blue, yellow - sanguineous (hemorrhagic) exudate consists of?
-
large amounts of red blood cells
seen in open wounds - Mixed types of exudate are?
-
serosanguineous
purosanguineous - Purosanguineous drainage
-
consists of pus and blood
seen often is new wound that is infected - serosanguineous drainage consists of ?
-
clear and blood tinged drainage
seen in surgical incisions - Causes of an internal surgical hemorrhage.
-
dislodged clot
slipped stitch
erosion of a blood vessel - Signs of an internal hemorrhage ?
-
swelling
distention of the area
possible sanguineous drainage from the surgical drain - After surgery, the risk of a hemorrhage is greatest ?
- first 48 hours
- What are the nurses action when a client is hemorrhaging?
-
apply pressure dressings to the area
monitor vital signs
call the physician - Severe infection causes?
-
fever
elevated white blood cell count - When is surgical infection most likely to occur?
- 2 to 11 days postoperatively
- dehiscence
-
partial or total rupturing of a sutured wound.
usually involves an abdominal wound - evisceration. when does it occur? what clients are at risk?
-
protrusion of the internal viscera through an incision
likely to occur 4 to 5 days post-op
obesity, poor nutrition, multiple trauma, failure of suturing, coughing, vomiting, and dehydration increase the risk - What should the nurse do in the event the client states " something has given away" ?
-
apply sterile dressing
place client in bed with knees bent
notify surgeon - Pressure points with the client in a supine position?
-
heels ( calcaneus)
sacrum
elbows
scapulae
back of the head - Pressure points if the client is in a side lying position?
-
malleolus
knee=medial & lateral condyle
greater trochanter
ilium
shoulders
ears
side of the head - Pressure points with the client in the prone position?
-
toes
knees
genitalia (men)
breast (women)
shoulders
cheeks and ears - Pressure points with the client is a Fowler's position?
-
heels
pelvis
sacrum
vertebrae - What are the nutritional needs of a client who has a wound that is healing?
-
rich in+ Protein
carbohydrates
lipids
vitamins A & C
iron, zinc, and copper - Areas most likely to have problems with skin break down?
-
skin folds ex:under the breast
areas that are frequently moist=perineum
areas that receive extensive pressure ex:trochanter and coccyx - Assessing common pressure sites
-
1.natural or fluorescent light
2. a room that is not too cold or hot
3.inspect for whitish or reddened area
4. inspect for areas of abrasions or excoriations
5. palpate surface temperature
6. palpate over bony prominence and areas of edema - yellow wounds=liquid to semi-liquid slough may be accompanied by purulent drainage.
-
remove nonviable tissue
apply wet to dry dressing
irrigating the wound
using absorbent dressing material= impregnated nonadherent, hydrogel dressing, or exudate absorber
consult DR. about the use of an antimicrobial gel. - red wounds= late regenerative phase
-
protect to avoid disturbance
1. gently cleansing w/o pressure
2. avoid dry gauze or wet-to dry dressings
3. apply a antimicrobial agent
4. apply gauze or transparent film, or hydrocolloid dressing
5. change infrequently - black wounds= covered with thick nerotic tissue aka eschar
-
require debridement
when eschar is removed the wound is treated as a yellow wound then a red wound - How does a nurse treat a wound if more than one color is present?
-
treats the more serious color first.
black, yellow, then red - treating pressure ulcers
-
reposition q 2 hours
clean the ulcer w/ q. dressing change
use surgical asepsis
do not use alcohol
if infected get a sample of drainage
use pressure relief devices
teach client to move often
provide range of motion exercises - What are some special considerations that require caution when using heat and cold applications?
-
Neurosensory impairment
Impaired mental status
Impaired circulation
Immediately after injury or surgery
open wounds - Would cold therapy be used on an open wound?
- No because cold decreases blood flow: which will slow down healing
- Would heat therapy be affective immediately after surgery?
- No. heat increases bleeding.
- Would heat or cold therapy be used on a client who has diabetes, peripheral vascular disease, or congestive heart failure?
- NO, because they would not have the ability to dissipate heat via blood circulatory system= tissue damage.
-
People with impaired mental status would require ____________________by the nurse
during heat or cold therapy? - monitoring to ensure safe therapy
- When using heat/cold therapy neurosensory impaired persons are at risk for __________________________?
- tissue damage
- What type of injuries would require heat therapy?
-
musculoskeletal problems, stiff joints from arthritis, low back pain ,
contractures - What type of injuries would require cold therapy?
- sports injuries= sprain, strains, and fractures
- Obtaining an aerobic culture
-
clean wound
rotate swap over clean areas of granulation tissue from the sides or base of the wound - aerobic cultures should not be taken from ?
- pus or pooled exudate
- obtaining an anaerobic wound culture?
-
clean wound
insert syringe into wound
aspirate 1 ml of drainage - What should the nurse do if the client is complaining of pain at the wound site before obtaining a wound culture?
- administer pain relief meds 30 minutes before performing the procedure
- What is a disadvantage to sheep skins ?
- makes the client hot.
- the temperature for heat therapy?
-
46-52C (115-125F)adults
debilitated or unconscious clients= 40.5 -46C (105-115F) - The purpose of primrose drains ?
-
to permit the drainage of serosanguineous and purulent drainage.
promote the healing of underlying tissue. - the purpose of Jackson Pratt drains?
-
connected to a reservoir to maintains constant low suction.
provide accurate drainage measurements
reduces the possible entry of microorganisms.
drainage of purulent and serosanguineous drainage - Occlusive dressings are used on what type of wounds?
-
ulcerated
or
burned skin - Advantages to a transparent wound dressings ?
-
1. acts as temp. skin
2. remain in place until healing is complete or as long as they are intact.
3. transparent= assessed through them
4. occlucive =moisture= retains serous exudate.
5. can be used over a joint.
adhere to skin not to wound
6. client can bath with dressing
7. removed w/o causing damage. - Advantages to hydrocolloid dressings
-
1. last a long time.
2. are water resistant - If obtaining a wound culture, where would the nurse swab the wound?
- rotate the swab back and forth over granulation tissue (viable tissue) from the sides and base of the wound.
- Why does the nurse swab over viable wound tissue?
- microorganisms that are the cause of the infection are within the viable tissue
- For an anaerobic specimen the nurse knows ?
-
insert 10ml. syringe
aspirate 5 ml. of drainage. attach needle to syringe, expel air
inject the drainage into the anaerobic tube.
send to lab immediately