Ch. 36 Flashcards
Hematoma
Localized collection of blood under the tissues.
Evisceration
Separation of wound layers with protrusion of visceral organs.
Approximate
wound edges come together
Abrasion
Superficial loss of dermis
Shearing force
pressure exerted against the skin when the patient is moved.
Cachexia
general poor health and malnutrition with weakness and emaciation. loss of adipose tissue.
Debridement
Removal of devitalized tissue.
Laceration
Torn, jagged damage to the epidermis
Dehiscence
Separation of skin and tissue layers.
Fistula
Abnormal passage between two body organs or between an organ and the outside of the body.
Example of a contributing for pressure ulcer formation:
Shear, friction, moisture on the skin, poor nutrition, cachexia, infection, impaired peripheral circulation, obesity, advanced age.
A clean surgical wound with little tissue loss heals by:
primary intention
A severe laceration or chronic wounds heal by:
secondary intention
Separation of the layers of the skin with serosanguineous drainage noted.
dehiscence
Bluish swelling or mass at the site
hematoma/ bleeding
Fever, general malaise, and increased white blood cell count
Infection
Decreased blood pressure, increased pulse rate, increased respirations.
bleeding/shock
Green, odorous local drainage
infection
Visceral organs protruding through abdominal wall
Evisceration
Wound edges swollen, painful, with redness, extending from the edges outward.
infection
Wound drainage:Serous
Clear, watery plasma
Wound drainage: Sanguineous
Fresh bleeding
Wound drainage: Serosanguineous
Pale, more watery, with plasma and red blood cells
Wound drainage; purulent
Thick, yellow, green, or brown with organisms and white blood cells
Steps for obtaining an aerobic wound culture:
- cleanse the wound and allow to dry.
- Moisten swab with normal saline
- Swab wound in a 1X1 cm area
- Apply pressure to express fluid from wound onto swab.
- Return the swab to the culture tube.
For wound irrigation, identify the following that are considered as safe guidelines; Syringe size, needle gauge, psi?
syringe size:35 mL
Needle gauge: 19 gauge
psi: 8
The nurse should be held how far above the wound?
1 in (2.5 cm) above the wound.
During the irrigation, the nurse notes sanguineous return. The nurse should?
reduce the irrigating pressure and notify the health care provider.
Identify the steps in caring for a traumatic wound:
1) stabilize the pt cardiopulmonary function.
2) promote hemostasis (stop any bleeding)
3) cleanse the wound
4) protect the site for further injury.
Tissue Ischemia
decreased blood flow to tissue resulting in tissue death, occurs when capillary blood flow is obstructed, as in the case of pressure.
Blanchable hyperemia
area that appears red and warm will blanch
Nonblanchable hyperemia
is redness that persists after palpation and indicates tissue damage.
Unstageable
Full-thickness tissue loss in which the base of the ulcer is covered by slough.
A wound with little or no tissue loss such as a clean surgical incision, heals by:
Primary intention
A wound involving loss of tissue such a severe laceration, heals how?
secondary intention
Full thickness wound repair:
Hemostasis, inflammation, proliferative, remodeling.
Hemostasis phase
involving a full thickness wound healing by primary intention is hemostasis, the control of bleeding.
Inflammation phase
establish a clean wound bed and to obtain bacterial balance.
Proliferative phase
production of new tissue, epithelialization, and contraction.
Remodeling phase
last up to 1 year, reorganizes collagen to produce more elastic, stronger collagen for the scar tissue.
Ecchymosis
skin discoloration, or bruising caused by blood leakage into subcutaneous tissues after trauma to underlying vessels.
maceration
softening of the skin due to moisture
Types of dressings:
Hydrocolloid, hydrocel
Hydrocolloid
gelling agents and have adhesive wound surface.
Hydrocel
available in sheets or gel in a tube. high percentage of water and are indicated for wounds that require moisture, either a wound with granulation (maintaining the moist wound environment needed for healing) or a wound that has high necrotic tissue.
