Ch.28 Wound Care Flashcards
A ____________ is damaged skin or soft tissue that results from trauma.
Wound
____________ is the physiologic defense immediately after tissue injury that lasts for approximately 2 to 5 days.
Inflammation
____________ is a process by which the white blood cells consume pathogens, coagulated blood, and cellular debris.
Phagocytosis
____________ is the period during which new cells fill and seal a wound, and it occurs from 2 days to 3 weeks after the inflammatory phase.
Proliferation
____________ (a period during which the wound undergoes changes and maturation) follows the proliferative phase and may last 6 months to 2 years.
Remodeling
____________ debridement is appropriate for uninfected wounds or for clients who cannot tolerate sharp debridement.
Enzymatic
One of the chief advantages of ____________ dressings is that they allow a nurse to assess a wound without removing the dressing.
Transparent
____________ are tubes that provide a means for removing blood and drainage from a wound.
Drains
____________ are knotted ties, generally constructed from silk or synthetic materials such as nylon, which hold an incision together.
Sutures
A ____________ is a type of bandage generally applied to a particular body part such as the abdomen or breast.
Binder
Identify the type of dressing.
The image is that of a transparent dressing.
What is the chief advantage of using a tranparent dressing?
The chief advantage of a transparent dressing is that it allows the nurse to assess a wound without removing the dressing. In addition, it is less bulky than gauze dressings and does not require tape because it consists of a single sheet of adhesive material. It commonly is used to cover peripheral and central intravenous insertion sites.
Surface of the skin or mucous membrane is no longer intact
Open Wound
Occurs more often from blunt trauma or pressure
Closed Wound
A combination of new blood vessels, fibroblasts, and epithelial cells
Granulation tissue
A reparative process during which the wound edges are directly next to each other
First-intention healing
Wound caused by prolonged capillary compression
Pressure ulcer
Presented here, in random order, are descriptions of the stages of a pressure ulcer. Place them in the correct sequence in the boxes provided.
- Ulcer is red and accompanied by blistering or skin tear.
- Tissue is deeply ulcerated, exposing muscle and bone.
- Characterized by intact but reddened skin.
- Ulcer has a shallow skin crater that extends to the subcutaneous tissue.
- Characterized by intact but reddened skin.
- Ulcer is red and accompanied by blistering or skin tear.
- Ulcer has a shallow skin crater that extends to the subcutaneous tissue.
- Tissue is deeply ulcerated, exposing muscle and bone.
What is the purpose of inflammation during the process of wound repair?
Inflammation is the physiologic defense, immediately after tissue injury, which lasts for approximately 2 to 5 days. The purpose of inflammation is to:
Limit the local damage
Remove injured cells and debris
Prepare the wound for healing
How is the integrity of skin and damaged tissue restored?
Generally, the integrity of skin and damaged tissue is restored by:
Resolution, a process by which damaged cells recover and reestablish their normal function.
Regeneration or cell duplication
Scar formation, which is the replacement of damaged cells with fibrous scar tissue. Fibrous scar tissue acts as a nonfunctioning patch. The extent of scar tissue that forms depends on the magnitude of tissue damage and the manner of wound healing.
What are the factors that affect wound healing?
Several factors that affect wound healing include
Type of wound injury Expanse or depth of wound Quality of circulation Amount of wound debris Presence of infection Status of the client’s health
What are the factors that affect blood flow to the injured tissue?
The key to wound healing is adequate blood flow to the injured tissue. Factors that may interfere include compromised circulation; infection; and purulent, bloody, or serous fluid accumulation that prevents skin and tissue approximation. In addition, excessive tension and pulling on wound edges contribute to wound disruption and delay in healing. One or several of these factors may be secondary to poor nutrition or impaired inflammatory or immune responses secondary to drugs like corticosteroids and obesity.
What are the possible causes of surgical wound complication?
Two potential surgical wound complications include dehiscence (the separation of wound edges) and evisceration (wound separation with protrusion of organs). These complications are most likely to occur within 7 to 10 days after surgery. They may be caused by an insufficient dietary intake of protein and sources of vitamin C; premature removal of sutures or staples; unusual strain on the incision from severe coughing, sneezing, vomiting, dry heaves, or hiccupping; weak tissue or muscular support secondary to obesity; distension of the abdomen from accumulated intestinal gas; or compromised tissue integrity from previous surgical procedures in the same area.
What purpose does the dressing of a wound serve?
A dressing or a cover over a wound is used to
Keep the wound clean Absorb drainage Control bleeding Protect the wound from further injury Hold medication in place Maintain a moist environment
Heat and cold have various therapeutic uses and each can be used in several ways. Examples include an ice bag, collar, chemical pack, compress, and aquathermia pad. Answer the following questions involving a nurse’s role in the application of a compress.
A nurse is caring for a 2-year-old client who is being treated for viral fever at a health care facility. The nurse uses a cold compress for the child.
What is the purpose of a cold compress?
The nurse applies the cold compress to reduce the temperature of the client.
*A nurse is caring for a 2-year-old client who is being treated for viral fever at a health care facility. The nurse uses a cold compress for the child.
How should the nurse apply the compress to the client?
Before applying the compress, the nurse soaks it in tap water or medicated solution at the appropriate temperature and then wrings out excess moisture. To maintain the moisture and temperature, a piece of plastic or plastic wrap is used to cover the compress, and the area is secured in a towel. As the compress material cools or warms outside the range of the intended temperature, the nurse removes it and reapplies it if necessary.
