chap 38 pt2 ques 8 Flashcards
types of wound
first
second
and third intention
wound w/ little tissue loss
edges are close together and aligned; usually
most rapid healing;
example
surgical wounds
first intention
what is an example of first intention wound
a surgical wound
A wound w tissue loss
severe laceration
not approximated
WOUND IS LEFT OPEN TO HEAL=LONGER HEALING TIME
GRANULATION
higher risk of infection
example; DECUBITUS (PRESSURE) OR LACERATION OR BURNS
second intention
known as delayed or secondary closure
third intention
occurs when there is delayed SUTURING of wound
wound are suture after the granulation tissue has begun
Example; Abdominal wound left open for drainage and then later closed
third intention
some factors that affect wound healing
age
nutrition
lifestyle
chronic illness
infection
medication
Peripheral vascular disease impairs what ?
impairs the blood flow, which impede healing
If A pt has Atherosclerosis and atrophy how does it affect the skin
reduce skin capillaries and blood flow to wound;
Protein,
adequate fluid intake,
vitamins A & C,
thiamine,
pyridoxine,
riboflavin,
zinc, iron, and copper
nutrition for wound healing
Regular exercise enhances blood circulation.
lifestyle
Use of steroids, immunosuppressants and other antiinflammatory drugs, anticoagulants, and antineoplastic agents interfere with healing
medication
haracterized by vascular changes of inflammation, and fluid collecting in the tissues
infection
Decreased oxygen and nutrients at the cellular level, disruptions in the normal metabolism of substances, each of which impede healing
such as diabetes
chronic illness
Why does smoking slow the healing process?
reduces function of hemoglobin in blood and oxygen perfusion at the wound site
What are some key steps to ensure appropriate wound healing?
keep surrounding skin and tissue clean and dry
adequate O2 & nutrition to site; position to prevent pressure
dressings, stockings, drains applied and position correctly to reduce risk of lymphedema
report S/S infection immediately
nutrition and optimized glucose levels aid in healing process
swelling or distention in the area of wound and
sanguineous drainage from a surgical drain
hemorrhage
if internal hemorrhage is extensive what happens
hypovolemic shock which =
fall in BP;
rapid, thready pulse;
increased resp. rate; diaphoresis;
cold, clammy skin
fall in BP;
rapid, thready pulse;
increased resp. rate; diaphoresis;
cold, clammy skin
are sign of what
hypovolemic shock if hemorrhage occurs
what are some other cases that can occur in hemorrhage
hematoma
how do hematoma look
swelling that is bluish red
the risk for hemorrhages is greatest during what period?
the first 48 hours
requires emergency intervention
what do you w/ a external hemorrhage ?
reinforce dressings, monitor vitals and notify provider
-thick, often malodorous, pus
purulent
blood; darker red and less watery in appearance
drainage from a surgical drain
Sanguineous drainage
combination of serous drainage and blood; watery and pink to light red in color
Serosanguineous drainage
localized collection of blood leaked from adjacent blood cells to organ or tissue
Hematoma
fluid accumulation containing cell debris
wound fluid comprised of dead cells, serum, bacteria, pus, WBCs
Exudate
a localized infection
is accumulation of purulent exudate made up of debris from phagocytosis when microorganism have been present
abscess
inflammation of cellular or connective tissue
subcutaneous
cellulitis
an abnormal passage or communication usually formed between two internal organ
or leading from an internal organ to the surface of the body
fistula
is a fistula leading from a purulent exudate-filled CAVITY to the outside of the body
sinus
what is the best way to prevent wound infections
is to maintain strict aseptic technique
natural shedding of dead tissue may caused drainage
sloughing
removal of all foreign or unhealthy tissue from the wound
black wounds
mechanical or chemical removal
debridement
dead tissue that may be brown to black ;
from
gangrene
burns
pressure
wounds
eschar
Please describe the process of obtaining a specimen for a wound culture:
Pre-procedure & explanation of process
Hygiene and gloves
Remove dressing, discard in biohazard with soiled sides together
cleanse per orders/policy
dispose gloves/hygiene
sterile glove
use swabs from sterile culture tube and insert tip into wound where draining, rotate gently, re-insert swab into culture tube without touching any surface
redress wound with sterile technique
deglove, hand hygiene
transfer labeled sample to lab according to facility policy
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