chap 38 pt2 ques 8

Question 1

types of wound

Answer 1

first
second
and third intention

Question 2

wound w/ little tissue loss

edges are close together and aligned; usually

most rapid healing;

example
surgical wounds

Answer 2

first intention

Question 3

what is an example of first intention wound

Answer 3

a surgical wound

Question 4

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

Answer 4

second intention

Question 5

known as delayed or secondary closure

Answer 5

third intention

Question 6

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

Answer 6

third intention

Question 7

some factors that affect wound healing

Answer 7

age

nutrition

lifestyle

chronic illness

infection

medication

Question 8

Peripheral vascular disease impairs what ?

Answer 8

impairs the blood flow, which impede healing

Question 9

If A pt has Atherosclerosis and atrophy how does it affect the skin

Answer 9

reduce skin capillaries and blood flow to wound;

Question 10

Protein,

adequate fluid intake,

vitamins A & C,

thiamine,

pyridoxine,

riboflavin,

zinc, iron, and copper

Answer 10

nutrition for wound healing

Question 11

Regular exercise enhances blood circulation.

Answer 11

lifestyle

Question 12

Use of steroids, immunosuppressants and other antiinflammatory drugs, anticoagulants, and antineoplastic agents interfere with healing

Answer 12

medication

Question 13

haracterized by vascular changes of inflammation, and fluid collecting in the tissues

Answer 13

infection

Question 14

Decreased oxygen and nutrients at the cellular level, disruptions in the normal metabolism of substances, each of which impede healing

such as diabetes

Answer 14

chronic illness

Question 15

Why does smoking slow the healing process?

Answer 15

reduces function of hemoglobin in blood and oxygen perfusion at the wound site

Question 16

What are some key steps to ensure appropriate wound healing?

Answer 16

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

Question 17

swelling or distention in the area of wound and

sanguineous drainage from a surgical drain

Answer 17

hemorrhage

Question 18

if internal hemorrhage is extensive what happens

Answer 18

hypovolemic shock which =

fall in BP;
rapid, thready pulse;
increased resp. rate; diaphoresis;
cold, clammy skin

Question 19

fall in BP;
rapid, thready pulse;
increased resp. rate; diaphoresis;
cold, clammy skin

are sign of what

Answer 19

hypovolemic shock if hemorrhage occurs

Question 20

what are some other cases that can occur in hemorrhage

Answer 20

hematoma

Question 21

how do hematoma look

Answer 21

swelling that is bluish red

Question 22

the risk for hemorrhages is greatest during what period?

Answer 22

the first 48 hours

requires emergency intervention

Question 23

what do you w/ a external hemorrhage ?

Answer 23

reinforce dressings, monitor vitals and notify provider

Question 24

-thick, often malodorous, pus

Answer 24

purulent

Question 25

blood; darker red and less watery in appearance

drainage from a surgical drain

Answer 25

Sanguineous drainage

Question 26

combination of serous drainage and blood; watery and pink to light red in color

Answer 26

Serosanguineous drainage

Question 27

localized collection of blood leaked from adjacent blood cells to organ or tissue

Answer 27

Hematoma

Question 28

fluid accumulation containing cell debris

wound fluid comprised of dead cells, serum, bacteria, pus, WBCs

Answer 28

Exudate

Question 29

a localized infection

is accumulation of purulent exudate made up of debris from phagocytosis when microorganism have been present

Answer 29

abscess

Question 30

inflammation of cellular or connective tissue

subcutaneous

Answer 30

cellulitis

Question 31

an abnormal passage or communication usually formed between two internal organ

or leading from an internal organ to the surface of the body

Answer 31

fistula

Question 32

is a fistula leading from a purulent exudate-filled CAVITY to the outside of the body

Answer 32

sinus

Question 33

what is the best way to prevent wound infections

Answer 33

is to maintain strict aseptic technique

Question 34

natural shedding of dead tissue may caused drainage

Answer 34

sloughing

Question 35

removal of all foreign or unhealthy tissue from the wound

black wounds

mechanical or chemical removal

Answer 35

debridement

Question 36

dead tissue that may be brown to black ;
from

gangrene
burns
pressure
wounds

Answer 36

eschar

Question 37

Please describe the process of obtaining a specimen for a wound culture:

Answer 37

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

document