Chapter 31 Wound Care Flashcards
biofilm is ___
a thick grouping of microorganisms
epithelialization is ___
stage of wound healing in which epithelial cells form across the surface of a wound; tissue color ranges from the color of “ground glass” to pink
granulation tissue is ___
new tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal
maceration is ___
softening through liquid; overhydration
subcutaneous tissue is ___
underlying layer that anchors the skin layers to the underlying tissues of the body
j
Jaundice, a condition caused by excessive bile pigments in the skin, results in a yellowish skin color. The skin is often itchy and dry; patients with jaundice are more likely to scratch their skin and cause an open lesion, with the potential for infection.
hiv risk
Assessment needs to include careful examination of the skin for purple blotches that may be indicative of Kaposi’s sarcoma.
piercing assessment
Potential interference with airway management. Potential risk for bacterial and viral infections, scarring, nerve damage, tissue trauma, and deformity.
GI procedure approach
The GI cleansing preparations administered to patients having GI studies done may result in diarrhea, which irritates the sensitive skin in the perianal area—especially if the patient had bouts of diarrhea before the studies; anticipating the problem, noting redness and inflammation, and beginning warm baths and ointments are welcome nursing measures that patients may be too embarrassed to seek.
m
moist desquamation (loss of skin integrity).
c
complex (the dermis and underlying subcutaneous fat tissue are damaged or destroyed).
ecchymosis
a discoloration of the skin resulting from bleeding underneath, typically caused by bruising.
a
Avulsion Tearing a structure from normal anatomic position; possible damage to blood vessels, nerves, and other structures
c
Avulsion Tearing a structure from normal anatomic position; possible damage to blood vessels, nerves, and other structures
a surgical incision can cause a variety of systemic reactions, including increased body temperature, increased heart and respiratory rates, anorexia or nausea and vomiting, musculoskeletal tension, and hormonal changes.
n
f
The blood transports increased numbers of leukocytes, erythrocytes, and platelets to the site of injury. Antibodies are carried by the plasma.
j
Undernourished patients are at greater risk for developing a wound infection because they have difficulty mounting their cell-mediated defense system associated with T-lymphocyte activity, a
l
Various vitamins, minerals, and trace elements are also needed for efficient wound healing. Vitamin A is necessary for collagen synthesis and epithelialization. Vitamin B complex serves as a cofactor of enzyme reactions needed for wound healing. Vitamin C is needed for collagen synthesis, capillary formation, and resistance to infection. Vitamin K is needed for the synthesis of prothrombin. Zinc, copper, and iron assist in collagen synthesis. Manganese serves as an enzyme activator.
,
four phases will be discussed: hemostasis, inflammation, proliferation, and maturation.
d
Hemostasis occurs immediately after the initial injury. Involved blood vessels constrict and blood clotting begins through platelet activation and clustering. After only a brief period of constriction, these same blood vessels dilate and capillary permeability increases, allowing plasma and blood components to leak out into the area that is injured, forming a liquid called exudate. The accumulation of exudate causes swelling and pain. Increased perfusion results in heat and redness. If the wound is small, the clot loses fluid and a hard scab is formed to protect the injury. The platelets are also responsible for releasing substances that stimulate other cells to migrate to the injury to participate in the other phases of healing.
d
The inflammatory phase follows hemostasis and lasts about 4 to 6 days. White blood cells, predominantly leukocytes and macrophages, move to the wound. Leukocytes arrive first to ingest bacteria and cellular debris. About 24 hours after the injury, macrophages (a larger phagocytic cell) enter the wound area and remain for an extended period. Macrophages are essential to the healing process. They not only ingest debris, but also release growth factors that are necessary for the growth of epithelial cells and new blood vessels. These growth factors also attract fibroblasts that help to fill in the wound, which is necessary for the next stage of healing.
x
The proliferation phase is also known as the fibroblastic, regenerative, or connective tissue phase. The proliferation phase lasts for several weeks.
s
Fibroblasts are connective tissue cells that synthesize and secrete collagen and produce specialized growth factors responsible for inducing blood vessel formation as well as increasing the number and movement of endothelial cells.
granulation tissue: new tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal
s
x
The final stage of healing, maturation (or remodeling) begins about 3 weeks after the injury, possibly continuing for months or years. Collagen that was haphazardly deposited in the wound is remodeled, making the healed wound stronger and more like adjacent tissue.
d
Edema at a wound site interferes with the blood supply to the area, resulting in an inadequate supply of oxygen and nutrients to the tissue.
x
In addition, toxins produced by bacteria and released when bacteria die interfere with wound healing and cause cell death.
Excessive bleeding results in large clots. Large clots increase the amount of space that must be filled during healing and interferes with oxygen diffusion to the tissue. In addition, accumulated blood is an excellent place for growth of bacteria and promotes infection
z
elderly pt wound care labs
Monitor lab results such as serum albumin, total protein.
c
fatty tissue is more difficult to suture, is more prone to infection, and takes longer to heal.
z
Patients who are taking corticosteroid drugs or require postoperative radiation therapy are at high risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing. Radiation depresses bone marrow function, resulting in decreased leukocytes and an increased risk of infection.
aa
Chemotherapeutic agents impair or stop proliferation of all rapidly growing cells, including cells involved in wound healing. Prolonged antibiotic therapy increases a patient’s risk for secondary infection and superinfection.
lupus
Suppression of the immune system as a result of disease (e.g., AIDS, lupus),
x
Symptoms of wound infection usually become apparent within 2 to 7 days after the injury or surgery;
wound infection complications
osteomyelitis (bone infection) and sepsis (presence of pathogenic organisms in the blood or tissues).
c
An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence.
c
he Semi-Fowler’s position is the position of a patient who is lying in bed in a supine position with the head of the bed at approximately 30 to 45 degrees. Upright at 90 degrees is full or high Fowler’s position. Semi-Fowler’s would be tilted back to approximately 30 degrees.
trochanter def
any of two bony protuberances by which muscles are attached to the upper part of the thigh bone.
odd risk factor for pressure ulcar
History of corticosteroid therapy
e
A stage I pressure ulcer is a defined area of intact skin with nonblanchable redness of a localized area usually over a bony prominence.
d
A stage II pressure ulcer involves partial thickness loss of dermis and presents as a shallow, open ulcer
s
A stage III ulcer presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed.
x
Stage IV ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle.
d
Penrose Provides sinus tract After incision and drainage of abscess, in abdominal surgery T-tube For bile drainage After gallbladder surgery Jackson-Pratt Decreases dead space by collecting drainage After breast removal, abdominal surgery Hemovac Decreases dead space by collecting drainage After abdominal, orthopedic surgery Gauze, iodoform gauze, NuGauze Allow healing from base of wound Infected wounds, after removal of hemorrhoids
maggots
Penrose Provides sinus tract After incision and drainage of abscess, in abdominal surgery T-tube For bile drainage After gallbladder surgery Jackson-Pratt Decreases dead space by collecting drainage After breast removal, abdominal surgery Hemovac Decreases dead space by collecting drainage After abdominal, orthopedic surgery Gauze, iodoform gauze, NuGauze Allow healing from base of wound Infected wounds, after removal of hemorrhoids
Corticosteroids: how do they affect healing?
decrease the inflammatory process, which may delay healing.
Describe gunshot wound care.
A wound with heavy exudate will need a more absorptive dressing and a dry wound will require rehydration with a dressing that keeps the wound moist. The nurse would not keep the surrounding tissue moist. The nurse would not pack the wound cavity tightly, rather loosely. The nurse would not use wet-to-dry dressings continuously
