Chp 26 Flashcards
Abrasion
A superficial open wound that generally heals if kept clean
Debridement
The surgical removal of dead tissue
Dehiscence
An uncommon but extremely serious complication of wound healing in which there is a partial or complete separation of the outer layers of a wound
Erythema
Redness
Eschar
Hard, dry, dead tissue that has a leathery appearance
Evisceration
The protrusion of abdominal contents through an opened abdominal wound
Granulation tissue
New, fragile tissue that grows and fills in a wound
Hemorrhage
Profuse bleeding
Ischemia
Reduced blood flow to an area
Laceration
An open wound made by the accidental cutting or tearing of a tissue
Methicillin-resistant Staphylococcus aureus (MRSA)
A resistant strain or staphylococcus aureus that can live on the skin of healthy individuals without causing illness but which can cause serious illness when a wound is infected with it
Necrotic
The death of cells or tissue
Pressure injury
A wound that results from pressure and friction
Purulent
Containing pus
Sanguineous
Resembling blood
Serosanguineous
Having a pink appearance
Serous
Having a somewhat clear to slightly yellow color
Sinus tract
A channel or tunnel that develops between two cavities or between an infected cavity and the surface of the skin
Contusion
A bruise
Puncture
A puncture wound is a forceful injury caused by a sharp, pointed object that penetrates the skin
Penetrating wounds are caused by objects that penetrate the body, that is, they pierce the skin and lacerate, disrupt, destroy, or contuse adjacent tissue, thus creating an open wound
Penetrating wounds
Stasis ulcers
A stasis ulcer is an ulcer (a crater) that develops in an area in which the circulation is sluggish and the venous return (the return of venous blood toward the heart) is poor. A common location for stasis ulcers is on the ankle.
Types of Wound drainage
-Sangiuneous
-Serous
-Purulent
-Bilious
Sometimes more than one type of drainage in present. These words are conbined to indicate the 2 types of drainage from the wound
-Serosanguineous
-Seropurulent
Sanguineous
It refers to red, bloody drainage
Serous
It refers to clear to pale yellow drainage that looks like serum
Purulent
“Containing pus. It is thick yellow or green drainage and is a sign of infection
Bilious
Made by the body to hell break down fats for digestion. It is a dark greenish color and is often present in wound drainage after gallbladder surgery
Serosanguineous
Both good and clear drainage are present. Combined, they turn dressing materials into a pink color
Seropurulent
Both clear drainage and drainage with pus are present
Wound Assessment Summary
- Site: anatomical location
- Wound type: open or closed
- Wound closure: sutures, staples, Steri-Strips, approximation
- Size: width, length, depth
- Condition of wound bed: color, texture, eschar, sloughing, presence of granulation tissue, undermining, sinus tracts
- Condition of skin surrounding wound: color, texture, maceration
- Pain: rate discomfort/ tenderness using pain scale
- Drainage: Amount, type/ color, odor
Clean
A wound that is not infected
Clean- contaminated
A wound that was surgically made, but it has direct contact with the normal flora in either respiratory tract, the urinary tract, or the GI tract. It has more potential to become infected
Contaminated
This can be a surgical wound or a wound caused by trauma that has been grossly contaminated by breaking asepsis
Infected
An infected wound is one is which the infection process is already established, as evidenced by high numbers of microorganisms and either purulent( containing pus) drainage or necrotic (dead) tissue. The classic signs of infection are erythema (redness), increased warmth, edema (swelling) , pain. odor and drainage
Colonized
A colonized wound differs from an infected wound in that it has a high number of microorganisms present but it is without signs of infection
Closed wound
A wound in which the skin remains intact
Open wound
A wound in which the skin integrity has been breached
Risk factors for pressure ulcers
- Elderly: Skin is thinner and more elastic, more susceptible to friction and shearing force
- Emaciated or Malnourished: Emaciation is the state of being very lean or having little muscle
- Incontinent of bowel or bladder: the skin of the perineal area tends to be more wet making it macerated(soft)
- Immoblie: Includes patients who are paralyzed or who have cast or splints or restricted to a bed or chair
- Impaired circulation or chronic metabolic conditions: Chronic metabolic conditions such as diabetes result in impairment of circulation, which can increase risk of ischemic tissue
Nursing measures to prevent pressure ulcers
- Reposition patient at least every 2 hours
- Keep the skin clean and dry
- Assess incontinence pads or linens every hour
- Keep linens free of wrinkles
- For immobile patients, apply lotion to dry skin and assess pressure points for erythema every 1 to 2 hr
- Lift patients who can’t move with a drawsheet or lift
- Encourage adequate nutrition and fluid
- Use specialty beds
- Remove linens from underneath a patient by rolling them to one side and folding the linens to the center of the bed. Then the patient is rolled to the other side and linens are removed to prevent shearing
Rationale for keeping wounds moist to promote healing
-Keep wound bed moist and wick out any drainage
Stage 1 Pressure Injury
Is indicated by erythema of intact skin generally over a bony prominence that will not blanch or turn white when you gently touch it with your finger tip
Stage 2 Pressure Injury
Occurs when there is a partial thickness loss and exposed dermis. Includes intact serum filled blisters and broken blisters and broken blisters that reveal a shallow pink or red ulceration that is moist
Stage 3 Pressure Injury
A full thickness loss involving damage to the epidermis, dermis, and subcutaneous tissue but not involving muscle or bone. Tunneling may be seen. Tend to be infected and produce drainage. Rolled wound edges are usually present
Stage 4 Pressure Injury
A full thickness skin tissue loss, only it involves deep tissue necrosis of muscle, fascia, tendon, joint capsule, and sometimes bone. May be tunneling and undermining. Sometimes osteomyelitis due to massive tissue destruction
Unstageable
Involve full thickness tissue loss but are impossible to stage due to the wound bed being obscured by eschar or excessive slough
First Intention Healing
When the wound is clean with little tissue loss, such as a surgical incision, the edges are approximated and the wound is sutured closed. This helps prevent pathogens from entering the wound and allows healing to occur quickly
Second Intention Healing
When there is greater tissue loss and the wound edges are irregular, the edges can not be brought together. Ex. Pressure injury or a traumatic wound. The wound must be left open to gradually heal by filling in with granulation tissue, which will leave a wide scar. Open wounds must be packed with moist gauze to absorb drainage and allow tissue to grow. They are covered with additional dressings to help prevent microorganism from entering the wound. Must use sterile technique when apply dressings to open wounds
Third Intention Healing
When used the wound is left open for a time to allow granulation tissue to form , and then it is sutured closed, An example would be a draining wound , which is left open until the drainage ceases and then is sutured closed
Review factors that can interfere with wound healing and complications that may occur
p 531 table 26.1
Identify wound dressing supplies and uses for such dressings
p538 table 26.2
Sutures
- Used to close up a wound (closed from inner layer to outer layer)
- Absorbable sutures are used in the inner layers of tissue
- Nonabsorbale sutures or staples are used on the outer layer of skin and removed in 7-14 days
Surgical Adhesive
- Can only be used on outer layers of the skin layers and “glues” the wound together
- No removal is necessary, and the edges of the wound remain approximated during the healing process.
Sterile Adhesive Strips
- Used to close small wounds, or wounds that are healing
- Narrow reinforced tape strips that eventually will peel free of skin
Removal of staples and sutures
pg 545 Skill 26.1
Penrose Drain
An open drain that is where a flat tube is inserted in the wound during surgery and is brought out through a stab wound or slit in the skin
Hemovac and Jackson-Pratt drain
Are both active drains that operate on the suction principal
T tube drain
A passive drain that is placed in the common bile duct after gallbladder surgery to drain excess bile
Documenting wound care
- Describe the amount and color of drainage on the old dressing
- Document the length, width. or diameter and the depth of the wound
- Refer to a clock face to describe the interior of the wound, included sinus tracts and their length
- Describe color and appearence of surrounding skin
- Document type of dressing applied
- Review documentation to make sure wound is getting smaller
