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Fundamentals Wound Care Chp 26 > Chp 26 > Flashcards

Chp 26 Flashcards

1
Q

Abrasion

A

A superficial open wound that generally heals if kept clean

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2
Q

Debridement

A

The surgical removal of dead tissue

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3
Q

Dehiscence

A

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

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4
Q

Erythema

A

Redness

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5
Q

Eschar

A

Hard, dry, dead tissue that has a leathery appearance

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6
Q

Evisceration

A

The protrusion of abdominal contents through an opened abdominal wound

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7
Q

Granulation tissue

A

New, fragile tissue that grows and fills in a wound

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8
Q

Hemorrhage

A

Profuse bleeding

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9
Q

Ischemia

A

Reduced blood flow to an area

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10
Q

Laceration

A

An open wound made by the accidental cutting or tearing of a tissue

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11
Q

Methicillin-resistant Staphylococcus aureus (MRSA)

A

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

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12
Q

Necrotic

A

The death of cells or tissue

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13
Q

Pressure injury

A

A wound that results from pressure and friction

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14
Q

Purulent

A

Containing pus

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15
Q

Sanguineous

A

Resembling blood

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16
Q

Serosanguineous

A

Having a pink appearance

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17
Q

Serous

A

Having a somewhat clear to slightly yellow color

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18
Q

Sinus tract

A

A channel or tunnel that develops between two cavities or between an infected cavity and the surface of the skin

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19
Q

Contusion

A

A bruise

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20
Q

Puncture

A

A puncture wound is a forceful injury caused by a sharp, pointed object that penetrates the skin

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21
Q

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

A

Penetrating wounds

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22
Q

Stasis ulcers

A

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.

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23
Q

Types of Wound drainage

A

-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

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24
Q

Sanguineous

A

It refers to red, bloody drainage

25
Q

Serous

A

It refers to clear to pale yellow drainage that looks like serum

26
Q

Purulent

A

“Containing pus. It is thick yellow or green drainage and is a sign of infection

27
Q

Bilious

A

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

28
Q

Serosanguineous

A

Both good and clear drainage are present. Combined, they turn dressing materials into a pink color

29
Q

Seropurulent

A

Both clear drainage and drainage with pus are present

30
Q

Wound Assessment Summary

A
  • 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
31
Q

Clean

A

A wound that is not infected

32
Q

Clean- contaminated

A

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

33
Q

Contaminated

A

This can be a surgical wound or a wound caused by trauma that has been grossly contaminated by breaking asepsis

34
Q

Infected

A

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

35
Q

Colonized

A

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

36
Q

Closed wound

A

A wound in which the skin remains intact

37
Q

Open wound

A

A wound in which the skin integrity has been breached

38
Q

Risk factors for pressure ulcers

A
  • 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
39
Q

Nursing measures to prevent pressure ulcers

A
  • 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
40
Q

Rationale for keeping wounds moist to promote healing

A

-Keep wound bed moist and wick out any drainage

41
Q

Stage 1 Pressure Injury

A

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

42
Q

Stage 2 Pressure Injury

A

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

43
Q

Stage 3 Pressure Injury

A

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

44
Q

Stage 4 Pressure Injury

A

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

45
Q

Unstageable

A

Involve full thickness tissue loss but are impossible to stage due to the wound bed being obscured by eschar or excessive slough

46
Q

First Intention Healing

A

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

47
Q

Second Intention Healing

A

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

48
Q

Third Intention Healing

A

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

49
Q

Review factors that can interfere with wound healing and complications that may occur

A

p 531 table 26.1

50
Q

Identify wound dressing supplies and uses for such dressings

A

p538 table 26.2

51
Q

Sutures

A
  • 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
52
Q

Surgical Adhesive

A
  • 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.
53
Q

Sterile Adhesive Strips

A
  • Used to close small wounds, or wounds that are healing

- Narrow reinforced tape strips that eventually will peel free of skin

54
Q

Removal of staples and sutures

A

pg 545 Skill 26.1

55
Q

Penrose Drain

A

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

56
Q

Hemovac and Jackson-Pratt drain

A

Are both active drains that operate on the suction principal

57
Q

T tube drain

A

A passive drain that is placed in the common bile duct after gallbladder surgery to drain excess bile

58
Q

Documenting wound care

A
  • 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

Fundamentals Wound Care Chp 26 (1 decks)

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