EXAM 3 Flashcards
Primary Intention
tissue surfaces have been well approximated; approximated with stitches, staples, skin glue, or tapes; used with very little tissue loss
examples of primary intention healing or primary union
surgical incisions, IV therapy, lumbar puncture
secondary intention healing
edges of wound not well approximated; wounds are extensive and involve considerable tissue loss
examples of secondary intention healing
large open wounds such as burns, pressure ulcers, venous stasis ulcers
secondary intention healing vs. primary intention healing
repair time is longer, scarring is greater, higher chance of infection d/t open and exposed wound
when stating a wound is well approximated…
means that the edges of the wounds fit nicely together and line up
tertiary intention healing
delayed or secondary closure; used when there is a reason to delay suturing or closing a wound to allow for drainage and/or edema/infection to resolve; used for heavy contamination in wound; usually held open for 48 hours after cleaned and then is surgically closed
examples of tertiary intention healing
abdominal wound that is initially left open to allow for drainage but later closed like dog bites
tunneling
wound is tunneling into the deeper tissue; usually in one direction
undermining
tissue loss occurring underneath the skin
use of cotton tipped appllicators
used to poke around the skin and determine how deep a wound is if the eyes cannot see; depth of applicator is then measured as part of the wound assessment
necrotic eschar
black tissue representing death of tissue; needs to be removes usually by surgical interventions
granulation
indicative of a healing wound; red an rich blood supply to area causing the bright coloring; slough on top needs to be removed
bright red colored wound means…
the wound is healing
types of wound exudate or drainage
serous- clear and watery with slight yellow tint; serosanguinous- combination of serous mixed with blood; sanguinous- mostly red blood composed from new bleeding; purulent- thicker green/yellow drainage that is sign of infection (pudding-like pus)
biofilm
wound biofilms are result of wound bacteria in clumps, embedded i n thick self-made protective slimy barrier of sugars and proteins; they impair wound healing; proper wound care requires removal of biofilm
dessication
process of drying up, cells dehydrate and die in dry environment forming crust over wound site delaying the healing
keeping wounds moist and hydrated (not wet)…
support epithilialization
maceration
softening and breakdown of the skin due to prolonged exposure to moisture
purpose of wound drains
used when anticipating collection of fluid
placement of wound drains
decided by the surgery that took place and the type of the wound
how often to assess wound drain
frequently throughout sift making note of the drainage, the site, thee pain associated, and the patient tolerance
common types of drains
open- gauze, iodoform gauze, nugauze, penrose; closed- chest tube, hemovac, jackson pratt (JP), T-tube
gauze, iodoform gauze, NuGauze open drain
gauze dressings packed loosely so wound is allowed to drainallow healing from base of wound up
Penrose open drain
consists of rubber tube that provides a sinus tract; drains blood and fluid
example of open drain- gauze, iodoform gauze, NuGauze
infected wounds, after removal of hemorrhoids
examples of penrose open drain
after incision and drainage of an abscess, used in abdominal surgery
chest tube closed drain
mediastinal placement (different from chest tube in pleural space) used to drain blood
chest tube example
after cardiac surgery
hemovac closed drain
portable negative pressure suction device used to drain blood and fluid
jackson pratt closed drain
bulb suction device used to drain blood and fluid; bulb is squeezed prior to closing to create negative pressure; is sutured in place
jackson pratt example
used after breast surgery or mastectomy, used after abdominal surgery, (used for underarm)
examples of hemovac
used after abdominal surgery, used after orthopedic surgery, (breast surgery, underarm)
T-tube closed drainage
placed in the common bile duct to collect bile
example of t-tube
used following gallbladder surgery
NuGauze
used for wound packing via cotton tip applicator; allows for wound to heal from bottom up
montgomery strap
corsette looking dressing holding abdominal pad to wound; used for large wounds
hemovac vs JP
hemovac works the same way as JP by creating negative pressure but can hold more volume
flagging tubing
connect drain to clothing via safety pin to avoid disconnecting and pulling out of body
when to use negative pressure wound therapy or wound V.A.C.
used for large deep wounds that are not able to heal on own; used for individuals that have poor wound healing
purpose of NG tube
decompress or drain stomach of fluid, gastric secretions, or to instill solutions into stomach such as medications or feedings; used when conditions of peristalsis is absent; could be used for paralytic ileus or used to bypass areas of the stomach/intestines to allow for healing
salem sump pump
only NG tube used when continuously suctioning because it is a double lumen that stops a vacuum effect; contains a suction port, a passive air port for equalizing pressure (may have a pig tail over vent/passive air movement piecce)
where should the vent portion of sump pump be located?
higher then the stomach to avoid secretions backing up
is pt NPO with salem sump?
most likely because pump would immediately suck food/liquid out
levine tube
NG tube used for feeding only (AKA feeding tube); can be used for intermittent suctioning but not continuous; size correlates to size of pt
when measuring for placement of NG tube…
begin at tip of nose, to the tragus/ear lobe, then down to the xiphoid process; mark at xiphoid process and that is how far to insert the tube to reach pt stomach
providing enteral feeding via NG tube
used for short-term (~4 weeks); used for pt that have difficulty swallowing, failure to thrive/anorexia, and to give meds; need to flush tube prior to using
After inserting the NG tube…
need to confirm with x-ray for placement to avoid aspiration; if correctly placed then can begin using immediately; used to be able to aspirate stomach content and test pH for correct placement
when using the NG tube after placement confirmed prior…
need to recheck the length of the tube to ensure it has not moved and then can aspirate stomach contents to check pH
if NG tube placed in pt lungs
likely start coughing immediately
delivering enteral feeds in 3 ways
pump, gravity, bolus
pump enteral feeding
rate depends on pt; is required for continuous feedings; need to prime tubing prior to using
gravity enteral feeding
need to calculate drip rate
bolus enteral feeding
at an increased risk of distention; increased risk of aspiration
when delivering enteral feedings…
want pt sitting upright during and 1 hour after to decrease risk of aspiration
what to watch for when enteral feeding?
vomiting- how much was here, what was it consisting of, was there to much enteral feed being given to fast; aspiration- coughing and difficulty breathing
caring for NG tube
ensure tube is secured, ensure tube is taped to nose (specifically for salem sump d/t rigid tube), pin to gown to avoid removal of tube, assess skin irritation under/around tape, ensure mucous membranes are hydrated, if NPO then provide oral care
to promote safety when administering tube feeding…
ensure adequacy of tube by aspirating contents and checking pH, flush prior to giving food/meds and flush after, check placement before administering meds fluids or feedings
if meet resistance when flushing…
flush with coke to break down the clogging; can also use cranberry juice; removing tube is last resort
how long to leave tube in place
as long as possible unless there is policy at hospital or a defect with tube
how long is food bag good for?
usually good for 24 hours
