F- WOUND CARE Flashcards
is a break or disruption in the
normal integrity of the skin and tissues. That disruption may range
from a small cut on a finger to a third -degree burn covering almost
all of the body.
wound
wounds made by blunt force that typically does not break the skin but causes considerable tissue damage with bruising and swelling.
CONTUSED WOUNDS
is an open wound that’s caused by the skin rubbing against a rough surface.
Abrasion
is a penetration of the skin and often the underlying tissues by a sharp instrument.
PUNCTURE
wounds—made by an object
that tears tissues producing jagged, irregular edges; examples include glass, jagged wire, and blunt knife.
LACERATED WOUNDS
is a penetration of the skin and the underlying tissues, (e.g., from a bullet or metal fragments) and coming out of the skin.
Penetrating wound
The skin surface is broken, providing a portal of entry for microorganisms. Bleeding, tissue damage, and increased risk for infection and delayed healing may accompany open wounds. Examples include incisions and abrasions.
OPEN WOUND
- results from a blow, force, or strain caused by trauma such as a fall, an assault, or a motor vehicle crash.
- The skin surface is not broken, but soft tissue is damaged, and internal injury and hemorrhage may occur. Examples include ecchymosis and hematomas.
CLOSED WOUND
such as surgical incisions, usually heal within days to weeks. The wound edges are well approximated (edges meet to close skin surface) and the risk of infection is lessened. Usually move through the healing process without difficulty
ACUTE WOUNDS
A chronic wound is one that has failed to progress through the phases of healing in an orderly and timely fashion and has shown no significant progress toward healing in 30 days.
CHRONIC WOUND
DEGREE OF CONTAMINATION: are uninfected wounds in which there is minimal inflammation and the respiratory, gastrointestinal, genital, and urinary tracts are not entered. Primarily closed wounds.
CLEAN WOUNDS
DEGREE OF CONTAMINATION:
are surgical wounds in which
the respiratory, gastrointestinal, genital, or urinary tract has been
entered. Such wounds show
no evidence of infection.
Clean-contaminated wounds
include open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique or a large amount of spillage from the gastrointestinal tract. show evidence of inflammation.
CONTAMINATED WOUND
include wounds containing dead tissue and wounds with evidence of a clinical infection, such as purulent drainage.
Dirty or infected wounds
is material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces.
EXUDATE
give some functions of exudate
- Dilution of toxins produced by bacteria and dying cells
- Transport of leukocytes and plasma proteins, including antibodies, to the site
- Transport of bacterial toxins, dead cells, debris, and other products of inflammation away from the site
is composed primarily of serum, watery in appearance, and has a low protein count.
SEROUS EXUDATE
This type of exudate is seen with mild inflammation resulting in minimal capillary permeability changes and minimal protein molecule escape.
EX. BLISTER FORMATION AFTER A BURN
SEROUS EXUDATE
_______ exudate is also called pus. It generally occurs with severe inflammation accompanied
by infection.
PURULENT
What makes purulent exudate thicker than serous exudate?
- presence of leukocytes, liquefied dead tissue debris, and dead living bacteria.
T OR F: PURULENT EXUDATE may vary in color depending on the causative organism (yellow, green, brown)
consists of large amounts of red blood cells, indicating damage to capillaries that is severe enough to allow the escape of red blood cells from plasma. This type of exudate is frequently seen in open
wounds.
Sanguineous exudate
exudate consisting of both clear and blood- tinged drainage, is commonly seen in surgical incisions.
Serosanguineous exudate
consisting of pus and blood, is often seen in a new wound that is infected.
purosanguineous discharge
consisting of pus and blood, is often seen in a new wound that is infected.
purosanguineous discharge
give some factors affecting wound healing
- nutrition, balanced diet is needed to increase body’s resistance to pathogens and to decrease susceptibility to infection and trauma
- age, blood circulation and oxygen delivery to the wound, clotting and inflammatory response, and phagocytosis may be impaired in the very young and older adults. Cell growth and epithelialization of open wounds is lower with advancing age,
- oxygenation, decreased arterial oxygen alters synthesis of collagen and epithelial cell formation causing healing to slow. reduced hemoglobin levels decrease oxygen delivery.
- smoking, contains more than 4000 toxic compounds, nicotine, carbon monoxide and hydrogen cyanide primarily cause impaired wound healing.
- drug therapy
when assessing the wound what do we take note of?
- size- length, width and depth measured in cm.
- general appearance and drainage
- granulation tissue
- foreign bodies
- wound drainage (amount, color, odor and consistency)
- pain
The new fibrous connective tissue, containing a large mass of small blood vessels, which form on the surfaces or edges of wounds during the initial stage of the healing process.
granulation tissue
what is the color of a healthy granulation tissue vs an unhealthy granulation tissue?
healthy- pink
unhealthy- dark red in color, bleeds on contact and may indicate infection
AMOUNT OF WOUND DRAINAGE:
-only stains the dressing
MINIMAL DRAINAGE
amount of wound drainage:
saturates the dressing without leakage prior to scheduled dressing changes
MODERATE DRAINAGE
AMOUNT OF WOUND DRAINAGE:
overflows the dressing prior to scheduled changes
HEAVY DRAINAGE
persistent bleeding is abnormal
and may indicate a slipped surgical suture, a dislodged clot, or erosion of a blood vessel.
this is an emergency and nurse should apply pressure to dressings to the wound and monitor vs, client must be taken to the hospital
Hemorrhage,
what are the signs of internal hemorrhaging?
-swelling or distention in the area of the wound, sanguineous drainage from a surgical drain
hematoma may also be seen and appear as a reddish-blue swelling or mass
PURPOSES OF WOUND DRESSING
- To protect the wound from mechanical injury
- To splint or immobilize the wound
- To absorb drainage
- Wound debridement
- To prevent contamination from bodily discharges
- To promote hemostasis, as in pressure dressings.
- To inhibit or kill microorganisms by using dressings
with antiseptic or antimicrobial properties. - To provide mental and physical comfort for the
patient
• Used primarily for wounds closing by primary intention.
• Offers good wound protection,
absorption of drainage, and aesthetics for the patient and
provides pressure for hemostasis.
• Disadvantage—they adhere to the wound surface when drainage dries.
Dry dressings
What should you apply to the dressing if it adheres to the wound surface?
NORMAL SALINE
These are particularly useful for untidy or infected wounds that must be debrided and closed by secondary intention.
Wet -to -dry dressings
in a wet-to-dry dressing
Gauze saturated with _____ is packed into the wound, eliminating dead space.
sterile saline or an antimicrobial solution
involves the removal of debris, such as foreign materials, excess slough, necrotic tissue, bacteria, and other microorganisms.
WOUND CLEANING
note: choices of cleaning agent and method depend largely on agency protocol and the primary care provider’s preference
is the washing or flushing out of an area. Sterile technique is required because there is a break in the skin integrity.
WOUND IRRIGATION/ IRRIGATION (LAVAGE)
what is the range for irrigation pressure?
4 to 15 psi (pounds per square inch)
why should irrigation pressure not be below 4 psi and more than 15?
4 psi when using a bulb syringe may not be effective
above 15psi it may damage tissue
what is the preferred cleanser for most wounds?
SALINE/ NORMAL SALINE because it is physiologic and will always be safe.
T OR F: SALINE will clean well in dirty, necrotic wounds, and studies have shown that bacterial growth in saline is not present.
FALS: saline will not clean dirty or necrotic wound, and studies show that in saline bacterial growth may be present in the opening of the container within 24hrs
- Cytotoxic to healthy cells and granulating tissues.
- Broad spectrum antimicrobial effective against a variety of pathogens including Staphylococcus aureus.
- Dries and discolors skin.
Povidone Iodine
Cytotoxic to healthy cells and granulating tissues.
• Effervescent cleansing action helps to lift debris from the wound surface when used at full strength.
• If used full strength, irrigation with normal saline after use is recommended.
• Ineffective at killing bacteria.
• Do not use on wounds with sinus tracts.
HYDROGEN PEROXIDE
T OR F: ALL objects used in a sterile field must be sterile
TRUE
T OR F: sterile objects have a prescribed storage time, once it is past that it will be considered unsterile
TRUE
T OR F: STERILE objects become unsterile when touched by unsterile objects
TRUE
TRUE OR FALSE: sterile objects that are out of sight or below the waist or table level are considered sterile.
FALSE: THEY ARE NOT CONSIDERED STERILE. NURSES DO NOT TURN THEIR BACKS ON A STERILE FIELD
What are essential qualities to have when maintaining asepsis
conscientiousness, alertness, and honesty.
TRUE OR FALSE: Sterile objects can become unsterile by prolonged exposure to airborne microorganisms.
TRUE
What components of a nutrition is important in wound healing?
- protein
- carbohydrates
- vitamin A
- vitamin C
- Zinc
- Iron and copper
what is the final step to wound care?
-promoting wound healing client teaching/ patient education
