Final Flashcards
some escape of blood from a wound is
normal
hemorrhage (extensive bleeding) from a wound is
abnormal
internal hemorrhage (from a wound) can often be detected by swelling or
distention in the area of the wound and possibly sanguineous drainage from a surgical drain
some clients will have a hemoatoma which is a
localized collection of blood underneath skin, which may appear as a reddish-blue swelling.
body wounds are either ___________ or ___________
unintentional or intentional
intentional wounds
are the result of therapy such as with surgery or venipunctures
in which the wounding of the skin, though causing trauma is done to implement the therapeutic intervention
unintentional wounds
are not planned, nor are they part of the therapeutic intervention ex. wound from a motor vehicle accident
wounds can be described according to how they are acquired. they also can be described according to the _________________
likelihood and degree of contamination
Clean wounds
are uninfected wounds in which there is minimal inflm and the respiratory, gastrointestinal, genital and urinary tracts are not entered.
clean wounds are primarily closed wounds.
Clean-contaminated wounds
are surgical wounds in which the respiratory, gastrointestinal, genital or urinary tracts have been entered under controlled conditions. such wounds show no evidence of infection
contaminated wounds
include open, fresh, accidental wounds and surgical wounds that involve a major break in sterile technique or gross spillage from the gastrointestinal tract and incisions in which acute, non purulent inflammation is visible
dirty or infected wounds
include old traumatic wounds which retained dead tissue and wounds that involve existing clinical infection or perforated viscera
wounds are considered to be acute or chronic depending on
the healing process and the inflammatory response to trauma
acute wound
is a wound that heals within an expected time frame
chronic wound
describes any break or alteration in skin that is of long duration (often 3 months or more) or reoccurs frequently
classifying wounds by depth
- partial thickness wound
- full thickness wound
partial thickness wound
confined to skin, that is the dermis and epidermis, heals by regeneration
full thickness wound
involving the dermis, epidermis subcutaneous tissue and possibly muscle and bone; requires connective tissue repair
Types of wounds based on how they were acquired
- Incision
- Contusion
- Abrasion
- Puncture
- Laceration
- penetrating
incision
cause: sharp instruments (eg. Knife or Scalpel) usually intentional
description and characteristics: open wound; painful; deep or shallow
contusion
cause: blow from a blunt instrument
description and characteristics: closed wound, skin appears bruised because of damage to blood vessels
abrasion
cause: surface scrape, either unintentional (ex. scraped knee form a fall) or intentional (eg. dermal abrasion to remove pock marks)
description and characteristics: open wound involving skin, painful
puncture
cause: penetration of skin and often underlying tissues by a sharp instrument, either intentional or unintentional
description and characteristics: open wound
laceration
cause: tissues torn apart, often from accidents (eg. with machineray)
description and characteristics: open wound, edges are often jagged
penetrating
cause: penetration of skin and underlying tissues usually unintentional (from a bullet or metal fragments)
description and characteristics: open wound
define a primary line
a primary line is the IV tubing used to set up a primary IV infusion
describe the purpose of a saline lock
the purpose of a saline lock is to administer IV medications when the patient does not require continuous IV fluids
list three complications of IV sites
phlebitis
inflitartion
infection
how often should an IV site be monitored
1 hr
general guidelines for insulin administration
- store vials of insulin in the refrigerator, not the freezer. keep vials currently being used at room temp. DO NOT INJECT COLD INSULIN
- inspect vials before each use for changes in appearance (eg. clumping, frosting, precipitation, change in clarity or colour)
- do not interchange insulin types unless approved by the patients prescriber
- preferred injection site includes abdomen, avoiding a 5 cm radius from umbilicus and the outer aspect of thighs
- have a pt self administer insulin whenever possible
- pts who take insulin need to self monitor their blood glucose
- all patients who take insulin should carry at least 15g carbs in the event of a hypoglycemic reaction
Isotonic solutions
ex. normal saline (NaCl 0.9%), Lactated ringers
isotonic solutions initally remain in the vascular compartment, expanding vascular volume. Ringers is consiered a physiologic (balanced electrolyte)solution. Assess client carefully for signs of hypovolemia such as bounding pulse and SOB
hypotonic solutions
0.45% NaCl ( half normal saline)
0.33% NaCl (one third normal saline)
hypotonic soultuions are used to provide free water and treat cellular dehydration. These solutions promote waste elimination by the kidneys. DO not administer to clients at risk for IICP or third space fluid shift.
hypertonic solutions
hypertonic solutions draw fluid out of the intracellular and interstitial compartments into vascular compartment, expanding vascular volume.
do not administer to clients with kidney or heart disease or clients who are dehydrated. watch for signs of hypovolemia
ex. 5% dextrose in normal saline, 5% dextrose in 0.45% NS
5% dextrose in water (D5W)
D5W is defined as isotonic, but becomes a hypotonic solution in plasma. Upon administration dextrose is rapidly metabolized, providing only free water, therefore expanding intracellular and extracelluar fluid volumes. D5W is avoided in clients at risk for increased intracranial pressure (IICP) because it can increase cerebral edema
three clinical measurements that nurse can use to track fluid electrolyte balance
- daily weights
- vital signs
- fluid intake and ouput
fluid intake and output
the measurement and recording of all fluid I&O during a 24 hr period provides important data about the clients fluid and electrolyte balance
all fluids that need to be recorded on the input
- oral fluids
- Ice chips
- foods that are or become liquid at room temp
- tube feedings
- parenteral fluids
- intravenous medications
- catheter or tube irrigants
fluids that need to be recorded on the output
- vomit and liquid feces
- tube drainage
- wound and fistula drainage
isotonic solutions are often used to
restore and maintain vascular volume
ringers lactate contains
sodium, chloride, potassium and calcium
promoting healthy fluid and electrolyte balance
- consume 2000ml to 2500ml water daily, unless contradicted
- avoid excess amounts of foods or fluids high in salt, sugar and caffeine
- eat well balanced diet
- limit aclchol d/t diuretic effect
- incre
lactated ringer solution is an alkalinizing solution that may be given to treat
metabolic acidosis
volume expanders
are solutions used to increase the blood volume following severe blood loss or loss of plasma. Examples of volume expanders are plasma and human serum albumin
appropriate regulation of fluid rates reduces complications such as
phlebitis
infiltration
fluid overload
or clotting of VAD
IV fluids are administered through a peripheral line such as in
- arm
- leg
peripheral veins can accommodate a maximum glucose concentration of
12% and the rate of infusion in peripheral veins should not exceed 200ml in an hour
major complications associated with IV therapy
- phlebitis
- inflitartion
- and infection at IV site
Phlebitis occurs when
vein becomes irritated red or painful (think warm and cordlike)
infiltration occurs when
IV catheter becomes dislodged from the vein and IV fluid escapes into the subcutaneous tissue (think cool and puffy)
infection can also occur at the IV site
think redness and discharge or elevated temp
should phlebiitis, infection or inflitration occur …
the IV is discontinued and another IV site is chosen to restart the IV. the patient should be instructed to notify the nurse of any pain or swelling
mnfts of hypoglycemia
sweating, trembling, palpitations, anxiety, and a sensation of hunger, difficulty concentrating, confusion, weakness, drowsiness, vision changes, difficulty speaking, dizziness, headache
only regular insulin can be administerd
intravenously
rapid acting insluin has onset of about
15 minutes
short acting insulins have an onset of about
30-60 minutes
long acting insulins are not mixed with
any other insulins
practice guidelines for cleansing a wound
clean a wound in an outward direction
primary intention wound healing
occurs when tissues surfaces have been approximated (closed) and minimal or no tissue loss has occurred; it is characterized by the formation of minimal granulation or tissue and scaring
an example of a wound healing by primary intention is a surgical incision
wound healing by secondary intention
a wound that is extensive, involves considerable tissue loss and in which the edges cannot or should not be approximated, heals by secondary intention healing. An example of wound healing by secondary intention is a pressure ulcer
secondary intention healing differs from primary intention healing in three ways
a) the repair time is longer
b) the scarring is greater
c) the susceptibility to infection is greater
those wounds that are left open for 3-5 days to allow edema or infection to resolve or exudate to drain and are then closed with sutures, staples, or adhesive skin are
closures healed by tertirary intention healing
factors affecting wound healing
- life span considerations: healthy children and adults heal quicker than older adults and persons with chronic diseases
- nutrition: wound healing increases the body’s energy and protein needs. clients require a diet rich in protein, carbohydrates, lipids, vitamins a&C
- Lifestyle: people who exercise regularly tend to have good circulation and because blood brings oxygen and nourishment to wound more likely to heal quickly
- medications: -infalmmatory drugs (eg. steroids and aspirin) heparin, and antineoplastic agents interfere with healing
- contamination, colonization and infection
Dressings are applied for the following purpose:
- to protect wound from mechanical injury
- to protect the wound from microbial contamination
- to provide or maintain moist wound healing
- to provide thermal insulation
- to absorb drainage or debride a wound or both
- to prevent hemorrhage (when applied as a pressure dressing or with elastic bandages)
- to splint or immoblilize the wound site and thereby facilitate healing and prevent injury
- to provide psychological (asthetic comfort)
Asses surgical wounds for the following:
Appearance: inspect colour of wound and surronding area and approximation of wound edges. if present note the security of the sutures or staples
Size:
note the size and loaction of dehiscence if present
Drainage:
observe the location, colour, consistency, odour and degree of staturatiion of dressings. note the number of gauze saturated or the diameter of drainage on the gauze
edema:
observe the amount of swelling; minimal to moderate swelling is normal in early stages of wound healing
pain;
expect severe to moderate postoperative pain for 3-5 days presistnat severe pain or sudden onset of severe pain may indicate internal hemorrhaging or infection. Note specific areas of incision that cause pain when cleansed or dressed
Drains or tubes:
inspect drain security and or placement, amount and character of drainage, and functioning of collecting apparatus if present note the method of securtiy (eg. sutures, saftey pin)
phases of wound healing
- hemostasis phase
- inflammatory phase
- proliferative phase
- maturation phase
restoration of both epidermal and dermal layers is
neccessary to promote healing. Risk for local or systemic infection, impaired circulation and breakdown of tissue directly impairs the wound-healing ability of the skin layers
a partial thickness wound (loss of tissue limited to epidermis and possible partial loss of dermis) heals by process of
regeneration
a full thickness wound (total loss of skin layers and some deeper tissues) heals by
scar formation
do not remove an initial surgical dressing for direct wound inspection until
health care provider writes an order for the removal
negative pressure wound therapy is
a wound care treatment that uses the application of subatmospheric (negative) pressure to a wound throughout suction to facilitate healing and collect wound fluid.
negative pressure wound therapy accelerates wound healing by edema and fluid removal, wound contraction and mechanical stretch perfusion
supports wound by optimizing blood flow
principles of basic wound irrigation include
- cleanse in a direction from the least contaminated to the most contaminated area
- when irrigating verify that all the solution flows form the least contimanted to most contaminated area
for post-operative wounds the irrigation solutions should be sterile, for chronic wounds
clean solutions can be used
types of wound drainage
serous: clear watery plasma
sanguineous: which indicates fresh bleeding, bright red
serosanguineous: which is pale, red, more watery drainage than sanguineous drainage
purulent: thick, yellow or green or brown drainage
