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NF 2 - Midterm 1 > Module 2 - Surgical Wound Care > Flashcards

Module 2 - Surgical Wound Care Flashcards

1
Q

Healing process of Surgical Incisions

A

Primary Intention, Secondary Intention and Tertiary intention

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2
Q

Primary Intention

A

Edges are approximated, low infection risk, quick healing, minimal scar

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3
Q

Secondary Intention

A

Edges are not well approximated, longer healing time, higher risk of infection, risk of large scar

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4
Q

Tertiary Intention

A

Edges approximated after wound is cleaned, wound left open due to possible contamination, requires observation

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5
Q

Phases of Wound Healing

A

1) Inflammatory phase
2) Proliferation phase - collagen building, granulation tissue
3) Maturation phase - early - raised scar formation
4) Maturation phase - later - thin scar

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6
Q

Assessments prior to surgical dressing change

A 
Pain Assessment
Client discomfort/tenderness
Checking clients care plan
Mobility issues
Continence
Presence of wound
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7
Q

Wound Assessments during a surgical dressing change

A 
Skin Assessment
Wound Assessment - REEDA
Wound Drainage - TACO 
Staples, Sutures or Tape quality
Palpation of wound for temperature/tenderness/pain
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8
Q

Dressing Removal Steps

A

Assessment of Client
Put on clean disposable gloves - Hand Hygiene
Remove tape, pulling parallel to skin toward dressing, remove remaining adhesive
Remove gauze one layer at a time
Observe drainage (TACO)
Observe Wound (REEDA)
Throw away soiled dressing in bio hazard

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9
Q

Wound Cleansing Steps

A

Sterile technique
Clean gloves
Use only noncytotoxic solution (Saline or 0.9% NACI)
Cleanse in direction from least contaminated to most contaminated (inside to out)
Irrigate - removing exudation
Debridement - removes necrotic tissue

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10
Q

Suture/Staple Removal Steps

A

Read MD order
Count staples/sutures
Clean from least contaminated to most contaminated (inside to outside) - depends on policy
Use appropriate tools
Remove every other suture/staple depending on order
Never pull the suture through tissue - cut at knot and pull from there
Place remover under suture, pinch, wiggle(back and forth) and gently pull
Place steri-stripes on areas with no staples/sutures

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11
Q

New Dressing Steps

A 
Apply with new gloves
Assess wound and surrounding skin
Dry wound edges with gauze
Apply appropriate dressing
Window formation with tape
Initial and Date tape and place over new dressing
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12
Q

Intermittent Suture

A

Surgeons ties individual sutures made in skin

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13
Q

Continuous Suture

A

Series of sutures with only two knots, one at beginning and one at the end

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14
Q

Blanket Suture

A

A continuous suture that has a lock stitch used to pull together the skin of the wound

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15
Q

Absorbable Sutures

A

Disappear over time, no need for removal, used on internal tissues

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16
Q

Non-Absorabable Sutures

A

Must be removed after a few weeks, used on superficial tissues or at times internal if absorbable sutures cannot

17
Q

Deep Sutures

A

Placed in the dermal layer to reduce tension

18
Q

Superficial Sutures

A

Placed in the epidermis skin layer

19
Q

Purpose of Skin Closures

A
  • minimize scar formation
  • reduces bleeding
  • minimal trauma
  • less tension on tissues
  • keeps edges approximated
20
Q

Assessment prior to Suture/Staple removal

A
  • client history of suture/staple removal
  • site of surgery - REEDA, Skin Assessment
  • tissues involved
  • purpose of removal
21
Q

Supplies required for Suture/Staple Removal

A
  • Special scissors with curved tip - Sutures
  • Tweezers
  • Special scissors for staples
  • Steri strips
22
Q

Sutures vs Staples

A

Sutures are absorbable or non-absorbable, sewn into tissues by intermittent, continuous or blanket continuous. Minimal scar tissue and precise, available in different materials.

Staples are quicker to use, used on outer tissue and cause less trauma and also stronger than sutures. Not as precise and create round wound edges that may lead to abnormal scar formation

23
Q

Process of applying Steri-Stripes

A

Steri-strips are applied over the areas where the sutures/staples were removed, this keeps edges closed and support the wound eliminating scarring.

24
Q

Potential complications of Suture/Staple Removal

A
  • Skin Trauma - Incision separates
  • Unable to remove
  • Pain
25
Q

Nursing action for complications of Suture/Staple Removal

A
  • Notify physician
  • Stop removal
  • Apply steri-strips
  • Take breaks if required
  • Avoid distractions
26
Q

Wound Care Education

A
  • increase fluid intake
  • increase protein intake
  • pain assessments
  • avoid touching or pulling at dressing
  • assessment of wound drainage
27
Q

Intrinsic factors of wound healing

A 
Age
Disease process
Circulation
Immune system
Nutritional and Fluid balance
28
Q

Extrinsic factors of wound healing

A 
Mechanical stress
Temperature
Medication
Radiation
Debris
Smoking
29
Q

Hemorrhage

A

Bleeding from a wound site, normal during or immediately after initial trauma

30
Q

Infection

A

Bacterial growth, entry and multiplication of microorganisms that can cause disease

31
Q

Dehiscence

A

Partial or total separation of wound layers

32
Q

Contraindications of Sutures and Staples

A
  • If MD order states otherwise
  • Wound is not approximated
  • Infection
  • Bleeding
  • Pain
  • Evisceration

NF 2 - Midterm 1 (7 decks)

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