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cp 3 > POD 2 > Flashcards

POD 2 Flashcards

1
Q

3 layers of skin

A
  • epidermis
    -dermis
  • subcutaneous
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2
Q

epidermis

A

outermost layer of skin on your body. It protects your body from harm, keeps your body hydrated, produces new skin cells and contains melanin

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3
Q

dermis

A

middle layer of skin in your body. It has many different purposes, including protecting your body from harm, supporting your epidermis, feeling different sensations and producing sweat and hair.

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4
Q

hypodermis

A

storing energy, connecting the dermis layer of your skin to your muscles and bones, insulating your body and protecting your body from harm

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5
Q

wound is

A
  • disruption of integrity and function of tissue in body
  • causes cells that would normally be connected to become separated (not all equal & therefore treatment varies)
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6
Q

wound healing is

A

complex and ordered sequence of biochemical events that occur in response to tissue injury and leads to tissue repair

tissue layers involved & their capacity for regeneration determine the mechanism of repair of any wound

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7
Q

2 types of wound healing

A
  • primary intention
  • secondary intention
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8
Q

primary intention is

A

tissue edges are brought together (approximated) or closed with sutures, staples, or steri-strips & minimal or no tissue loss

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9
Q

does primary intention have minimal granulation tissue or scarring

A

YES

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10
Q

primary intention has minimal risk of

A

infection or deficits

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11
Q

with primary intention does healing occur quickly or slowly

A

QUICK

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12
Q

examples of primary intention

A

lacerations, punctures, thermal burns, blisters, surgical incisions

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13
Q

secondary intention is

A

wound edges are unable to be approximated & involves loss of tissue

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14
Q

with secondary intention, how does the wound heal

A

it is left open until it fills with scar tissue & occurs from bottom up & from outer edges toward the centre

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15
Q

secondary intention there is an increase in

A

infection & more likely to scar

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16
Q

secondary intention examples

A

pressure ulcers

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17
Q

wound healing is divided into 3 phases

A

inflammatory phase, proliferative phase, maturation phase

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18
Q

inflammatory phase

A
  • commences as soon as tissue integrity is disrupted by injury; this begins the coagulation cascade to limit bleeding
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19
Q

duration of inflammatory phase

A

0-14 days

wounds closed by primary intention = lasts 4 days

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20
Q

inflammatory phase is characterized by

A

erythema, edema, pain

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21
Q

proliferative phase

A

begins as the cells that migrate to site of injury (fibroblasts, epithelial cells, vascular endothelial cells)

fibroblas proliferation stimulated by macrophage-released growth factors

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22
Q

during the proliferative phase, what kind of tissue is started

A

granulation

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23
Q

duration of proliferative phase

A

4-42 days

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24
Q

maturation phase

A

collagen degradation, and collagen remodeling

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25
Q

duration of maturation phase

A

24 days -18months

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26
Q

scar tissue formation occurs during which stage

A

maturation

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27
Q

what is the #1 enemy of surgical wound

A

INFECTION

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28
Q

local symptoms of infection

A
  • redness
    -induration
  • swelling
  • pain
    change in exudate
29
Q

systemic symptoms of infection

A
  • fever
  • elevated WBC
  • diaphoresis
  • decreased energy
30
Q

internal hemorrhage

A

presenting as distention, swelling, pallor, diaphoresis combined with tachycardia & low BP

31
Q

external hemorrhage

A

copious amounts of sanguineous drainage on dressings, into drains or out of orifices combined with tachycardia, and low BP

32
Q

what do you need to do with hemorrhage

A

assess vital signs

apply pressure dressings

inform dr STAT

33
Q

hematoma

A

localized collection of blood underneath tissues

34
Q

hematoma appears as

A

swelling, change in colour, change in sensation or warmth or as mass with blue colour

35
Q

hematomas should be monitored for

A

increasing size & outlined with pen for observation

36
Q

hematomas may ne reabsorbed by body or drained by dr

A

TRUE

37
Q

dehiscence

A

partial or total separation of would layers

38
Q

monitor for dehiscence by ..

A

looking at wound approximation & increased serosanguinous drainage

39
Q

to prevent dehiscence, teach pateints how to

A

splint when doing deep breathing & coughing exercises to help stabilize incisions

40
Q

evisceration

A

protrusion of internal viscera through incision

requires emergent surgical erpair

41
Q

nursing responsibilities for evisceration

A

place sterile over organs (abdo pads soaked in warmed normal saline & notify the dr STAT)

42
Q

fistulas are

A

abnormal passages between 2 organs or between an organ and outside of body

43
Q

most fistulas form as a result of

A

poor wound healing or complications of disease

44
Q

fistulas are difficult to treat surgically due to

A

increased risk of developing further fistulas

45
Q

treatment for fistulas are

A

resting the gut (NPO), IV nutrition (TPN), surgery

46
Q

intrinsic factors that affect healing

A

diabetes, cancer, renal disease, liver disease, obesity, impaired immune system, age of the patient

47
Q

extrinsic factors that affect healing

A

malnutrition, tobacco use, inappropriate use of dressings, stress, medication use (systemic steriod use)

48
Q

assessment: type of wounds

A
  • pressure ulcers
  • diabetic/neuropathic ulcers
  • venous stasis ulcers
  • arterial / ischemic ulcers
  • surgical wounds
  • atypical wounds
  • fungating / malignant wounds
  • burns
49
Q

assessment: location

A
  • sacral region
  • sacroiliac region
  • buttock
  • coccyx
  • hip
  • thigh
  • ischial tuberosity
  • posterior thigh
50
Q

assessment: wound measurement

A
  • allows the nurse to assess wound healing & adjust treatment plans
51
Q

when measuring wounds it is essential to measure the wounds:

A

length, width, depth

52
Q

undermining is

A

a separation of tissue from the surface under the edge of wound

53
Q

accurate measurement of undermining allows the nurse to

A

treat the wound to optimize healing

54
Q

undermined areas must

A

packed appropriately, healing occur from “ground” up (wound bed)

55
Q

documentation: describing the wound

A

appearance of wound bed (percentage of granulation tissue visible)

56
Q

granulation tissue in documentation

A

red or pink colour with cobblestone like appearance (healing, filling in)

57
Q

necrotic/non-viable in documentation

A

slough-yellow, tan dead tissue

eschar-black/brown necrotic tissue, can be hard or soft

58
Q

serous

A

clear watery plasma

59
Q

purulent

A

thick yellow green tan or brown

60
Q

serosanguineous

A

pale red watery, mixture of clear and red fluid

61
Q

sanguineous

A

bright red, indicates active bleeding

62
Q

what else do we document

A
  • exudate
  • amount (scant, small, moderate, large, saturated)
  • type (serous, sanguineous, purulent)
  • odor
  • measurements (length, width, depth)
  • presence of sutures, staples
  • wound approximation
  • drains
  • condition of surrounding skin (red swelling)
  • pain!!
63
Q

what to do to assess odor of wound

A

be sure to clean wound well first before assessing odour

64
Q

dressing changes

A
  • common to reinforce surgical dressings within the first 24hr after surgery to reduce incidences of infections
65
Q

only sterile objects may be placed on a sterile field

A

TRUE

66
Q

a sterile object out of range of vision or below waist level is

A

considered contaminated

67
Q

when a sterile surface comes into contact with a wet substance the field is

A

considered comtaminated

68
Q

how to do a dressing change

A
  1. verify order
  2. gather equipment
  3. verify pt
  4. explain procedure to pt
  5. assess pt for need of analgesia (admin 30 mins prior)
  6. set up work space
  7. open sterile dressing kit by pulling back (furthest away from you) open first
  8. add sterile items to your sterile field using drop technique
  9. gloves & remove dressing
  10. inspect wound (redness, edema, ecchymosis, drainage, approximation)
  11. cleanse wound from top to bottom & center to outside (clean to dirty) (dry wound with gauze)
  12. dress wound as per protocol

cp 3 (2 decks)

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