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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
duration of maturation phase
24 days -18months
26
scar tissue formation occurs during which stage
maturation
27
what is the #1 enemy of surgical wound
INFECTION
28
local symptoms of infection
- redness -induration - swelling - pain change in exudate
29
systemic symptoms of infection
- fever - elevated WBC - diaphoresis - decreased energy
30
internal hemorrhage
presenting as distention, swelling, pallor, diaphoresis combined with tachycardia & low BP
31
external hemorrhage
copious amounts of sanguineous drainage on dressings, into drains or out of orifices combined with tachycardia, and low BP
32
what do you need to do with hemorrhage
assess vital signs apply pressure dressings inform dr STAT
33
hematoma
localized collection of blood underneath tissues
34
hematoma appears as
swelling, change in colour, change in sensation or warmth or as mass with blue colour
35
hematomas should be monitored for
increasing size & outlined with pen for observation
36
hematomas may ne reabsorbed by body or drained by dr
TRUE
37
dehiscence
partial or total separation of would layers
38
monitor for dehiscence by ..
looking at wound approximation & increased serosanguinous drainage
39
to prevent dehiscence, teach pateints how to
splint when doing deep breathing & coughing exercises to help stabilize incisions
40
evisceration
protrusion of internal viscera through incision requires emergent surgical erpair
41
nursing responsibilities for evisceration
place sterile over organs (abdo pads soaked in warmed normal saline & notify the dr STAT)
42
fistulas are
abnormal passages between 2 organs or between an organ and outside of body
43
most fistulas form as a result of
poor wound healing or complications of disease
44
fistulas are difficult to treat surgically due to
increased risk of developing further fistulas
45
treatment for fistulas are
resting the gut (NPO), IV nutrition (TPN), surgery
46
intrinsic factors that affect healing
diabetes, cancer, renal disease, liver disease, obesity, impaired immune system, age of the patient
47
extrinsic factors that affect healing
malnutrition, tobacco use, inappropriate use of dressings, stress, medication use (systemic steriod use)
48
assessment: type of wounds
- pressure ulcers - diabetic/neuropathic ulcers - venous stasis ulcers - arterial / ischemic ulcers - surgical wounds - atypical wounds - fungating / malignant wounds - burns
49
assessment: location
- sacral region - sacroiliac region - buttock - coccyx - hip - thigh - ischial tuberosity - posterior thigh
50
assessment: wound measurement
- allows the nurse to assess wound healing & adjust treatment plans
51
when measuring wounds it is essential to measure the wounds:
length, width, depth
52
undermining is
a separation of tissue from the surface under the edge of wound
53
accurate measurement of undermining allows the nurse to
treat the wound to optimize healing
54
undermined areas must
packed appropriately, healing occur from "ground" up (wound bed)
55
documentation: describing the wound
appearance of wound bed (percentage of granulation tissue visible)
56
granulation tissue in documentation
red or pink colour with cobblestone like appearance (healing, filling in)
57
necrotic/non-viable in documentation
slough-yellow, tan dead tissue eschar-black/brown necrotic tissue, can be hard or soft
58
serous
clear watery plasma
59
purulent
thick yellow green tan or brown
60
serosanguineous
pale red watery, mixture of clear and red fluid
61
sanguineous
bright red, indicates active bleeding
62
what else do we document
- 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
what to do to assess odor of wound
be sure to clean wound well first before assessing odour
64
dressing changes
- common to reinforce surgical dressings within the first 24hr after surgery to reduce incidences of infections
65
only sterile objects may be placed on a sterile field
TRUE
66
a sterile object out of range of vision or below waist level is
considered contaminated
67
when a sterile surface comes into contact with a wet substance the field is
considered comtaminated
68
how to do a dressing change
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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