Sterile Dressings Flashcards
What is a Stage I wound?
Non-blanching erythema or redness that remains visible for more than 30 minutes
What is a Stage II wound?
Partial thickness; loss of the epidermal skin layer, possible loss of dermis but not through the dermis
What is a Stage III wound?
Full thickness; loss through dermis and into the hypodermis but not through the hypodermis
What is a Stage IV wound?
Tissue loss through the hypodermis
What are the three stage of wound healing?
- Inflammatory phase
- Proliferative phase
- Remodeling phase
What are the three types of wound healing?
- Primary intention
- Secondary intention
- Tertiary intention
What is primary intention?
A process that closes the edges of a wound with little or no inflammatory reaction (little or no scar)
What is secondary intention?
Healing by granulation or indirect union
- granulation tissue is formed to fill the gap between the edges of the wound with a thing layer of fibrinous exudate
What is tertiary intention?
Delayed wound healing
- occurs in the base of ulcerated or cavitary wound
- especially after infection
- wound fills very slowly with granulation tissue and often forms a large scar
Describe serous drainage
Clear or yellow tinged plasma like fluid
Describe serous sanguineous drainage
Thing watery red drainage
Describe sanguineous drainage
Bright red blood
Describe purulent drainage
Green or yellow drainage
What are some factors that influence the healing of an incision?
- Age
- Nutrition
- Circulation
- Blood counts (Hct < 33% impairs tissue repair)
- Smoking
- Chronic illness
- Drug therapy
- Steroids
- Cortisone
- Chemotherapy
- Wound infection
- Wound environment
Why do steroids affect wound healing?
Steroids slow collagen synthesis
How does cortisone affect wound healing?
Depresses fibroblast activity and capillary growth
- impair phagocytosis by WBCs
How does chemotherapy affect wound healing?
Depresses bone marrow production of WBCs and impairs immune function
How does a wound infection affect wound healing?
Prolongs the inflammatory response and the microorganisms use nutrients and oxygen that are intended for repair
What are some complications of wound healing?
- Hemorrhage
- Hematoma
- Infection
- Dehiscence
- Evisceration
- Fistula formation
What is a hematoma?
A solid swelling of clotted blood within the tissues
What is dehiscence?
Wound ruptures along a surgical incision
What is evisceration?
Protrusion of the internal organs through an incision
What is a fistula formation?
An abnormal tube-like passage from a normal cavity or tube to a free surface or to another cavity
What do you need to look for/at when assessing a wound?
- type of wound
- length of incision
- amount of bleeding
- dehiscence?
- redness, swelling, pain
- hematoma?
- smell?
- drains?
What do you need to do before you clean a wound or change a dressing?
- check the orders
- offer pain meds
- offer bathroom break
- ensure patient has no tests
- gather all necessary materials
What is a partial-thickness wound?
Shallow and involve the loss of the epidermis and partial loss of the dermis
What is a full thickness wound?
Extend into the dermis and heal by scar formation
If you had to clean an incision site, a penrose drain, and a nephrostomy tube, what order would you clean them in?
- Incision site
- Nephrostomy tube
- Penrose drain
