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Nursing 134 fundamentals > Wound Care > Flashcards

Wound Care Flashcards

1
Q

Principles of wound healing

A
  • intact skin is the first one a defense against microorganisms
  • carful hand hygiene is used in caring for a wound
  • the body responds systematically to trauma of any of its parts
  • adequate blood supply is essential for normal body response to injury
  • Normal healing is promoted when the moon is free of foreign materials
  • extent of damage and the persons state of health affect wound healing
  • Response to wound is more effective and proper nutrition is maintained
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2
Q

Health status that delay wound healing

A

Corticosteroids and postoperative radiation therapy

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3
Q

Tissue repair

A

1) primary intention
- best healing
- clean, surgical incision

2) secondary invention
- edges do not close, heals from inside out
- jagged edge, no surgery, takes longer

3) tertiary intention
- delay in surgical suturing, but is eventually sutured
- May have an infection that needs draining before canned suture

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4
Q

Phases of wound healing

A

1) Hemostasis
2) inflammatory
3) proliferation, reconstruction, or granulation phase
4) maturation or wound remodeling phase

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5
Q

Hemostasis

A
  • occurs immediately after initial injury
  • involved blood vessels constrict and blood clotting begins
  • exudate is formed, causing swelling and pain
  • increased perfusion results in heat and redness
  • platelets stimulate other cells to migrate to the injury to participate in other phases of healing
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6
Q

Inflammatory phase

A
  • follows Hemostasis and last about 4-6 days
  • WBC move to wound
  • macrophages enter area and remain for an extended period
    • they ingest debris and release growth factors that attract fibroblast to fill in the wound
  • generalized body response
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7
Q

Proliferation phase

A
  • begins within 2-3 days of injury and may last up to 2-3 weeks
  • New tissue is built to fill the wound space through the action of fiber blast
  • capillaries grow across the wound
  • thin layer of epithelial cells form across the wound
  • granulation tissue forms the foundation for scar tissue development
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8
Q

Maturation or remodeling phase

A
  • final stage; begins about 3 weeks, months and up to 2 years after injury
  • collagen is remodeled
  • new collagen tissue is deposited
  • scar becomes a flat, thin, white line
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9
Q

Local factors affecting wound healing

A 
Pressure 
Desiccation ( dehydration)
Maceration (over hydration)
Trauma
Edema 
Infection 
Excessive bleeding 
Necrosis ( death of tissue)
Presence of biofilm ( thick grouping of micro organisms)
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10
Q

Wound dehiscence

A

Wound separate

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11
Q

Evisceration

A

Protrude out

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12
Q

Assessment of wound drainage

A

Serous- clear
Sanguineous- contain RBC, fresh blood, full thickness wound
Serosanguinous- thin, watery, pale, red-pink color
Purulent- contain pus, cloudy, yellow- tan color

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13
Q

Exudate

A

Accumulation of fluid, dead tissue cells, WBC

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14
Q

Wound assessment

A
  • inspect for sight and smell
  • palpating for appearance, drainage, and pain
  • types of exudate/ drainage
  • sutures, drains or tubes and manifestation of complications
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15
Q

Presence of infection

A
  • wound is swollen
  • wound is deep red in color
  • wound feels got on palpation
  • drainage is increased and possibly purulent
  • foul odor
  • edges may be separated, with dehiscence present
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16
Q

Factors affecting the response to hot and cold treatment

A
  • method and duration
  • degree of heat or cold
  • patients age / physical condition
  • amount of body surface covered
17
Q

Effects of applying heat

A
  • dilates peripheral blood vessels
  • increase tissue metabolism
  • reduce blood viscosity and increase capillary permeability
  • reduce muscle tension
  • helps relieve pain
18
Q

Effects of applying cold

A
  • constructs peripheral blood vessels
  • reduces muscle spasms
  • promote comfort
19
Q

C diff

A
  • seen largely in older adults
  • symptomatic and asymptomatic reservoir
  • prolonged antibiotics kill “ helpful” bacteria in intestine the c diff grows
  • watery diarrhea, fever, abnormal cramps
20
Q

Preventing c diff

A
  • avoid use of hard to clean equipment
  • disinfect care items between patients
  • PPE
  • hand hygiene- soap and water, not killed by alcohol
  • keep environment clean
  • educate health care provider
21
Q

Multi drug resistant organisms

A
  • prevent infections, thereby preventing the spread of resistance
  • Tracking
  • improving antibiotic prescribing/stewardship
  • develop new drugs and diagnostic test
22
Q

Airborne precautions

A
  • infection spread via air( TB, rubeola, varicella)
  • Private room
  • monitor negative air pressure
  • 6-12 Air changes per hour
  • monitored filtration if air recirculated
  • door closed, patient stays in your room
  • if the patient comes out of room must have on surgical mask
23
Q

Droplet precautions

A
  • spread in large droplets
  • private room if available door may be open
  • if patient must come out room must wear surgical mask
  • PPE and keep visitors 3 feet from patient
24
Q

Contact precautions

A
  • spread by direct or in direct contact with patient or patient’s environment
  • used with multi drug resistant organisms
  • limit movement out of the room
  • avoid sharing patient care equipment

Nursing 134 fundamentals (31 decks)

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