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Med/Surg 1 Exam 3 > Wound Care > Flashcards

Wound Care Flashcards

1
Q

What are the three types of healing?

A

Primary intention
Secondary intention
Tertiary intention

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2
Q

What is part of primary intention healing?

A

Tissue surfaces approximated
Minimal or no tissue loss
Minimal granulation tissue and scar
Surgical incision

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3
Q

What is part of secondary intention healing?

A

Edges cannot or should not be approximated
Repair time longer
More scarring and risk of infection

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4
Q

What is part of tertiary intention healing?

A

Left open for 3-5 days and then closed
Allows edema to resolve exudate to drain
Closed with sutures, staples, or adhesive skin closures
“Delayed primary intention”

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5
Q

What are the phases of wound healing?

A

Hemostasis phase
Inflammatory phase
Proliferative phase
Maturation phase (remodeling)

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6
Q

What are some complications of wound healing?

A

Hemorrhage
Infection
Dehiscence
Evisceration

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7
Q

What are some modifiable factors for wound healing?

A

Nutrition
Lifestyle
Medications

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8
Q

What happens in the hemostasis phase?

A

Cessation of bleeding
Vasoconstriction and formation of clot
- Scab inhibits infection
- Epithelial cells migrate into wound- prevent entry of microorganisms

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9
Q

What happens in the inflammatory phase?

A

Blood supply increases

  • Erythema and edema
  • Exudate cleanses wound
  • Neutrophils first 24 hours
  • Replaced by macrophages
  • Phagocytosis
  • Crucial to healing
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10
Q

What happens in the proliferative phase?

A

Day 3-4 to 21 days

  • Fibroblasts synthesize collagen: adds strength to wound
  • Capillaries grow across wound, bring fibrin
  • Granulation tissue forms
  • Light red or pink
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11
Q

What happens in the maturation phase?

A

From day 21 up to 1-2 years
- Fibroblasts continue to synthesize collagen
- Wound site is remodeled and contracted
- Scar becomes stronger
-

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12
Q

What happens with a hemorrhage complication?

A

May bleed uncontrollably: emergency
Apply pressure
Surgery may be needed

Hematoma under wound may obstruct blood flow to area

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13
Q

What happens with an infection complication?

A
  • Microbes compete for oxygen and nutrition: impairs wound healing
  • Change in wound color, pain, drainage
  • May occur during injury, surgery, or post-op
  • Confirmed by culture
  • May have fever, elevated WBC
  • Immunosuppressed increased risk
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14
Q

What happens with a dehiscence complication?

A
  • Partial or total rupture of sutured wound
  • Cover with sterile saline gauze
  • Patient to bed with knees bent
  • Notify doctor
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15
Q

What happens with an evisceration complication?

A
  • Protrusion of internal viscera through an incision
  • Cover with large sterile dressing
  • Patient in bed with knees bent
  • Notify surgeon immediately
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16
Q

What are some risk factors for evisceration?

A 
Obesity 
Poor nutrition 
Trauma 
Failure to suture 
Coughing 
Vomiting 
Straining
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17
Q

When does evisceration usually occur?

A

4-5 days post-op

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18
Q

Prevention: Nutrition

A 
Protein 
CHO's 
Lipids
Vitamins A and C
Iron
Zinc 
Copper
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19
Q

Prevention: Lifestyle

A

Regular exercise leads to better circulation

Smokers at risk for delayed healing

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20
Q

Prevention: Medications

A

Anti-inflammatory
Anti-neoplastic
Prolonged antibiotics

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21
Q

What is serous exudate?

A

Clear, thin, watery plasma.

Normal during inflammatory: in small amounts Moderate to heavy amount may indicate a high bioburden.

22
Q

What is sanguineous exudate?

A

Fresh bleeding
In deep partial-thickness and full-thickness wounds.
Small amount may be normal during the inflammatory stage

23
Q

What is Serosanguineous exudate

A

Thin, watery, and pale red to pink in color

The pink tinge indicates damage to the capillaries with dressing changes

24
Q

What is a clinical manifestation of wounds?

A

Exudate

25
Q

What is purulent exudate?

A

Thick and opaque
Tan, yellow, green, or brown in color
Never normal in a wound bed.

26
Q

What are the different types of exudate?

A

Serous
Serosanguineous
Sanguineous
Purulent

27
Q

Why are elderly patients at risk for impaired wound healing?

A 
Impaired liver function 
Nutritional deficiencies 
Chronic illness
Vascular changes 
Delayed inflammatory response 
Slowed collagen synthesis
28
Q

What is a diagnostic test for wounds?

A

Wound culture and sensitivity

29
Q

When would there be a need for an emergency surgery for wounds?

A

Life threatening

Repair tissue or vessels

30
Q

When would there be a non-emergency surgery for wounds?

A

Ineffective healing

31
Q

What are some types of non-emergency surgeries?

A

Debridement for infected necrotic tissue
Abscess- incision and drain
Escharotomy to remove eschar

32
Q

What is the difference between necrotic tissue and eschar?

A

sret

33
Q

What is involved in pharmacologic therapy?

A

Antibiotics
Topical gels or injectable meds with growth factors
Opioids and NSAIDS

34
Q

What is involved in non-pharmacologic therapy?

A 
Nutrition 
Compression 
Vacuum-assisted closure 
Hyperbaric oxygen therapy 
Stem cells
Maggots
Alternative
35
Q

What is part of the nursing care for wounds?

A

Maintain moist wound healing
Promote optimal nutrition and hydration
Prevent infection
Position to minimize pressure on the wound

36
Q

According to EBP, what is best for dry wound s?

A

Hydrocolloid dressings

37
Q

Why are hydrocolloid dressings used?

A

Impermeable to oxygen, moisture, and bacteria
Maintain moist environment
Support autolytic debridement

38
Q

According to EBP, a dry wound with no drainage should have what?

A

Transparent film

39
Q

According to EBP, an exudative wound should have what?

Example?

A

Absorptive dressings

Hydrofiber (Aquacel)

40
Q

What is the purpose of drains?

A

Allow excessive fluid, purulent drainage to drain

Assists with granulation tissue formation

41
Q

What should the drain be labeled with?

A

Type of drain
Date
Initials

42
Q

What is part of the nursing care for drains?

A

Maintain suction as needed

Assess and document drainage

43
Q

What some types of drains ?

A

Jackson-Pratt (JP)

Hemovac

44
Q

What is a wound V.A.C?

A

Continuous or intermittent negative pressure
Removes fluid and exudate
Prepares the wound for healing and closure

45
Q

What should patients be evaluated for ?

A

Risk for bleeding

46
Q

What are some complications of a wound V.A.C?

A

Hemorrhage from suction with anticoagulant therapy

Wound infection from dressing pieces left in wound

47
Q

When should a VAC be stopped?

A

When bright red blood is seen

Apply pressure and notify doctor

48
Q

Sutures can either be what

A

Absorbable

Non- absorbable

49
Q

What are staples used for?

A

Close skin

50
Q

How should staples and stitches be removed?

A

Ever other one

Med/Surg 1 Exam 3 (5 decks)

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