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Exam 3 > Wound Care > Flashcards

Wound Care Flashcards

1
Q

Body defenses against the invasion of pathogens: Skin

A

Break in skin allows pathograns in

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2
Q

Body defenses against the invasion of pathogens: Epidermis

A

Keeps fluids in, bacteria out

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3
Q

Body defenses against the invasion of pathogens: Dermis

A

Contains collagen for structure

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4
Q

Inflammatory response

A

Signs of local inflammation: ^ blood in area results in:

  1. Reddness
  2. Swelling
  3. Heat
  4. Pain: result of irritation of nerve endings by pressure or chemical stimulants
  5. Loss of function
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5
Q

Systemic response to pathogens

A

Fever: in response to pathogen (stimulates immune system)

^ WBC- “to the left”

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6
Q

Acute Wounds

A

Cause bleeding that stimulates clot formation that initiates wound healing cascade

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7
Q

Would healing cascade phases

A
  1. Defensive/inflammatory phase
  2. Proliferative phase
  3. Maturation phase
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8
Q

Defensive/Inflammatory phase

A

From insult to 3-6 days post-op

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9
Q

Defensive/Inflammatory phase-Initial vasocontriction of arterioles, histamine released by cell causes

A

Inflammatory response with vasodilation and ^ blood flow at surgical site

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10
Q

Defensive/Inflammatory phase: WBC, Neutrophils, Macrophages drawn into area of the surgical site…

A

Tissue injury initiates the mobilization of phagocytes into the wound before bacterial contamination actually occurs from the procedure: giving an advantage against infection

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11
Q

Defensive/Inflammatory phase: Deposit of fibrin and blood clot formation provide the matrix for cell repair within wound…

A

Scab forms on surface of wound, aids in homeostasis and inhibits contamination of wound from microorganisms
-^ blood flow brings oxygen and nutrients to aid in healing

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12
Q

Defensive/Inflammatory phase: By 24 hours, monocytes enter site and initiate 1 of two scenarios:

A
  1. Minimal Contamination: collagen displaces fibrin matrix to begin further wound healing
  2. Proliferation of microbes: monocyte becomes pro-inflammatory: eventually the wound bed is filled with necrotic tissue, neutrophils and bacteria that constitute pus (Not a good sign- keeps fibrin and collagen deposits from healing)
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13
Q

Proliferative phase

A

Replacement of fibrin with collagen; continues strengthening the wound
-Cappillaries grown across wound, ^ blood supply

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14
Q

Proliferative Phase: Fibroblasts move from bloodstream into the wound, depositing fibrin:

A

As the capillary network develops, the tissue becomes a translucent color, known as granulation tissue

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15
Q

Proliferative Phase: Wounds not sutured shut must be filled with granulation tissue:

A

When the granulation tissue matures, epithelial cells migrate to it, proliferating over it to fill the wound

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16
Q

Maturation Phase

A

Collagen fibers contract & scars strengthen

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17
Q

Chronic Wounds

A

Lack the clotting component, losing the healing cascade & result in slow healing wounds

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18
Q

Debriding a wound

A

to change from chronic to acute to start healing process (clean out)

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19
Q

Wound Depth: Partial Thickness

A

Shallow wounds of epidermis and dermis:
*Superficial, red, raw, and painful secondary to exposed nerve endings
*Rapid healing by regeneration and no scar formation
*Dermis repaired by collagen synthesis
Epidermis repaired by epithelial proliferation and migration to resurface the wound

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20
Q

Wound Depth: Full Thickness

A

Deep wound: often involving the epidermis, dermis, and extending into the subcut. tissue, muscle or bone

  • No exposed nerve endings but fluid collection may cause pressure and pain
  • heals slowly by scar formation: may experience loss of function
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21
Q

Color of Wound: Red

A

New wound without evidence of infection. Granulation process occurring
-promote healing by keeping wound, moist, clean, and protected.

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22
Q

Color of Wound: Yellow

A

Exudate is creamy in appearance: may have tinges of blue, green, or yellow, depending on causative organism

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23
Q

Color of Wound: Yellow (removing exudates)

A
  • cleansing with IVS
  • absorbing exudates
  • keeping a clean, moist environment
  • shows that wound has some sort of infection
  • *If culturing, do not get pus on there (clean first)
24
Q

Color of Wound: Black

A

Necrotic black eschar

-must be removed for healing to occur

25
Q

Healing Process: Primary intention

A
  • Wound with little tissue loss
  • Skin edges approximated (together)
  • Degree of reaction: redness and edema around incision
26
Q

Healing Process: Secondary intention

A

Wound edges are separated: heals with granulation tissue from bottom of wound up

  • large open wounds drain more fluid
  • chronic inflammation
  • Filled wit epithelial tissue in wound bed, rather than collagen
  • larger scar
27
Q

Healing Process: Tertiary Intention

A
  • Wound edges separated: heals with granulation tissue from the bottom up, but at a slow rate secondary to infection
  • occlusive dressing used to prevent bacterial contamination
  • wound closed at a later date & may require grafting to close
28
Q

Nutrition: Vitamin C

A

assists in formation of collagen fibers and capillary development

29
Q

Nutrition: Protein

A

Amino acids for tissue repair

30
Q

Nutrition: Carbohydrate

A

use as primary energy source so that protein is utilized for tissue repair

31
Q

Nutrition: Zinc

A

assits in epithelialization (what replaces granulation tissue)

32
Q

Nutrition: Calories

A

Support the ^ stress of healing

33
Q

Obesity & wound healing

A

Difficulty in approximating wound edges

  • location of wound may bacterial growth
  • poor blood supply of adipose tissue diminishes oxygen and nutrients required for healing
  • overhang is dark and warm so bacteria grows
34
Q

Impaired blood supply & wound healing

A
  • v nutrients to wound
  • impaired removal of exudates
  • inhibited inflammatory response
35
Q

Corticosteroid Drugs

A
  • inhibit inflammatory response
  • impair phagocytosis by WBC’s
  • inhibit fibroblast proliferation
  • depress formation of granulation tussue
  • inhibit wound contraction
36
Q

Anti-inflammatory drugs

A

(NSAIDS)- aspirin and non-steroidal - effects wound healing

37
Q

Antibiotics

A

prolonged use may increase risk of superinfection and antibiotic resistance

38
Q

Chemotherapeutic Drugs

A

Slows growth of rapidly growing cells

-depresses bone marrow function and resulting leukocytes

39
Q

Wound Stress

A

pressure may disrupt the collagen base (coughing improperly

40
Q

Diabetes

A
  • decreased collagen synthesis
  • impaired phagocytosis
  • reduces oxygen and nutrients due to vascular damage
  • increased risk of infection with blood glucose elevations
41
Q

Aging

A

All phases of wound healing are altered:

  • impaired circulation to wound
  • reduced liver function alters synthesis of clotting factors and protein
  • slowed inflammatory response
  • reduced formation of antibodies and lymphocytes
  • poor nutritional status
42
Q

Hemorrhage

A

Causes: slipped surgical suture dislodged incisional clot
Erosion of blood vessel by foreign object (drain)
Degrees of reaction: hematoma: distension or swelling at surgical site
Hemovolemic shock- pulse ^
**If you see bleeding on initial dressing, outline bleeding with sharpie and date and time.

43
Q

Common complications of wound healing: infection

A

Infection and delayed wound closure: generally accepted that wound is infected if pus is draining from it (may not develop until 4-5th post- op day
Symptoms: swelling, redness, fever, pain, ^ amount of drainage

44
Q

Common complications of wound healing: Dehiscence

A

partial or total separation of wound layers
-early dehiscence may be due to suturing
-later dehiscence may be due to ^ stress on wound: most common 3-11 days post-op
Causes: vomiting, abdominal distension, excessive coughing, infection, dehydration

45
Q

Common complications of wound healing: Evisceration

A

Protrusion of visceral organs through to wound after total separation of wound layers
s&s:
-“giving” sensation at incision
-sensation of wetness
-dressing saturated with clear, pink fluid
-pain

**Medical emergency

46
Q

Common complications of wound healing: Evisceration- care

A
  • soak sterile towels/dressings in normal saline and lay over organs to maintain moisture
  • take foods away, IV, check VS
47
Q

Common complications of wound healing: Fistulas

A

Abnormal passage between 2 organs or between an organ and outside of the body

  • Forms as a result of poor wound healing: ^ drainage as a s&s - may result in fluid/electrolyte imbalance & can predispose client to skin breakdown
  • increased risk of infection
48
Q

Gauze

A
  • non occlusive
  • absorbent
  • dry or wet to dry
49
Q

Non-adherent gauze (Telfa)

A
  • non occlusive
  • absorbent
  • dry, does not adhere to wound
50
Q

Self adhesive transparent film (Tegaderm)

A
  • semi-occlusive
  • keep bacteria out
  • lets oxygen in
  • promotes moist environment
  • allows visualization of wound
51
Q

Hydrocolloid

A
  • Occlusive- doesn’t let oxygen in
  • Supports debridement and infection prevention
  • superficial and partial thickness wounds with light to moderate drainage
52
Q

Hydrogel

A
  • provides debridement
  • maintains moist surface
  • requires secondary dressing
  • use for partial or full thickness wounds, deep wounds with minimal drainage, and necrotic wounds
53
Q

Alginates

A
  • Highly absorbent, made from seaweed
  • Available in rope and sheet forms
  • Forms gel-like substance that causes gently debridement
  • use for moderate to heavy exudate
  • requires second dressing
54
Q

Dressing Layers

A
  • Contact
  • Absorbent
  • Outer Protective
55
Q

Nursing Diagnoses

A
  • Risk for infection

* Potential complication: impaired wound healing

56
Q

Nursing Implementation

A
  • note type, color, and consistency of drainage
  • Assess affect of position changes on drainage
  • Notify surgeon of excessive or abnormal drainage and significant changes in vitals
  • note number and type of drains when changing dressing- examine incision site, clean gloves and sterile technique
57
Q

Planning for Discharge

A

Begins in pre-op period

  • Patient is informed and prepared and gradually assumes greater responsibility for self-care
  • Care of wound site and dressings
  • actions and side effects of drugs and when/how to take them
  • dietary restrictions/modifications

Exam 3 (6 decks)

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