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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
Healing Process: Primary intention
- Wound with little tissue loss - Skin edges approximated (together) - Degree of reaction: redness and edema around incision
26
Healing Process: Secondary intention
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
Healing Process: Tertiary Intention
- 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
Nutrition: Vitamin C
assists in formation of collagen fibers and capillary development
29
Nutrition: Protein
Amino acids for tissue repair
30
Nutrition: Carbohydrate
use as primary energy source so that protein is utilized for tissue repair
31
Nutrition: Zinc
assits in epithelialization (what replaces granulation tissue)
32
Nutrition: Calories
Support the ^ stress of healing
33
Obesity & wound healing
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
Impaired blood supply & wound healing
- v nutrients to wound - impaired removal of exudates - inhibited inflammatory response
35
Corticosteroid Drugs
- inhibit inflammatory response - impair phagocytosis by WBC's - inhibit fibroblast proliferation - depress formation of granulation tussue - inhibit wound contraction
36
Anti-inflammatory drugs
(NSAIDS)- aspirin and non-steroidal - effects wound healing
37
Antibiotics
prolonged use may increase risk of superinfection and antibiotic resistance
38
Chemotherapeutic Drugs
Slows growth of rapidly growing cells | -depresses bone marrow function and resulting leukocytes
39
Wound Stress
pressure may disrupt the collagen base (coughing improperly
40
Diabetes
- decreased collagen synthesis - impaired phagocytosis - reduces oxygen and nutrients due to vascular damage - increased risk of infection with blood glucose elevations
41
Aging
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
Hemorrhage
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
Common complications of wound healing: infection
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
Common complications of wound healing: Dehiscence
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
Common complications of wound healing: Evisceration
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
Common complications of wound healing: Evisceration- care
- soak sterile towels/dressings in normal saline and lay over organs to maintain moisture - take foods away, IV, check VS
47
Common complications of wound healing: Fistulas
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
Gauze
- non occlusive - absorbent - dry or wet to dry
49
Non-adherent gauze (Telfa)
- non occlusive - absorbent - dry, does not adhere to wound
50
Self adhesive transparent film (Tegaderm)
- semi-occlusive - keep bacteria out - lets oxygen in - promotes moist environment - allows visualization of wound
51
Hydrocolloid
- Occlusive- doesn't let oxygen in - Supports debridement and infection prevention - superficial and partial thickness wounds with light to moderate drainage
52
Hydrogel
- provides debridement - maintains moist surface - requires secondary dressing - use for partial or full thickness wounds, deep wounds with minimal drainage, and necrotic wounds
53
Alginates
- 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
Dressing Layers
- Contact - Absorbent - Outer Protective
55
Nursing Diagnoses
* Risk for infection | * Potential complication: impaired wound healing
56
Nursing Implementation
- 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
Planning for Discharge
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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