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NRS 210 exam 1 > wound care > Flashcards

wound care Flashcards

1
Q

any wound that lasts longer than 3 months is considered

A

chronic

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2
Q

what are the phases of wound healing

A

inflammatory
proliferative
remodeling

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3
Q

what is the inflammatory phase

A

is a sequential reaction to cell injury. It neutralizes and dilutes the inflammatory agent, removes necrotic materials, and establishes an environment suitable for healing and repair.

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4
Q

what is the vascular response of the inflammatory phase

A

transient vasoconstriction right after injury
histamine release/ vasodilation
fibrin/platelets
growth factors

goal is to stop the bleeding, “hemostasis”

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5
Q

what is the cellular response of the inflammatory phase

A

this phase is 6-12 hours later
neutrophils come from bone marrow
monocytes and macrophages come from blood
here we have chemotaxis which is the migration of cell to site of injury

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6
Q

which phase of wound healing creates vasodilation and increase capillary permeability resulting in hemostasis

  1. redness, swelling, heat at injury
  2. vascular response
  3. cellular response
  4. formation of exudate
A

2

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7
Q

what is exudate

A

fluid to site of injury

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8
Q

what is serous

A

clear

ex. blister

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9
Q

what is serosanguinous

A

pink

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10
Q

what is fibrinous

A

sticky
ex. Adhesions, gelatinous ribbons seen in surgical drain tubing
Frequently covers fluid-exuding wounds such as venous ulcers

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11
Q

what is hemorrhagic/sanguinous

A

red
blood
ex.Hematoma, bleeding after surgery or tissue trauma

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12
Q

what is purulent

A

pus, dead WBC

ex. Furuncle (boil), abscess, cellulitis (diffuse inflammation in connective tissue

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13
Q

what is catarrhal

A

mucus

ex. Runny nose associated with upper respiratory tract infection

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14
Q

what are the two phases of the healing process

A

regeneration

repair

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15
Q

what is the local manifestation of inflammation

A

redness, heat, pain, swelling, and loss of function

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16
Q

what is the systemic mainfestation of inflammation

A

increased WBC count with a shift to the left, malaise, nausea and anorexia, increased pulse and respiratory rate, and fever.

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17
Q

what is acute inflammation

A

the healing occurs in 2 to 3 weeks and usually leaves no residual damage. Neutrophils are the predominant cell type at the site of inflammation.

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18
Q

what is subacute inflammation

A

has the features of the acute process but lasts longer. For example, infective endocarditis is a smoldering infection with acute inflammation, but it persists for weeks or months

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19
Q

what is chronic inflammation

A

lasts for weeks, months, or even years. The injurious agent persists or repeatedly injures tissue.

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20
Q

what are the key concept in treating soft tissue injuries and related inflammation.

A

Rest, ice, compression, and elevation (RICE

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21
Q

what is regeneration of the healing process of inflammatory

A

Regeneration is the replacement of lost cells and tissues with cells of the same type.

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22
Q

what is repair of the healing process of inflammatory

A

is healing as a result of lost cells being replaced by connective tissue. Repair is the more common type of healing and usually results in scar formation.

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23
Q

repair has what 3 stages

A

primary
secondary
tertiary

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24
Q

what is primary intention

A

healing takes place when wound margins are neatly approximated, as in a surgical incision or a paper cut.
clean dry clean with normal saline

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25
Q

what is secondary intention

A

leave it open, edges cannot be approximated
cleansing, keeping wound moist
filling dead space
transparent dressing provides moisture and oxygen transfer
ex. from trauma, ulceration, and infection have large amounts of exudate and wide, irregular wound margins with extensive tissue loss.

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26
Q

what is tertiary intention

A

(delayed primary intention) healing occurs with delayed suturing of a wound in which two layers of granulation tissue are sutured together after infection is controlled

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27
Q

what are the wound classification

A 
superficial
partial thickness
full thickness
skin tear 
color system: red yellow black
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28
Q

what is a superficial wound

A

involves only the epidermis

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29
Q

what is a partial thickness wound

A

extends to the dermis

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30
Q

what is a full thickness wound

A

wounds have the deepest layer of tissue destruction because they involve the subcutaneous tissue and sometimes even extend into the fascia and underlying structures such as the muscle, tendon, or bone

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31
Q

what is a skin tear

A

is a wound caused by shear, friction, and/or blunt force resulting in separation of skin layers. A skin tear can be partial thickness or full thickness.

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32
Q

what are complications of wound healing

A 
adhesions
contractions
dishesnce
evisceration
fistula
excess granulation tissue
hypertrohpic scars
kelid formation
hemorrahge 
infection
33
Q

what is an adhesion

A

Bands of scar tissue that form between or around organs

34
Q

what is contractions

A

results in deformity

35
Q

what is dehisence

A

Separation and disruption of previously joined wound edges

usually occurs when primary site bursts open

36
Q

what is evisceration

A

Occurs when wound edges separate to the extent that intestines protrude through wound

37
Q

what is excess granulation tissue

A

Excess granulation tissue may protrude above surface of healing wound

38
Q

what is a fistula formation

A

An abnormal passage between organs or a hollow organ and skin

39
Q

what is hypertrophic scars

A

Inappropriately large, raised red and hard scars

40
Q

what is keloid formation

A

Great protrusion of scar tissue that extends beyond wound edges and may form tumor-like masses of scar tissue

41
Q

what is the proliferative stage of wound healing

A

new capillary networks
granulation tissue
epitheliaization
contracture- wound edges being pulled to each other

42
Q

what are the principles of care

A

wound hydration
blood supply
infection minimization

43
Q

when is the wound very fragile

A

during the proliferative stage

44
Q

what does moisture promote

A

epithelization

45
Q

what is the remodeling phase of the wound healing

A

cells responsible for the collagen synthesis and anigogensis undergo apoptosis
wound strength increases
wound contraction continues
scar formation

46
Q

how long could the remodeling phase take

A

up to 2 years

47
Q

what is leukocytosis

A

anything above 10,000

48
Q

what is a red wound

A

healthy
very fragile don’t scrub
non adherent dressing- moist techaderm

49
Q

what is a yellow wound

A

drainage, exudate needs to be removed to heal

clcium aginate- seaweed it absorbs drainage

50
Q

what is a black wound

A

necrosis going on, dead cells need to be removed for healing
gangerous wound, needs to be debrided

51
Q

what does the color system come from

A

secondary intention

52
Q

if a dehiscence happens between 1-3 day who’s fault

A

technical problem

53
Q

if a dehiscence happens between 3-10 days who’s fault

A

nutrtional status
obesity
infection
the surgeon would be charged because something is wrong inside

54
Q

what are the factors that delay wound healing

A 
nutrtional deficience
inadequate blood supply
corticosterioid drugs
infection
mechanical friction
advanced age
obesity
DM
anemia
poor general health
smoking
necrotic tissue
55
Q

what are the types of debridement

A

surgical
mechanical
autolytic
enzymatic

56
Q

what is surgical debridement

A

scapel or scissors
can change chronic wound into acute wound- promote bleeding stimulates platelets
Used when large amounts of nonviable tissue are present
• Prepares wound bed for healing, skin grafting, or flaps

57
Q

what is mechanic debridement

A

either wet to dry or wound irrigation

58
Q

what is wet to dry debridement

A

open-mesh gauze is moistened with normal saline, lightly packed into wound surface, and outer layer allowed to dry. Wound debris adheres to dressing and then dressing is removed

59
Q

what is wound irrigation

A

Make certain bacteria are not accidentally driven into wound with high irrigation pressure

60
Q

what is autolytic debridement

A

Semiocclusive or occlusive dressings used to soften dry eschar by autolysis

61
Q

what is enzymatic/biological debridement

A

Drugs applied topically to dissolve necrotic tissue and then covered with moist dressing

ex: leaches

62
Q

what are the stages of pressure ulcers

A 
stage 1
stage ll
stage lll
stage lV
deep tissue injury
nonstageable
63
Q

what is a stage 1 pressure ulcer

A

non-blancable
redness
intact skin
tender, firm, soft warm or cool

64
Q

what is stage ll pressure ulcer

A

partial thickness skin loss
exposure of dermis
no loud nor bruising
serios or serosanguious blister

65
Q

what is stage lll pressure ulcer

A

full thickness tissue loss,
stubcutaenous, fat, but bone tendon and muscle not exposed
slough present
undermining and tunneling

66
Q

what is stage lV pressure ulcer

A 
full thickness tissue elosee
bone, tendon, or muscle exposure
slough or eschar present
underminng and tunneling
ostomyelitis and osteitisi
67
Q

what is slough

A

stringy,attached to wound bed, could be necrotic

68
Q

what is a deep tissue injury pressure ulcer

A

a purple or maroon localized area of discolored intact skin or a blood filled blister due to damage of underlying soft tissue from pressure eo sheet.
painful, firm, mushy, boggy

69
Q

what is unstageable pressure ulcer

A

full thickenss tussue loss in which base of ulcer is covered in slough and/or eschar in the wound be

can’t see how deep it is because necrotic tissue on outside

70
Q

untreated ulcer may lead to

A

cellulitis

71
Q

Stage III or IV (full skin–thickness injury) pressure ulcer acquired after admission to a health care setting is considered

A

serious reportable event

72
Q

what do we assess with wounds

A 
location
size
color
surrounding skin
drainage
temperature
pain
wound closure
73
Q

what are some diagnostic tests

A 
CBC
sedirmentaion rate
C reactive protein
albumin 
total lymphocyte count
74
Q

what is the normal albumin levels

A

anything over 3.5

75
Q

what is a marker of sepsis

A

procalcitonin

76
Q

what is a negative pressure wound therapy

A

vaccum/suction

77
Q

what are additional therapies for wound healing

A

negative pressure wound
hyperbaric oxygen
positioning

78
Q

what types of dressings are ther

A 
gauze
nonadherent
transpaent films
hydrocolloids
hydrogels
calcium alignate
foam
antimircobials

NRS 210 exam 1 (8 decks)

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