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NURS1213 > Wound Care/Healing > Flashcards

Wound Care/Healing Flashcards

1
Q

What are the phases of wound healing?

A
  • hemostasis
    and inflammation
  • proliferation
  • maturation and remodeling
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2
Q

What is hemostasis?

A

Injured blood vessels constrict and platelets gather to stop bleeding

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3
Q

What is the purpose of the scab that forms when the clot dries out?

A

protect the cut by keeping germs and other stuff out and giving the skin cells underneath a chance to heal

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4
Q

What causes vasodilation?

A

Damaged tissue and mast cells secrete histamine, leading to vasodilation

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5
Q

What is the role of white blood cells (leukocytes)?

A
  • Neutrophil: ingest bacteria and small debris

- Monocyte = macrophages: clean wound of bacteria, dead cells, and debris by phagocytosis.

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6
Q

What is the role of macrophages?

A

They release growth factors to attract fibroblasts

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7
Q

What is the role of fibroblasts?

A

Synthesize collagen (connective tissue), providing matrix for granulation, in turn supporting re-epithelialization

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8
Q

Describe granulation

A
  • Supports re-epithelization as granulation tissue fills the wound
  • healing process in which lumpy, pink tissue containing new connective tissue and capillaries forms around the edges of a wound
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9
Q

What is the role of epithelials?

A

Migrate from wound edges and start to resurface. When surface has been repaired = epithelization

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10
Q

What is angiogenesis?

A

process by which new blood vessels form, allowing the delivery of oxygen and nutrients to the body’s tissues

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11
Q

Describe primary intention healing

A
  • skin edges are approximated, or closed, and risk of infection is low.
  • Healing occurs by epithelization and heals quickly with minimal scar formation, as long as infection and secondary breakdown are prevented
  • Caused by surgical incision, wound is sutured or stapled
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12
Q

Describe secondary intention healing

A
  • Wound involving loss of tissue (burn, pressure injury, severe laceration) heals by secondary intention
  • Wound is open until filled by scar tissue (not approximated)
  • Heals by granulation tissue formation, wound contraction, and epithelization
  • Takes longer to heal so risk of infection is greater
  • Scarring is severe
  • Loss of tissue function is often permanent
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13
Q

Describe tertiary intention healing

A
  • Wound open for several days, then wound edges are approximated
  • Caused by wounds that are contaminated and require observation for signs of inflammation
  • Closure of wound is delayed until risk of infection is resolved
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14
Q

What does WOUND represent? What do we use it for?

A
  • W: what happened
  • O: Oxygen/perfusion
  • U: underlying factors
  • N: Nutrition
  • D: Disease/Drugs
  • Whole patient assessment, interviewing patient
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15
Q

What is necrotic tissue?

A
  • dead cells in your body organ due to lack of oxygen and interrupted blood supply. Cannot be reversed
  • black or brown necrotic tissue is eschar
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16
Q

What is eschar

A

black or brown necrotic tissue is eschar

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17
Q

What is slough?

A

soft yellow or white tissue, stringy substance attached to wound bed

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18
Q

What is granulation tissue?

A

red, moist tissue composed of new blood vessels

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19
Q

List potential complications of wound healing

A
  • hemorrhage
  • Infection
  • Dehiscence
  • Evisceration
  • Fistula formation
  • Failure to heal progressing to a chronic wound
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20
Q

What is debridement?

A

removal of nonviable, necrotic tissue

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21
Q

What is wound dehiscence?

A
  • Partial or total separation of wound layers

- Could be due to failed healing

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22
Q

What is evisceration?

A
  • Protrusion of visceral organs through a wound opening (could be due to total separation of wounder layers)
  • Emergent, Requires surgical repair.
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23
Q

What nursing care do you do if you see evisceration?

A

Quickly place sterile towels soaked in sterile saline over extruding tissues to reduce chance of bacterial invasion and drying of tissues and contact the physician.

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24
Q

What is excoriated?

A

Linear erosion of skin tissue resulting from mechanical means

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25
Q

What is exudate?

A

Describes amount, colour, consistency, and odour of wound drainage and part of wound assessment

  • fluid leaking from wound
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26
Q

What is a fistula?

A
  • Abnormal passage between two organs or between an organ and the outside of the body
  • Formed due to poor wound healing, complication of disease like Crohn’s disease
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27
Q

What is a hematoma?

A
  • Localized collection of blood underneath tissues.

- Appears as a swelling, a change in colour, sensation, warmth, or a mass that takes a bluish discoloration

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28
Q

What is induration?

A

Increased firmness of the tissue

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29
Q

Define ischemia

A

Reduction in blood flow

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30
Q

What are the types of drainage?

A
  • purulent
  • serous
  • sanguineous
  • serosanguineous
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31
Q

Describe purulent drainage

A
  • white, yellow, green tan or brown fluid and might be slightly thick in texture
  • sign of infection
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32
Q

Describe sanguineous drainage

A

Bright red, indicates active bleeding

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33
Q

Describe serous drainage

A

clear, watery plasma

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34
Q

Describe serosanguineous

A

Pale, red, watery, mixture of clear and red fluid

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35
Q

Why are wound drains inserted?

A

When a large amount of drainage is anticipated, drain is inserted in or near a surgical wound.

36
Q

List the parameters that we would assess if patient has wound drainage system

A
  • The number of drains and drain placement
  • The security of the drainage apparatus (suture(s), safety pin)
  • Character of drainage
  • Drainage volume
  • Drainage flow through tubing and around (to ensure patency -not obstructed)
  • If connected to suction, system needs to be assessed to ensure pressure ordered is exerted
37
Q

What do you do if there is a sudden decrease in drainage?

A

 Sudden decrease in drainage through tubing may indicated blocked drain which may require surgical revision, contact physician

38
Q

Define hemorrhage

A

bleeding from a wound site. Risk of hemorrhage is greatest during first 24-48 hours after surgery or injury

39
Q

What are primary intention abnormalities?

A
  • Wound’s incision line poorly approximated
  • drainage present more than 3 days after closure
  • inflammation decreased in first 3-5 days after injury
  • no epithelization of wound edges by day 4
  • no healing ridge by day 9
40
Q

What are secondary intention abnormalities?

A
  • pale or fragile granulation tissue, granulation tissue bed is excessively dry or moist
  • exudate present
  • necrotic or sloughy tissue present in wound base
  • epithelization not continuous
  • fruity, earthy, or putrid smell
  • presence of fistulas, tunnelling, undermining
41
Q

How does infection impact wound healing?

A

Prolongs inflammatory phase, delays collagen synthesis, prevents epithelization, and increases production of proinflammatory cytokines, which leads to additional tissue destruction

42
Q

What is the role of protein in wound healing?

A

It helps rebuild epidermal tissue. Collagen is a protein formed from amino acids acquired by fibroblasts from protein ingested

43
Q

What is the role of vitamin C in wound healing?

A

promotes collagen synthesis, capillary wall integrity, fibroblast function, and immunological function

44
Q

What is the role of vitamin A in wound healing?

A

reduces negative effects of steroids on wound healing, epithelization, wound closure, inflammatory response, angiogenesis, collagen formation

45
Q

What is the role of zinc in wound healing?

A

collagen formation, protein synthesis, cell membrane and host defenses

46
Q

List the important vitamins and minerals for wound healing

A
  • protein
  • vit C
  • vit A
  • zinc
  • collagen
  • water
47
Q

How does ischemia impact wound healing?

A
  • decreases blood oxygen (O2 fuels cellular functions essential to healing)
  • impairs blood flow
48
Q

Define anemia

A

condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body’s tissues

49
Q

How does smoking impact wound healing?

A

Vasoconstricts and prevents blood flow getting to a wound

50
Q

How does corticosteroids impact wound healing?

A

topical corticosteroids can thin the skin and have anti-inflammatory properties that reduce healing

51
Q

How does anti-inflammatory medications impact wound healing?

A

reduce inflammatory response in wounds leads to decreased healing responses

52
Q

How does radiation impact wound healing?

A

harms cells responsible for cell repair

53
Q

How does stress on a suture line impact wound healing?

A

openings forming into the skin and leading to poor scar formation

54
Q

Define wound

A

disruption of the integrity and function of the tissues in the body

55
Q

What are the types of wounds?

A
  • with tissue loss
  • without tissue loss
  • acute wound
  • chronic wound
56
Q

What is an acute wound?

A

proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity

57
Q

What is a chronic wound?

A

fails to proceed through an orderly and timely process to produce anatomical and functional integrity

58
Q

What are the three teaching principles to prevent client contamination of procedures?

A

A) Avoid sudden movements of body parts covered by sterile drapes

B) refrain from touching sterile supplies, drapes, or nurse’s gloves or gown

C) avoid coughing, sneezing, or talking over sterile area

59
Q

What are some anticipated issues during a prolonged sterile procedure? (4)

A
  • pain
  • voiding
  • comfort
  • need to cough
60
Q

Nursing interventions for pain during procedure

A

Ensure that if patient is in pain before the procedure or it is anticipated they will develop pain during the procedure to administer analgesics no more than half an hour before procedure to allow relief from the pain so that they are better able to tolerate long procedures

61
Q

Nursing intervention for voiding during procedure

A

Ensure that the patient void’s before the procedure begins to ensure that they will be able to withstand the entire procedure during one sitting both for patient convenience and not needing to set up another sterile field

62
Q

Nursing intervention for comfort during procedure

A

Ensure that patient is comfortable enough in the position that they are in to be able to stay still for the entire duration of the sterile procedure

63
Q

Nursing intervention for needing to cough during procedure

A

Ensure that if patient needs to cough they do so before the sterile field is set up or if they are excessively coughing provide them with a mask to prevent the contamination of the sterile field with their own microorganisms

64
Q

Difference between surgical asepsis and medical asepsis

A

Medical: Reduce the number of microorganisms and their spread

Surgical: Eliminate all microorganisms, including spores, from an object or area.

65
Q

what is a nosocomial infection

A

Infection that is transmitted and contracted at the hospital also known as a healthcare associated infection

66
Q

Define sterilization

A

Removing of all microorganisms including bacteria spores

67
Q

Define superinfection

A

Develops when broad spectrum antibiotics eliminate a wide range of microorganisms and not just those causing infection. Normal bacterial flora is eliminated, reducing body’s defences, and allowing disease-producing microorganisms to multiply

68
Q

Define disinfection

A

Cleaning that eliminates all microorganisms but not bacteria spores

69
Q

What is an invasive procedure?

A

Body cavity or organ is entered by either puncture or incision

70
Q

List the 7 purposes for wound dressings

A

1) protects wound from microorganism contamination
2) aids in homeostasis
3) promotes healing by absorbing drainage and supports autolytic debridement
4) supports or splints wound site
5) protects patient from seeing wound (if unpleasant)
6) promotes thermal insulation of the wound surface
7) provides moist environment for the wound bed

71
Q

When are wound dressings no longer required?

A

in a normally healing wound, when wound drainage is minimal, the healing process forms a natural fibrin seal that eliminates the need for a dressing. Wounds that have extensive tissue damage always require a dressing.

72
Q

What is the purpose of the contact/primary layer of dressing?

A

thin, non-adherent sheets placed on an open wound bed to protect tissue from direct contact with other agents or dressings applied to the wound.

73
Q

What is the purpose of an absorbent layer of dressing?

A

to absorb large quantities of exudate and hold it away from the wound and surrounding skin

74
Q

What is the purpose of the outer protective/secondary layer of dressing?

A

an effective tool to protect the primary dressing or provide additional functionality beyond the primary dressing

75
Q

What are the characteristics of moist dressing/healing?

A
  • Reduced risk of infection
  • Reduced healing time
  • Faster re-epithelization
  • Better cosmetic
76
Q

What are characteristics for dry dressing/healing?

A
  • Encourages scab formation
  • Delays healing
  • Increases pain
  • May produce scar
77
Q

How do you prevent dehiscence?

A

provide support to area using folded thin blanket or pillow placed over abdominal wound when patient is coughing. This splints and supports healing tissue when coughing increases intra-abdominal pressure.

78
Q

What is an abdominal binder?

A

Supports large abdominal incisions that are vulnerable to tension or stress as patient moves or coughs. Secured with safety pins, Velcro strips, or metal stays

79
Q

What are 4 assessment parameters to complete before applying a binder?

A
  • Inspecting skin for abrasions, edema, discolouration, or exposed wound edges
  • Covering exposed wounds or open abrasions with sterile dressing
  • Assessing condition of underlying dressings and changing them, if soiled
  • Assessing skin of underlying areas that will be distal to the bandage for signs of circulatory impairment (coolness, pallor, cyanosis, diminished pulses, swelling, numbness, and tingling) to provide a means for comparing changes in circulation after bandage application
80
Q

What are the principles of surgical asepsis? (12)

A
  • All objects used in the sterile field must be sterile
  • Sterile objects touched by non-sterile objects are not sterile
  • Sterile objects out of vision or below waist level are not sterile
  • Sterile objects can become non-sterile by prolonged exposure to airborne micro-organisms (just-in-time set-up)
  • DO NOT use wet/previously wet packaged sterile items - contaminated
  • The edges of a sterile field are considered non-sterile (1” boarder)
  • DO NOT reach over the sterile field
  • DO NOT open sterile packages directly over the sterile field
  • Keep the tips of your forceps pointing downward after wet
  • DO NOT sneeze, cough or talk over your sterile field.
  • Ask your patient to avoid talking over the open wound
  • CHECK EXPIRATION DATES
81
Q

Under what circumstances does a nurse collect a culture of wound drainage?

A

When there needs to be tests ran on the drainage, when there is abnormal findings, when there is an order for it

82
Q

What are intermittent sutures?

A

surgeon ties each individual suture made in the skin

83
Q

What are continuous sutures?

A

series of sutures with only two knots, one at the beginning and one at the end of the suture line

84
Q

What are retention sutures?

A

placed more deeply than skin sutures, nurses may or may not remove them depending on agency policy

85
Q

How does diabetes impact wound healing?

A
  • poor circulation

- delays healing time

NURS1213 (11 decks)

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