Wound Care/ Nursing Process Flashcards
Contusion
BRUISE Tissue injury without breaking of the skin PURPLE COLOR
What are TED hose ?
Elastic hose to prevent blood clott ! Legs clean and dry , no wrinkle in hose , check for redness and swelling , take off once a day for hygiene purpose
Keloid
A overgrowth of collagen scar tissue. Form during maturation phase COLOR RANGE FROM RED TO PINK OR WHITE …. African American , dark complexion whites … Young woman have the highest formation of keloids
Granulation
SOFT PINK , GROWTH OF NEW HEALTHY TISSUE , Fills the incision during the process Of healing … Fills wound depending on size
Abscess
COLLECTION OF PUS ! –Contains pus , surrounding by inflamed tissue , localized infection …WHITE , YELLOW , PINK ,GREEN depending on the infected microorganism
Exudate
DRAINAGE ! Fluid cell , slowly exuded or discharged body cell or blood vessel through small pores or break in the membrane
How does the nurse cleanse a wound ?
, from the wound outward to prevent contaminating the wound . Away from the incision from cleanest to dryest , swipe once per swab
How is irrigation done ?
Flushing out of and area with liquid …. Tip of syringe 1INCH away from wound surface . Pat dry around the wound so the tape can stick …. Use normal saline sterile salt water , 0.9% , sodium chloride
What is evisceration ? What is the nurse response ?
Wound separation with protrusion of organs ……. Place the patient in supine position , cover organs with sterile saline soaked towels , notify surgeon immediately
Describe how to stage pressure ulcers ?
STAGE 1 - erythema (redness) non blanching or not getting white … may be BROWN /BLACK on dark pigmented people .. NO BREAKS IN SKIN ……STAGE 2 - superficial skin breaks or CLEAR BLUSTERS …..STAGE 3- full thickness skin break does not go into deeper tissue such as muscle or bone …may have underlying tunneling or slough
Arterial ulcers
- found on toes or ankles , skin tight , hard , shiny , cold to touch , may or may not have swelling , pain when walking , faint to absent pedal pulse , OFTEN ROUND SMOOTH EDGES , minimal drainage , , do not elevate legs , , walking is good for circulation , caused by arterial peripheral disease
venous stasis ulcer
Shallow beefy red , typically on the back of the lower leg , not like pressure ulcer , almost always edema of the leg , caused by high pressure in the veins or previous clot , elevate the legs it drains blood back into the heart , cause dysfunction of you veins
Diabetic ulcer
Diabetic prone to getting ulcers on their feet ,, due to neuropathy and poor circulation , diabetics have chronic wounds / slow wound healing
Moisture associated dermatitis
Fungus can cause a ras or skin irritation , common in vasodialated and incontinent persons …. Repeated expose of moisture to urinary , fecal , can cause dermatitis , itching , burning tenderness , shallow skin breakdown …. Easily confused with pressure ulcer
What is eschar ? What color is it ?
Scab, dead tissue that is cast off the surface of the skin …. A BLACK LATHERY CRUST OR THICK DRY BLACK NEROTIC TISSUE
What are the most common sites for pressure ulcers ?
Bony prominences eg: secrum , occipital bone , shoulder , elbow , scapula ,lower legs , heel , thigh , knee
What are signs of wound infection ?
Purulent drainage , fever , heat , pain , redness , loss of function , change in V/S , odor , swelling , WBC count
Unstageable wound
Has eschar
Maceration
Soft wrinkles eg: shower for too long or wearing of a Bandaid the skin gets wrinkle
Purulent
Pus/drainage - Thick , yellow , green , tan , brown
Evisceration
Purtrusion of an internal organ throught a wound or surgical incision
What are the phases of healing ?
INFLAMMATION -immediately after tissue injury 2-5 days , PROLIFERATION - period where new cell fill and heal wound 2- weeks , REMODLEING -period where wound undergoes change during maceration wound contracts and SCAR SHRINKS 16months to 3 years
