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
Who would be more at risk for skin breakdown ?
Elderly , recent surgery , immobility , incontinence
How is a sterile pack open ?
Distal , lateral , lateral , proximal
What are the types of drainage ?
Serous , sanguinous , serosanguineous , purulent
What are the steps of nursing process ?
ADPIE - ASSESSMENT - objective and subjective info put together , DIAGNOSIS - Nanada + problem +etiology + symptoms , PLAN - goal and intervention , IMPLEMENT - carry out the plan , EVALUATION - to see of plan worked out
t-tube
After gallbladder surgery a tube is inserted in the duct to maintain flow of the bile
Who is primarily responsible for initiating the care plan and selecting nursing diagnosis ? Who else should be responsible for initiating the care plan ?
RN, LVN , and patient
When is assessment done ?
It’s ongoing ! Everytime you see the patient
What is the subjective and objective information ?
Subjective - what the patient says ….objective - what is measured by the nurse
Dehiscence
Separating of a surgical incision or rapture of a wound closure
Serosanguineous
Pale , red , watery - a mixture of serous and sanguineous …… Blood and serum discharge from the wound
Sanguineous drainage
Bright red - indicates active bleeding ……bloody discharge from the wound .
Serous
Clear watery plasma
Wound vac
Negative pressure , remove debris and drainage , protective barrier , , provides moist healing enviorment , negative wound pressure therapy , change 3x a week for clean wound and 12-24hrs for infected
Penrose drainage
Soft rubber tube , placed in the wound arer to prevent build up of fluid
Describe different types of surgical drains
Hemovac and Jackson Pratt , tube- tube , Penrose , wound vacuum
What factors affect healing ?
Age , nutrition , medication , infection , lifestyles , chronic illness , smoking
What factors a affect healing ? Describe ?
AGE - elderly skin fragile … NUTRITION- diet rich in protein , carbohydrate …has less supply obese patient to infection & slower healing , EXCERSIZE - regular excersize helps healing , MEDICATION - steroids decrease immunity , thins blood INFECTION - infected wound slows the healing process CHRONIC ILLNESS - diabetes , resp ! SMOKING
How is An outcome statement (goal) properly written ?
Patient centered , shorterm or long term , at a certain time frame , realistic , measurable an specific , no vague words eg: want to patient to have less shortness of breath
How does the nurse assess the wound prior to the doctor ordering a wound change ?
Palpating , inspection , outline of drainage …. Doctor changes the first dressing .
What would signs of internal hemorrhage be ?
Increase heart rate , increase resp rate , decrease , blood pressure , decrease urinary out put , , skin cool and clamp , bruising , swelling , pain , restlessness , , dry skin , skin/blood drainage … Check for destention -could be pooling
Describe healing by primary , secondary , tertiary intentions ?
Primary - clean incision …. secondary - open wound heals by granulation upward ….tertiary - delayed infected closure , due to infection drainage , granulation and the closure
Hemovac and Jackson Pratt drainage
A closed drainage system , drains by creating a vaccume , empty when it’s half way ,COMPRESS BEFORE CLOSING THE GAP , THE GAP IS WHAT COMMUTE THE VACUME clip to gown , drain sponge dressing before draina
How does the nurse prioritize ?
ABC- airway , breathing , circulation & Maslow hierarchy - physical needs before psychosocial needs , safety
What is a nursing order ?
Specific instruction on who doing what to the patient , something the nurse can prescribe . Eg: who is taking the patient for a walk , WHO , WHAT , WHEN ,WHERE , WHY
What can be done to prevent stress on the incision and dehiscence ?
Avoid straining , no coughing - give cough suppressant , vomit , sneezing GIVE SUPPORT - use pillows to lessen strength , abdominal binder/bindings - to stop the wound called dihescence
What factors affect healing ?
Age , nutrition , medication , infection , lifestyles , chronic illness , smoking
What factors a affect healing ? Describe ?
AGE - elderly skin fragile … NUTRITION- diet rich in protein , carbohydrate …has less supply obese patient to infection & slower healing , EXCERSIZE - regular excersize helps healing , MEDICATION - steroids decrease immunity , thins blood INFECTION - infected wound slows the healing process CHRONIC ILLNESS - diabetes , resp ! SMOKING
How is An outcome statement (goal) properly written ?
Patient centered , shorterm or long term , at a certain time frame , realistic , measurable an specific , no vague words eg: want to patient to have less shortness of breath
How does the nurse assess the wound prior to the doctor ordering a wound change ?
Palpating , inspection , outline of drainage …. Doctor changes the first dressing .
What would signs of internal hemorrhage be ?
Increase heart rate , increase resp rate , decrease , blood pressure , decrease urinary out put , , skin cool and clamp , bruising , swelling , pain , restlessness , , dry skin , skin/blood drainage … Check for destention -could be pooling
Describe healing by primary , secondary , tertiary intentions ?
Primary - clean incision …. secondary - open wound heals by granulation upward ….tertiary - delayed infected closure , due to infection drainage , granulation and the closure
Hemovac and Jackson Pratt drainage
A closed drainage system , drains by creating a vaccume , empty when it’s half way ,COMPRESS BEFORE CLOSING THE GAP , THE GAP IS WHAT COMMUTE THE VACUME clip to gown , drain sponge dressing before draina
How does the nurse prioritize ?
ABC- airway , breathing , circulation & Maslow hierarchy - physical needs before psychosocial needs , safety
What is a nursing order ?
Specific instruction on who doing what to the patient , something the nurse can prescribe . Eg: who is taking the patient for a walk , WHO , WHAT , WHEN ,WHERE , WHY
What can be done to prevent stress on the incision and dehiscence ?
Avoid straining , no coughing - give cough suppressant , vomit , sneezing GIVE SUPPORT - use pillows to lessen strength , abdominal binder/bindings - to stop the wound called dihescence
