Wound Collection Retain Flashcards
What are they two types of testing for wounds?
Culture and sensitivity
What does a sensitivity wound culture determine?
Proper antibiotic therapy
What does a wound culture determine?
organisms that grow in the presence oxygen (aerobic) or without oxygen (anaerobic)
administer analgesic 30 min before procedure
Where should the nurse collect the specimen from ?
The center of the wound - NOT from the edges because it could contain skin flora and the procedure has to be repeated
Two things to never do when collecting a wound specimen are
- never collect from pus or pooled exudates
- never touch the swab to the outside of the test tube
Do you use the same swab in the drainage?
no
you rotate sterile swabs in the drainage
What makes a sputum specimen contaminated?
saliva
How much sputum is needed for a specimen collection?
1-2 tsp of sputum
What time of the day should sputum specimens be collected? and what is the rationale?
Collect sputum first thing in the morning before eating or drinking - the results are more accurate
What are ways to reduce contamination of sputum specimen?
clearing the nose and throat
rinsing the mouth
Which method is used to help a pt who is only producing saliva in specimen cup?
chest physiotherapy (postural drainage to help mobilize mucus and facilitate expectoration)
To collect a specimen of sputum, what is the method so that it is performed correctly?
Early in the morning 3 days in a row
Where are throat specimens collected?
Oropharynx or tonsillar region using a sterile swab.
A throat specimen can be contaminated if the sterile swab touches which parts of the mouth?
gums
tongue
teeth
Which is more accurate point of care (in the medical facility) or the lab?
Lab testing is more accurate
What are the risks of collecting specimens that can lead to a false positive or false negative?
storage conditions
poor method of specimen collecting
not rotating sterile swabs
Which solutions are used to irrigate or clean wounds
Isotonic saline
wound cleansers
If an antimicrobial solution is used to irrigate or clean a wound the nurse needs to ensure the solution is
diluted
Why is it contraindicated to microwave liquids or used cold liquids on a wound
lowering the wound temperature slows down the healing process
microwaving the solution could make it too hot
Solutions that are going on a wound should be this temperature
warm the solution to body temperature
Why should the nurse avoid drying the wound after cleaning it
helps retain wound moisture
If a wound is clean, has little exudate, and reveals healthy granulation (lumpy pink tissue containing new connective tissue and capillaries form around the edges of the wound), the nurse should avoid doing this and why
the nurse should avoid repeated cleaning because unnecessary cleaning can delay wound healing by traumatizing the newly produced tissues
if the wound appears clean, consider not cleaning it at all
What factors affect wound healing?
mental illness (they are not thinking of staying clean)
medications (antibiotics - tetracyclines, corticosteroids)
suppressed immune system
anti-neoplasm (drugs that are used to treat cancer)
cyclo-therapeutics
poor nutrition
What are tetracyclines and corticosteroids and how do they affect wound healing?
o corticosteroids - anti-inflammatory
-reduces swelling in mucous membranes
- increases risk of infection
o tetracycline - protein synthesis inhibitor antibacterial
- slows protein synthesis preventing bacterial from forming bacteria uses protein to stay alive and multiply
How does tetracycline affect wounds
fights infection caused by bacteria
Hoe does corticosteroids affect wound healing
they increase risk for infection and they delay wound healing
skin thinning
How does a suppressed immune system affect wound healing
it causes a delay in wound healing because it effects fibroblast proliferation (migration toward wound) and angiogenesis (formation of new blood vessels)
Define reactive hyperemia
when the pressure is relieved the skin will turn a bright red flush color (erythema)
the red face you get when sleeping on the desk
if reactive hyperemia does not go away, what does this indicated
tissue damage has occurred
Is reactive hyperemia a pressure ulcer
NO
What is a stage 1 pressure ulcers
unbroken skin and red but does NOT blanch
what is a stage 2 pressure ulcer
partial thickness skin loss (2 layers - epidermis and dermis affected)
Abrasions and blisters are examples of white stage of pressure ulcer or partial thickness loss
stage 2
describe stage 3 pressure ulcers
full thickness loss
damage to the subQ layer
could reach as deep as the fascia and adipose tissue
CANNOT SEE BONE YET
describe stage 4 pressure ulcers
full thickness loss and damage to muscle and bone
muscle and bone damage to the sacral and greater trochanter is considered what stage of pressure ulcer
stage 4
How does a partial thickness wound heal
regeneration
how does a full thickness wound heal
complete tissue repair
Describe maceration
moisture from fecal or urinary matter
the tissue is softened by prolonged wetting making the epidermis more easily eroded and at risk for injury
If the skin is wrinkled and damaged by moisture from a swimming pool this is called
maceration
this object contributes to shearing and friction
linen (the raised sewn part)
The Braden scale is used to assess pts at high risk for a pressure injury, this scale has the max point of
23 points
An adult who scores between this range on the Braden scale is at risk for developing a pressure injury
18-19
Describe the primary intention healing of the wound healing process
closed or approximated
edges are closed by sutures or tissue adhesive
How does the primary intention healing of wound healing process look
closed surgical incision
Describe how a secondary intention healing of wound healing is different from the primary phase
longer repair time
scaring time is greater
risk for infection is greater
What does the secondary phase of wound healing look like
bigger tissue loss
edges around wound are big
heals through granulation and regeneration from the inside out
How does the secondary intention healing of wound healing heal
heals through granulation and regeneration from the inside out
If the first layer of a dressing becomes soiled, what does the nurse do
apply a second layer because blood clots might be disturbed if the first layer of dressing is taken off
If the nurse suspects internal bleeding or severe bleeding she will asses for signs of shock which are
rapid thready pulse
cold clammy
pallor
low BP
Describe the tertiary intention healing
the wound is left open
edema
infection
exudate
If a pt falls, which type of therapy will the nurse get ready for the pt
cold therapy
What is occurring during regeneration
granulated tissues grow like collagen and protein synthesis occurs
The phases of healing are
inflammation phase
proliferative phase
maturation phase
Which type of medication impairs the inflammatory phase
steroids
corticosteroids
When does the inflammation phase begin
immediately after injury and last for 3-6 days
What is occurring in the inflammatory phase
homeostasis
phagocytosis
fibrin - migration of the epithelial cells
When does the proliferative phase begin
from day 3 or 4 - 21 days postinjury
What is occurring in the proliferative phase
o collagen
o granulation tissue (connective tissue + new capillaries)
o eschar (necrotic tissue if the wound does not heal by epithelialization)
o serosanguinous (blood - red) [healing by secondary intention - healing by the inside out {granulation + regeneration}}
When does the maturation phase begin
~day 21 and can last 1-2 years post injury
What is occurring in the maturation phase
fibroblasts are synthesizing collagen and the scar becomes stronger
Keloids are formed during which phase
maturation
How do you get rid of keloids
abd
How can the nurse teach a pt how to take care of a wound at home
determine their current level of knowledge taking care of a wound (understanding the risk of pressure injuries or the cause of the wound)
self- care abilities for mobility and wound care - can they ambulate and change positions, can they see the wound or have the hand coordination to change it out
teach that nutrition plays a key role in wound healing
Which nutrients are important for wound healing
iron
vitamin B and C (water soluble)
fluid
protein
calories
Why does the blood for reactive hyperemia rush to the area
compensative
bright sanguineous bleeding indicates
fresh bleeding
dark sanguineous bleeding indicated
older bleeding
Define evisceration
the protrusion of the internal oragans through an incision
A viscera rupture in surgery is called
evisceration
If evisceration happens to a pt, what does the nurse do
get a dressing with sterile saline
Describe debridement
removing damaged tissue or foreign objects from a wound removal of necrotic material
list the kinds of exudate
purulent
serous
sanguineous
