Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

N1213 > Wound Healing > Flashcards

Wound Healing Flashcards

1
Q

What 2 processes are simultaneous?

A

hemostasis and inflammation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Hemostasis/Inflammation

A
  • injured blood vessels constrict and platelets form to stop bleeding
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Inflammation

A
  • histamine
  • vasodilation
  • normal rxn = redness/edema and throbbing
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Proliferation

A
  • new blood vessels appear, reconstruction, 3 days to 3 weeks
  • filling with granulation tissue
  • contraction
  • resurfacing
  • fibroblasts
  • angiogenesis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Maturation/Remodelling

A
  • 2 years, depending on wound and collagen scar
  • fewer pigments
  • little redder
  • not same consistency
  • healed wounds = inc. risk for pressure injuries
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Primary intention

A
  • non infected
  • wound edges well approximated
  • little scaring
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Secondary intention

A
  • wound edges unable to approximate = extensive tissue loss
  • heals from inside out
  • granulation tissue forms to fill spaces
    ex: replaces fibrin clot, pressure ulcer
  • heals by any size
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Tertiary intention

A
  • closing granulated ends together after initial healing
  • surgical closure
  • left open for several days, then wound edges are approximated
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

WOUND

A 
What happened
Oxygen/perfusion
Underlying factors (age, psychosocial, mobility, incontinence, sleep
Nutrition
Disease/drugs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Patient centered concerns

A 
pain
money
isolation
mobility
sleep
stress
depression
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Local wound assessment

A
  • location
  • size: length, width, depth
  • characteristics: undermining, tunneling, presence of necrotic tissue or exudate
  • document
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Parameters to assess regarding drainage systems

A
  • # of drains
  • placement
  • character of drainage
  • condition of collecting equipment
  • type and # of dressings
  • monitoring of self suction devices
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

exert a constant low pressure as long as the suction device is completely compressed.

A

Hemovac and Jackson Pratt

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Describe the responsibility of a student nurse who identifies wound abnormalities and complications?

A
  • identify abnormalities
  • inform primary nurse
  • document
  • perform wound care, MPR, basic dressing
  • support patient
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

c) angiogensis

A

c) growth of new capillary blood vessels

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

c) why are scars lighter in colour?

A

c) contain fewer pigmented cells (melanocytes)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

The skin edges are closed by approximation of wound margins. The risk of infection is low. Healing occurs quickly with minimal scar formation, as long as infection and secondary breakdown is prevented. Healing occurs by epithelialization (The formation of granulation tissue in an open wound allows the re-epithelialization phase to take place, as epithelial cells migrate across the new tissue to form a barrier between the wound and the environment).

A

Primary wound intention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Wound edges are not approximated and the wound is left open until it becomes filled with scar tissue. Wounds being healed by secondary intention can be caused by pressure ulcers and surgical wounds that have tissue loss. It takes longer to heal by secondary intention thus the chance of infection is greater. If scaring is severe enough loss of tissue function can occur.

A

Secondary wound intention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Also referred to as: “delayed primary closure”. In some situations, wounds are not closed due to infection. Instead, these wounds are irrigated and dressings applied until the infection is cleared and the wound is closed, surgically, at a later date.

A

Tertiary wound intention

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

When a wound fails to heal properly the layers of skin and tissue separate.

A

Wound dehiscence

- Dehiscence is the partial or total separation of wound layers.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Evisceration

A

With total separation of wound layers, evisceration (protrusion of visceral organs through a wound opening) sometimes occur

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Evisceration - Nursing Care

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

approximated wound edges

A

When a wound is well approximated, it means that both sides of the cut fit together really well, nice and tight together. Hopefully the scar from a well-approximated cut will be almost none existent.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

An abrasion of the skin or of the surface of other organs by scratching, traumatic injury, chemical burns, or other causes

A

excoriated

25
Q

Exudate

A

Describes the amount, colour, consistency, and odour of wound drainage. Excessive exudates usually indicates the presence of an infection

26
Q

An abnormal passage between 2 organs or between an organ and outside of the body. Most form as a result of poor wound healing.

A

fistula

27
Q

hematoma

A

A localized collection of blood underneath the tissues. It appears as a swelling, change in colour, sensation, or warmth, or a mass

28
Q

dermal thickening causing the cutaneous surface to feel thicker and firmer

A

induration

29
Q

loss (marked reduction) of blood flow to an area

A

ishemia

30
Q

purulent drainage

A

Drainage that appears thick, yellow, green, tan or brown.

- infection is suspected

31
Q

Sanguineous

A

drainage that is bright red

- indicates active bleeding

32
Q

serous

A

Drainage that is a clear, watery plasma.

33
Q

Serosanguineous

A

Drainage that appears pale, red watery: mixture of clear and red fluid.

34
Q

Why are wound drains inserted?

A

If a large amount of drainage is anticipated than a drain is often inserted.

35
Q

Review the following steps to empty a drainage system (no dressing change):

A

A) Preparation

  1. Checked physician’s orders & institutional policy
  2. Gather supplies: clean gloves, measuring device, blue pad
  3. Identify client and explain procedure
  4. Provide for comfort and privacy.
  5. Wash hands and don clean gloves.
  6. Elevated bed to workable height.
36
Q

B) Procedure

A
  1. Examined drain & tubing for patency, seal, and stability.
  2. Open drainage plug
  3. Poured drainage into specimen cup, measure and note characteristics.
  4. Compress the Hemovac by pushing top and bottom together OR squeezing ball of Jackson-Pratt (JP) Drain (see Figure 1.1, 1.2 below)
  5. Position suction device on bed & attach safety pin if required.
  6. Lower bed, ensure client comfort and safety (side rails if required)
  7. Discard drainage, remove gloves & wash hands
  8. Recorded amount of drainage.
  9. Record color, consistency, and odour of drainage (exudates).
37
Q

JP DRAIN

A

The JP drain should remain concave (somewhat flat). It should not be fully inflated. If the drain is not flat, suction has not been properly established or the system has an air leak.

38
Q

Hemovac system

A

The Hemovac system is spring loaded. When suction is properly established, it should remain sandwiched together. If the drain is not flat and fills with air, check to see if there is an air leak.

39
Q

Hemmorhage

A

Loss of large amount of blood externally or internally in a short period of time
- hypovolemic shock, distention and swelling

40
Q

Symptoms of hemorrhage

A
  • internal bleeding = distention or swelling of affected body part
  • swelling, change in colour, sensation, warmth, or a mass
  • external haemorrhaging is obvious
  • hypotension
  • week and rapid pulse
  • cool clammy skin
  • rapid breathing
  • restlessness
  • reduced urine output
41
Q

List primary intention abnormalities (5).

A

1) Incision line poorly approximated
2) Drainage presence more than three days after closure
3) Inflammation decreased in first 3-5 days after injury
4) No epithelialization of wound edges by four days
5) No healing ridge by day 9

42
Q

List secondary intention abnormalities (6)

A

1) Pale of fragile granulation tissue; granulation tissue bed is excessively dry or moist
2) Exudate present
3) Necrotic or slough tissue (Necrotic tissue contains dead cells and debris that are a consequence of the fragmentation of dying cells) present in wound base
4) Epithelialization not continuous
5) Fruity, earthy, or putrid odour present
6) presence of fistulas, tunneling, undermining

43
Q

Secondary prevention

A
  • educate, monitor site for early signs of infection
44
Q

Tertiary prevention

A

wound care, changing of dressing, addressing associated symptoms

45
Q

Malnutrition

A
  • protein
  • vitamin C
  • vitamin A
  • Zinc
  • Dehydration
46
Q

List components of documentation of a wound.

A 
Periwound skin
Undermining or tunnelling
Location
Stage
Edges
Measurement
Exudate
Type of tissue
Odour
Epithelialisation

Documentation: Wound is 3.5-4 cm. Purulent exudate present on 4X4 gauze and surrounding wound. Epithelialization is non continuous. Presence of fistula(s), tunnelling and undermining.

47
Q

Signs of infection for wound healing?

A
  • pain and tenderness
  • erythema (inc. blood flow to skin - redness)
  • edema
  • purulent discharge
  • warmth
  • fever/chills
  • foul odour
  • elevated white blood cell count
  • delayed healing
48
Q

List some factors of malnutrition?

A
  • Protein: formation of wound remodelling and immune function. Fibroplasia, angiogenesis, and collagen.
  • Vitamin C: Collagen synthesis, capillary wall integrity, fibroblast function, immunological function, antioxidant.
  • Vitamin A: Epithelialization, wound closure, inflammatory response, angiogenesis, and collagen formation.
  • Zinc: Collagen formation, protein synthesis cell membrane and host defenses
  • Dehydration: There is an essential fluid volume for all cell function.
49
Q

Risk factors for age?

A
  • Vascular changes: decreased circulation
  • Liver Function:
  • Collagen: decreases needed for cell repair
  • Inflammatory response: Slow with age
  • Immune Response: Slow with age
50
Q

Risk factors for obesity?

A

• Constant strain is placed on wounds, as well as the poor healing quality of fat tissue.

51
Q

Impaired oxygenation?

A
  • low blood oxygen
  • Impaired blood flow
  • Anemia
52
Q

Risk factors for smoking?

A

Nicotine is a vasoconstrictor that reduces nutritional blood flow to the skin

  • resulting in tissue ischemia and impaired healing of injured tissue
  • carbon monoxide diminishes oxygen transport and metabolism
  • whereas hydrogen cyanide inhibits the enzyme systems necessary for oxidative metabolism and oxygen transport at the cellular level.
53
Q

Other risk factors?

A
  • corticosteroids
  • anti-inflammatory medication
  • radiation
  • stress of suture line
54
Q

You are caring for a client with a large incision on her left leg. Assuming there are not contraindications to her mobilizing, why would encouraging your client to ambulate, a tertiary prevention strategy, promote wound healing?

A
  • ambulating and moving takes pressure off of bony predominance’s on the body and protects the body from pressure sores. It also encourages blood flow, bringing nutrients and taking away waists from the wound
55
Q

For some clients, the psychological manifestation of their wound may be frightening and may even trigger a grieving process over anticipated loss of body function or alteration of body/self image. Write down some interventions?

A
  • Promote self image and esteem
  • SES help or rehab for work
  • Psychologist if needed
  • Support groups
  • Utilize support systems
56
Q

Health promotion for immobility?

A
  • get patient up and moving, or if not possible reposition patient in bed to reduce pressure ulcers. Practice ROM activities. Use heat therapy to increase circulation
57
Q

Health promotion for obesity?

A

By promoting proper diet and activity as tolerated, you can increase blood circulation to the wound. Also by decreasing amount of fat tissue you increase healing quality to the wound.

58
Q

Drains should be ____ everyday

A

measured

N1213 (9 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions