wounds Flashcards
1
Q
factors that affect wound healing
A
- age
- nutrition-need protein to build new tissue
- condition of tissue-infection slows healing
- efficiency of circulation-will interfere w/healing
- rest/activity/stress-stimulates the release of hormones slows healing
- medications-some drug slow down healing by stopping formation of fibrous tissue and impairs healing
2
Q
wound assessment
A
- inspect and gently palpate surrounding area/could be tunneling
- note wound edges
- note presence and characteristics of drainage
- observe for signs of infection, redness swelling, increased tenderness,disruption of wound edges, body temp and wbc.
- braden scale to assess wound- 16 or less-pt high risk for pressure ulcers
3
Q
classification of wounds
A
- incised-cut clean w/sharp instrument
- lacerated-jagged, irregular edges
- puncture-small opening in the skin (bullet, stab wound)
- debridement-wounds don’t heal if infected, operation to cut out infected tissue (ex. wet to dry dressing)
4
Q
wound discharge
A
- serous drainage-clear, watery
- sanguineous drainage-bright red, active bleeding
- serosanguineous drainage-pale, red watery mix of serous and sanguineous
- purulent drainage-thick yellow green,, tan or brown, sign of infected wound
5
Q
wound
A
a disruption in the normal integrity of the skin
6
Q
dressing changes
A
- initial post-op dressing-circle drainage on dressing w/date & time to assess progression, reinforce dressing as needed
- MD will change first dressing, call if saturated prior to first dressing change-keep track of number of pads patient is saturating
- after initial change-change as needed
- frequent dressing changes allow better observation of wound and eliminates dark and warm area that bacteria needs to grow
- dry dressing-protects wounds from bacteria
- wet dressing-provides way for bacteria to enter wound from outside
- change pad every 8 hrs(shift)
- changing pads-put in nurses notes
7
Q
purpose of dressing
A
- prevent contamination
- absorb drainage
- will support or splint wound site
- protect from injury
- promotes homeostasis if pressure dressing homeostasis stops bleeding
8
Q
purpose for maintaining a wound dressing
A
- eliminate conditions that favor growth of organisms
- allows better observation and assessment
- avoids adhesive tape reaction
- avoid friction and irritation
9
Q
dressing
A
- telfa-special gauze that covers incision line and allows drainage to pass through and be absorbed by the center absorbent layer.It prevents other dressings to stick to wound and cause further injury when removed
- transparent dressing-occlusive dressing decreasing the possibilities of infection while still seeing wound. Use over IV sites, central line sites, and healing wounds.
10
Q
exudate
A
- drainage
- swelling-pain that occurs from drainage caused by accumulation of exudates
- neutrophils-arrives first in the inflammatory cellular stage
11
Q
granulation tissue
A
- new tissue found in a wound that is highly vascular and bleeds easily
- formed in proliferated phase
- pink/red in color
12
Q
scar
A
avascular collagen tissue that does not sweat, grow hair, or tan in sunlight
13
Q
red wounds
A
wounds in the proliferation stage of healing that are the color of granulated tissue
14
Q
eschar
A
necrotic tissue (death of tissue)
15
Q
wound healing-surgical wound
PRIMARY INTENTION
A
- wounds with little loss of tissue heal by primary intention
- primary intention-the skin edges approximate or close-little tissue reaction-little scar formation-partial thickness wounds-risk of infection low
