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73 Cards in this Set
- Front
- Back
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accumulation of pus made up of debris from phagocytosis when microorganisms have been present. ( fluid may be white, yellow, pink or green) |
abscess 764 |
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fibrous bands that hold together tissues that are normally seperated. |
adhesions 762 |
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To close together |
approximate 762 |
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The degree of closure of a wound. |
approximation 771 |
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Wide elasticizied fabric bands used to decrease tension around a wound or suture line, increase Pt. comfort or hold dressing in place. |
binders 769 |
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Inflammation of the tissue around the intial wound with redness and induration. |
celluitis 764 |
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Fibrous structural protein of all conective tissues, it is the main ingrediant of scar tissue. |
collagen 761 |
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Removal of all foreign or unhealthy tissue from a wound. |
debridment 765 |
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Another name for redness. |
erythema 760 |
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Sloughing dead tissue, usually caused by a thermal injury or gangrene. |
eschar 765 |
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Fluid accumulation containing cellular debris. |
exudate 764 |
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Protein essential to clotting. |
fibrin 760 |
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Surgical wounds, little tissue loss at the surface. They close from the edges. |
first intention 762 |
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Abnormal passage or communication usually formed between tow internal organs or leading from an internal organ to the surface of the body. |
fistula 764 |
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Connective tissue with multiple small vessels. |
granulation tissue 776 |
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Blood clotting or vessel compression. |
hemostasis 760 |
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Pt. with poorly functioning immune systems. |
immunocompromised 764 |
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Another name for skin. |
integument 759 |
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Permanent, raised enlarged scar tissue. |
keloid 762 |
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A torn, ragged or mangled wound. |
laceration 762 |
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Another name for removal or breakdown. |
lysis 761 |
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Softening of tissue from soaking in moisture. |
maceration 779 |
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Monocytes that are phagocytic. |
macrophages 761 |
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Fatal injury to the cells |
necrosis 760 |
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Engulfing or eating of microorganisms or foreign particles. |
phagocytosis 760 |
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Clumping of the bodies platelets. |
platlet aggregration 760 |
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Containing pus. |
purulent 764 |
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Blood drainage. |
sanguineous 764 |
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Type of wound healing by granulation and contraction. |
second intention 762 |
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A serum and blood mixture. |
serosanguineous 765 |
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A fistula leading from a pus-filled cavity to the outside body. |
sinus 764 |
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Natural shedding of dead tissue. |
sloughing 765 |
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The formation of pus. |
suppuration 784 |
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Delayed or secondary closure, occurs when there is a delayed suturing of a wound. Like an abdominal wound that is left open for drainage. |
third intention 762 |
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Complications of healing include
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Negative pressure wound Vac. may be used for
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chronic wounds that are not healing
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red wound
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ready to heal |
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yellow wounds
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black wounds
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need debridement |
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Why we dress wounds
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Prevent microorganisms from entering Help support/stabilize tissues Reduce Pt. discomfort |
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Clean wounds should be irrigated with
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Normal saline online |
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S/S of infection
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Odor Increased Redness, pain or swelling Limitation of movement --systematic signs--- Fever over 101 F WBC over 10,000 Felling of Malaise |
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Hydrocolloid dressings are applied to
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uninfected wounds only. |
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Sutures are typically removed
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Uses for heat in healing
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+ blood supply which brings oxy. and nutrients to the tissues and removes waste products.
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Uses for cold in healing
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15-20 min. at a time |
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wound type where the dermal layer is no longer present.
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full- thickness |
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cell type generally unable to regenerate
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S/S of inflammation
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Erythema/Redness + heat at the site Pain and tenderness at site Possible loss of function |
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The risk of wound separation is less likely after
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15-20 days |
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Proliferations begins
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on the 3rd or 4th day and lasts 2-3 weeks |
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Remodeling/Maturation phase begins
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about 3 weeks after injury and can last years. |
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S/S of hypovolemic shock
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rapid thread pulse + respirations restlessness diaphoresis cold clammy skin |
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Risk for hemorrhage is greatest
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during the first 48 hours after surgery |
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Greatest risk for dehiscence is
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Increased risk factors for dehiscence
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Obesity Poor nutrition Multiple traumas Excessive coughing Vomiting Strong sneezing Suture failure dehydration |
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Nursing Interventions for Dehiscence and Evisceration |
Place Pt. Supine Place large sterile dressing over incision and viscera Notify Surgeon Prepare Pt. for Surgery |
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Dermabond
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Jackson-Pratt drainage systems should be drained and recompressed at least every
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4 hours or when 2/3 full. |
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Why the elderly heal slower. |
Metabolism and regeneration slower. Peripheral vascular disease impairs blood flow. Athersclerosis and atrophy impair blood flow. Decline in immune function reduces formation of anti-bodies. Decreases in lung function reduce oxygen. Older skin is more fragile. |
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Nutriton needs for healing. |
+ Protein, carbohydrates, lipids, vitamin A, C, thiamine, pyridoxine, and riboflavin. |
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Lifesytle changes for healing. |
Exercise enhances blood cirulation, brings oxygen and nutrients to the wound. Smoking reduces the functional hemoglobin of the blood. |
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Medications and healing. |
Steroids, immunosuppresants, anticoagulants, antineoplastic. Steroids may mas the signs of wound infection and inhibit the inflammatory response. |
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Infection and wound healing. |
Slows the healing process. |
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Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. |
Stage I pressure ulcers
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Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or serosangineous-filled blister. Tissue loss extends into the dermis. |
Stage II pressure ulcers
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Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. May include undermining and tunneling. |
Stage III pressure ulcers
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Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Often include undermining and tunneling. |
Stage IV pressure ulcer
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Full thickness tissue loss in which the base of the ulcer is completely covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.
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Unstageable/Unclassified Pressure Ulcer
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Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. |
Suspected Deep Tissue Injury (sDTI)
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Color and the mechanical stiffness of the skin (mushy, boggy) assist in the clinical differentiation between sDTI and a Category/Stage I pressure ulcer
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sDTI - purple or maroon color
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Skin intactness and blister type may assist in the clinical differentiation between an sDTI and a Category/Stage II pressure ulcer.
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sDTI - intact skin or blood-filled blister. Evolution may include a thin blister over a dark wound bed. Category/Stage II – partial thickness tissue loss. May also present as an intact or open/ruptured serum-filled blister. |
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