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75 Cards in this Set

  • Front
  • Back
Wound
Any injury to the bodys tissue involving a break in the skin.
Nursing focus during postsurgical recovery phase
Promote wound healing
Wound classifications derive from
Derive from their cause, the severity of injury, amount of contamination, skins integrity
Incision
Cut produced surgically creating an opening into an organ
Puncture
Stab wound for a drainage system
Classifications of wounds
Clean wound
Clean contaminated
Contaminated
Dirty or infected wounds
Four phases of wound healing
Hemostasis
Inflammatory phase
Reconstruction
Maturation
Hemostasis
Termination of bleeding
What happens during the hemostasis phase
Fibrin in the clot begins to hold the wound together, and bleeding subsides.
What happens during the inflammatory phase
Initial increase in the flow of blood elements. This process causes cardinal signs and symptoms of inflammation: erythema, heat, edema, pain, and tissue dysfunction
During what phase do cells in the injured tissue migrate divide and form new cells
Inflammatory phase
Collagen formation occurs during what phase
Reconstruction
During the reconstruction phase, encourage patients to consume foods rich in
Protein & vitamin A & C
Wound dehiscence most frequently occurs during which phase?
Reconstruction
Keloid
Overgrowth of collageneous scar tissue at the site of a wound
Keloids form during which phase
Maturation
Keloids color range from
Red to pink to white
Primary intention
Skin edges close together and little tissue is lost. Minimal scarring. Healing begins during inflammatory phase
Granulation tissue
Soft, pink, fleshy projections consisting of capillaries surrounded by fibrous collagen
Tertiary intention
Contaminated wound left open and surgeon closes it later after infection is controlled.
Serous
Clear, watery plasma
Purulent
Thick, yellow, green, tan or brown
Serosanguineous
Pale, red, watery. Mixture of serous and sanguineous
Sanguineous
Bright red: indicates active bleeding
Phagocytosis
Cells engulf and dispose of microorganisms
Gauze dressings
Permit air to reach the wound
Semiocclusive dressings
Permit oxygen but not air impurities to pass
Occlusive dressing
Permit neither air nor oxygen to pass
Who does the initial dressing change?
Physician or surgeon
Dry dressing
Choice for management of a wound with little exudate or drainage
Does dry dressings debride the wound?
No. Not the proper selection for wounds requiring debridement
Because removal of a dressing can be painful, what should you do
Give an analgesic at least 30 minutes before exposing the wound
Primary purpose of wet to dry dressing
Debride a wound
Common wetting agents for wet to dry dressing
Normal saline, lactated ringers solution, isotonic solutions
Transparent dressings
Thin, self-adhesive transparent film that belongs in semiocclusive or occlusive categories.
Irrigation
Gentle washing of an area with a stream of solution delivered through an irritating syringe
Can irrigations introduce prescribed medications in solution form
Yes
What direction should irrigation fluid flow
From least contaminated to most contaminated
Eschar
Black, leathery crust
Solutions used for irrigation
Warm water, saline, and mild detergent
How far should the tip of the syringe be when irrigating
1 inch (2.5cm) above the wound or area your cleansing
With small wounds, what size syringe and gauge is best used
35 mL syringe with a 19 gauge needle
Wound bleeding usually indicates
A slipped suture, dislodged clot, coagulation problem, trauma to blood vessels or tissue.
Abscess
Cavity containing pus and surrounded by inflamed tissue.
Adhesion
Band of scar tissue that binds together two anatomical surfaces normally separated
Cellulitis
Infection of the skin characterized by heat, pain, erythema, and edema
Dehiscence
Separation of a surgical incision or rupture of a wound closure
Evisceration
Protrusion of an internal organ through a wound or surgical incision
Extravastation
Passage or escape into the tissues
Hematoma
Collections of extravasated blood trapped in the tissue or in an organ
Signs of hemorrhaging
Rapid, thready pulse; decreased blood pressure; decreased urinary output; and cool, clammy skin
When a skin suture breaks and dehiscence occurs, you will be able to close the wound effectively using
Steri-strips or butterfly strip
If evisceration occurs after dehiscence, what should the nurse do
Pt must remain in bed in a low fowlers position, knees flexed. Keep patient on NPO status. Cover the wound and contents with warm, sterile dressing. Notify the surgeon immediately.
The CDC labels a wound infected when it contains what?
Purulent (pus) drainage
A patient with an infected wound shows what type of signs
Patient displays fever, tenderness, and pain at the wound site, edema, and an elevated WBC count
Does purulent drainage have an odor
Yes. Purulent drainage is brown, yellow, or green
Normal wbc count
4,500-10,000 white blood cells
per microliter (mcL)
How long are retention sutures left in place
14 days or more
Who removes wire sutures
Physician
Abnormal quantity of exudate or drainage is greater than how much the first 24 hour
300 mL. Report it immediately.
Normal bile drainage
250 to 500 mL/ 24 hours
Wound vac
Device that assists in wound closure by applying negative pressure to draw edges of a wound together
Acceptable negative pressure ranges
5 mmHg and 200 mmHg. The average is 125 mmHg
Maceration
Damage to wound edges.
Wound dessication
To cause to dry up
Bandage
Strip or roll of cloth that can be wound around a part of the body
Binder
A bandage that is made of large pieces of material to fit a specific body part
When applying a binder, patient should flex their arm approximate at what angle
80 degree angle
Basic bandage turns
Spiral, figure of 8, recurrent, circular, spiral reverse
Circular bandage used
Cover small body regions (Digits or Wrist)
Spiral bandage use
Cover cylindrical body parts. Wrist or forearm
Spiral- reverse bandage use
Use to cover inverted cone shaped body parts. Calf or thigh
Figure of 8 bandage use
Used to cover joints and provide immobilization. Joints
Recurrent bandage use
Provides caplike coverage. Scalp
Secondary intention
Wound must granulate during healing. Skin edges not close together,or when pus has formed.