Chapter 13 - Surgical Wound Care

Front 1

Wound

Back 1

Any injury to the bodys tissue involving a break in the skin.

Front 2

Nursing focus during postsurgical recovery phase

Back 2

Promote wound healing

Front 3

Wound classifications derive from

Back 3

Derive from their cause, the severity of injury, amount of contamination, skins integrity

Front 4

Incision

Back 4

Cut produced surgically creating an opening into an organ

Front 5

Puncture

Back 5

Stab wound for a drainage system

Front 6

Classifications of wounds

Back 6

Clean wound
Clean contaminated
Contaminated
Dirty or infected wounds

Front 7

Four phases of wound healing

Back 7

Hemostasis
Inflammatory phase
Reconstruction
Maturation

Front 8

Hemostasis

Back 8

Termination of bleeding

Front 9

What happens during the hemostasis phase

Back 9

Fibrin in the clot begins to hold the wound together, and bleeding subsides.

Front 10

What happens during the inflammatory phase

Back 10

Initial increase in the flow of blood elements. This process causes cardinal signs and symptoms of inflammation: erythema, heat, edema, pain, and tissue dysfunction

Front 11

During what phase do cells in the injured tissue migrate divide and form new cells

Back 11

Inflammatory phase

Front 12

Collagen formation occurs during what phase

Back 12

Reconstruction

Front 13

During the reconstruction phase, encourage patients to consume foods rich in

Back 13

Protein & vitamin A & C

Front 14

Wound dehiscence most frequently occurs during which phase?

Back 14

Reconstruction

Front 15

Keloid

Back 15

Overgrowth of collageneous scar tissue at the site of a wound

Front 16

Keloids form during which phase

Back 16

Maturation

Front 17

Keloids color range from

Back 17

Red to pink to white

Front 18

Primary intention

Back 18

Skin edges close together and little tissue is lost. Minimal scarring. Healing begins during inflammatory phase

Front 19

Granulation tissue

Back 19

Soft, pink, fleshy projections consisting of capillaries surrounded by fibrous collagen

Front 20

Tertiary intention

Back 20

Contaminated wound left open and surgeon closes it later after infection is controlled.

Front 21

Serous

Back 21

Clear, watery plasma

Front 22

Purulent

Back 22

Thick, yellow, green, tan or brown

Front 23

Serosanguineous

Back 23

Pale, red, watery. Mixture of serous and sanguineous

Front 24

Sanguineous

Back 24

Bright red: indicates active bleeding

Front 25

Phagocytosis

Back 25

Cells engulf and dispose of microorganisms

Front 26

Gauze dressings

Back 26

Permit air to reach the wound

Front 27

Semiocclusive dressings

Back 27

Permit oxygen but not air impurities to pass

Front 28

Occlusive dressing

Back 28

Permit neither air nor oxygen to pass

Front 29

Who does the initial dressing change?

Back 29

Physician or surgeon

Front 30

Dry dressing

Back 30

Choice for management of a wound with little exudate or drainage

Front 31

Does dry dressings debride the wound?

Back 31

No. Not the proper selection for wounds requiring debridement

Front 32

Because removal of a dressing can be painful, what should you do

Back 32

Give an analgesic at least 30 minutes before exposing the wound

Front 33

Primary purpose of wet to dry dressing

Back 33

Debride a wound

Front 34

Common wetting agents for wet to dry dressing

Back 34

Normal saline, lactated ringers solution, isotonic solutions

Front 35

Transparent dressings

Back 35

Thin, self-adhesive transparent film that belongs in semiocclusive or occlusive categories.

Front 36

Irrigation

Back 36

Gentle washing of an area with a stream of solution delivered through an irritating syringe

Front 37

Can irrigations introduce prescribed medications in solution form

Back 37

Yes

Front 38

What direction should irrigation fluid flow

Back 38

From least contaminated to most contaminated

Front 39

Eschar

Back 39

Black, leathery crust

Front 40

Solutions used for irrigation

Back 40

Warm water, saline, and mild detergent

Front 41

How far should the tip of the syringe be when irrigating

Back 41

1 inch (2.5cm) above the wound or area your cleansing

Front 42

With small wounds, what size syringe and gauge is best used

Back 42

35 mL syringe with a 19 gauge needle

Front 43

Wound bleeding usually indicates

Back 43

A slipped suture, dislodged clot, coagulation problem, trauma to blood vessels or tissue.

Front 44

Abscess

Back 44

Cavity containing pus and surrounded by inflamed tissue.

Front 45

Adhesion

Back 45

Band of scar tissue that binds together two anatomical surfaces normally separated

Front 46

Cellulitis

Back 46

Infection of the skin characterized by heat, pain, erythema, and edema

Front 47

Dehiscence

Back 47

Separation of a surgical incision or rupture of a wound closure

Front 48

Evisceration

Back 48

Protrusion of an internal organ through a wound or surgical incision

Front 49

Extravastation

Back 49

Passage or escape into the tissues

Front 50

Hematoma

Back 50

Collections of extravasated blood trapped in the tissue or in an organ

Front 51

Signs of hemorrhaging

Back 51

Rapid, thready pulse; decreased blood pressure; decreased urinary output; and cool, clammy skin

Front 52

When a skin suture breaks and dehiscence occurs, you will be able to close the wound effectively using

Back 52

Steri-strips or butterfly strip

Front 53

If evisceration occurs after dehiscence, what should the nurse do

Back 53

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.

Front 54

The CDC labels a wound infected when it contains what?

Back 54

Purulent (pus) drainage

Front 55

A patient with an infected wound shows what type of signs

Back 55

Patient displays fever, tenderness, and pain at the wound site, edema, and an elevated WBC count

Front 56

Does purulent drainage have an odor

Back 56

Yes. Purulent drainage is brown, yellow, or green

Front 57

Normal wbc count

Back 57

4,500-10,000 white blood cells
per microliter (mcL)

Front 58

How long are retention sutures left in place

Back 58

14 days or more

Front 59

Who removes wire sutures

Back 59

Physician

Front 60

Abnormal quantity of exudate or drainage is greater than how much the first 24 hour

Back 60

300 mL. Report it immediately.

Front 61

Normal bile drainage

Back 61

250 to 500 mL/ 24 hours

Front 62

Wound vac

Back 62

Device that assists in wound closure by applying negative pressure to draw edges of a wound together

Front 63

Acceptable negative pressure ranges

Back 63

5 mmHg and 200 mmHg. The average is 125 mmHg

Front 64

Maceration

Back 64

Damage to wound edges.

Front 65

Wound dessication

Back 65

To cause to dry up

Front 66

Bandage

Back 66

Strip or roll of cloth that can be wound around a part of the body

Front 67

Binder

Back 67

A bandage that is made of large pieces of material to fit a specific body part

Front 68

When applying a binder, patient should flex their arm approximate at what angle

Back 68

80 degree angle

Front 69

Basic bandage turns

Back 69

Spiral, figure of 8, recurrent, circular, spiral reverse

Front 70

Circular bandage used

Back 70

Cover small body regions (Digits or Wrist)

Front 71

Spiral bandage use

Back 71

Cover cylindrical body parts. Wrist or forearm

Front 72

Spiral- reverse bandage use

Back 72

Use to cover inverted cone shaped body parts. Calf or thigh

Front 73

Figure of 8 bandage use

Back 73

Used to cover joints and provide immobilization. Joints

Front 74

Recurrent bandage use

Back 74

Provides caplike coverage. Scalp

Front 75

Secondary intention

Back 75

Wound must granulate during healing. Skin edges not close together,or when pus has formed.