Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
145 Cards in this Set
- Front
- Back
|
define the term wound
|
damaged skin or soft tissue
|
|
|
name three phases of wound repair
|
inflammation, proliferation, and remodeling.
|
|
|
identify five signs and symptoms classically associated with the inflammatory response.
|
swelling, redness, warmth, pain, and decreased function
|
|
|
discuss the purpose of phagocytosis, including the two typed of cells involved
|
process by which these cells consume pathogens, coagulated blood, and cellular debris. Two cells involved are: neutrophils and monocytes.
|
|
|
name three ways in which the integrity of a wound is restored
|
resolution, regeneration, and scar formation. Resolution is: process by which damaged cells recover and re-establish their normal function. Regeneration is: cell duplication. Scar formation is: replacementr of damaged cells with fibrous scar tissue.
|
|
|
explain the first, second, and third intention healing.
|
first intention healing: aka healing by primary intention, is a reparative process in which the woujnd edges are directly next to each other. Second intention healing: the wound edges are widely separated, leading to a more time consuming and complex reparative process. Third intention healing: wound edges are widely separated and are later brought together with some type of closure material.
|
|
|
Name two types of wounds
|
open wounds and closed wounds
|
|
|
state at least three reasons for using a dressing
|
keeping the wound clean, absorbing drainage, controlling bleeding, protecting the wound from further injury, holding medication in place, and maintaining a moist environment.
|
|
|
What are some examples of open wounds? There are 6!
|
incision, laceration, abrasion, avulsion, ulceration, and puncture.
|
|
|
What are some examples of closed wounds? There is 1!
|
contusion
|
|
|
What is an incision?
|
a clean separation of skin and tissue with smooth, even edges.
|
|
|
What is a laceration?
|
a separation of skin and tissue in which the edges are torn and irregular
|
|
|
what is an abrasion?
|
a wound in which the surface layers of skin are scraped away
|
|
|
what is a avulsion?
|
stripping away of large areas of skin and underlying tissue, leaving cartilagte and bone exposed
|
|
|
what is an ulceration?
|
a shallow crater in which skin or mucous membrane is missing
|
|
|
what is a puncture?
|
an opening of skin, underlying tissue, or mucous membrane caused by a narrow, sharp, pointed object.
|
|
|
what is a contusion?
|
injury to soft tissue underlying the skin from the force of contact with a hard object, sometimes called a bruise.
|
|
|
explain the rationale for keeping wounds moist
|
moust wounds heal more quickly because new cells frow more rapidly in a wet environment.
|
|
|
describe two types of drains, including the purpose of each
|
open drains and closed drains. Open drains are flat, felixble tubes that provide a pathway for drainage toward the dressing allowing drainage to occur passively by gravirt and capillary action. Closed drains are tubes that terminate in a receptacle.
|
|
|
name the two major methods for securing surgical wounds together until they heal
|
sutures and staples.
|
|
|
explain three reasons for using a bandage or binder
|
|
|
|
give examples of four methods used to remove nonliving tissue from a wound
|
sharp debridement, enzymatic debridement, autolytic debridement, and mechanical debridement.
|
|
|
list three commonly irrigated structures
|
wound irrigation, eye irrigation, and ear irrigation.
|
|
|
state two uses each for applying heat and for applying cold
|
heat: provides warmth, promotes circulation, speeds healing, relieves muscle spasm, and reduces pain. Cold: reduces fevers, prevents swelling, controls bleeding, relieves pain, and numbs sensation.
|
|
|
identify at least 4 methods for applying heat and cold
|
ice bag and ice collar, chemical packs, compresses, aquathermia pad, soaks and moist packs, and therapeutic baths.
|
|
|
list at least five risk factors for developing pressure ulcers
|
inactivity, immobility, malnutrition, emaciation, diaphoresis, incontinence, vascular disease, localized edema, dehydration, and sedation.
|
|
|
discuss three techniques for preventing pressure ulcers
|
change bedridden client's position frequently. Lift rather than drag the client during repositioning. Avoid using plastic covered pillows when positioning clients. Use positioning devices such as pillows to keep two parts of the body from direct contact. use lateral oblique position rather than the conventional lateral positiong for side lying. massage bony prominences only if the skin blanches with pressure relief. keep the skin clean and dry. use moisturizing skin cleanser rather than soap. Rinse and dry the skin well. Use pressure relieving devices. Pad body areas such as the heels, ankles, and elbows. Keep head of bed elevated no more than 30 degrees. Balanced diet and adequate fluid intake.
|
|
|
How long does inflammation usually last?
|
2 to 5 days
|
|
|
What are some purposes for inflammation?
|
limit the local damage, remove injured cells and debris, and prepare the wound for healing.
|
|
|
What are leukocytes?
|
A type of white blood cell
|
|
|
What are macrophages?
|
A type of white blood cell
|
|
|
what is leukocytosis?
|
increased production of white blood cells
|
|
|
How do labs determine how much white blood cells are being produced?
|
They do a test called a white blood cell count - where they draw blood and count the number of white blood cells in the sample.
|
|
|
What does a high white blood cell count mean?
|
Suggests an inflammatory and, in some cases, infectious process.
|
|
|
What is proliferation?
|
Period during which new cells fill and seal a wound
|
|
|
How long after injury does proliferation occur?
|
2 days to 3 weeks after the inflammatory phase.
|
|
|
What is granulation tissue?
|
combination of new blood vessels, fibroblasts, and epithelial cells.
|
|
|
During what phase of wound repair does granulation tissue appear?
|
Proliferation phase
|
|
|
What colors is granulation tissue?
|
Bright pink and red because of the extensive projections of capillaries in the area.
|
|
|
What is the remodeling stage of wound repair?
|
period during which the wound undergoes changes and maturation
|
|
|
How long does the remodeling stage of wound repair last?
|
It may last 6 months to 2 years.
|
|
|
What are factors that affect wound healing? There are 6!
|
type of wound injury. Expanse or depth of wound. Quality of circulation. Amount of wound debris. Presence of infection. Status of the client's health.
|
|
|
What determines the speed of wound repair?
|
What It heals by: first, second, or third intention.
|
|
|
What is an example of first intention healing?
|
most surgical wounds that are closely approximated.
|
|
|
What are some factors that interfere with wound healing?
|
compromised circulation, infection, and purulent, bloody or serous fluid accumulation that prevent skin and tissue approximation.
|
|
|
What are two potential surgical wound complications?
|
dehiscence and evisceration
|
|
|
What is dehiscence?
|
separation of wound edges
|
|
|
What is evisceration?
|
wound separation with protrusion of organs
|
|
|
When does dehiscence and evisceration usually take place?
|
Within 7 to 10 days after surgery
|
|
|
What is a pressure ulcer?
|
A wound caused by prolonged capillary compression that is sufficient to impair circulation to the skin and underlying tissue
|
|
|
What is the primary goal in managing pressure ulcers?
|
prevention
|
|
|
What is a dressing?
|
A cover over a wound
|
|
|
What are the purposes of a dressing?
|
keeping the wound clean, absorbing drainage, controlling bleeding, protecting the wound from further injury, holding medication in place, and maintaining a moist environment.
|
|
|
What is a gauze dressing made of?
|
Woven cloth fibers
|
|
|
What purpose does a gauze dressing provide?
|
their highly absorbant nature makes them ideal for covering fresh wounds that are likely to bleed or wounds that exude drainage.
|
|
|
What is usually combined with a gauze dreessing?
|
an ointment such as patroleum because granulation tissue may adhere to the gauze fibers and disrupt thew wound when removed.
|
|
|
What are montgomery straps?
|
Straps used to adhere gauze to a wound and allow for it to be changed without changing the tape. Strips of tape with eyelets.
|
|
|
What is a transparrent dressing?
|
Op-site- clear wound coverings.
|
|
|
What is a chief advantage of a transparrent wound dressing?
|
They allow the nurse to assess a wound without removing the dressing.
|
|
|
What is a hydrocolloid dressing?
|
self adhesive, opaque, air and water occlusive wound covering. Keeps wound moist.
|
|
|
How long can a hydrocolloid dressing be applied?
|
For up to a week if it stays intact.
|
|
|
What happens when urine or stool comes in contact with a hydrocolloid dressing?
|
nothing - it is repellent to these.
|
|
|
How much healthy skin should be included within the boundaries of a hydrocolloid dressing?
|
at least 1 inch
|
|
|
When should a dressing be removed?
|
When it requires assessment or care and when the dressing becomes loose or saturated with drainage.
|
|
|
What are drains in regards to wounds?
|
tubes that provide a means for removing blood and drainage from a wound.
|
|
|
What do drains do for a wound?
|
promote wound healing by removing fluid and cellular debris
|
|
|
What is an open drain?
|
flat, flexible tubes that provide a pathway for drainage toward the dressing. Drainage occurs passively by gravity and capillary action.
|
|
|
What is capillary action?
|
Movement of a pliquid at the point of contact with a solid.
|
|
|
What is a closed drain?
|
tubes that terminate in a receptacle.
|
|
|
What are some examples of a closed drain?
|
Hemovac and Jackson-Pratt (JP) drain.
|
|
|
Why are closed drains more efficient than open drains?
|
because they pull fluid by creating a vacuum or negative pressure.
|
|
|
How does a closed drain create a vacuum effect?
|
by opening the vent on the receptacle, squeezing the drainage collection chamber, then capping the vent.
|
|
|
What is used to keep a drain from entering the wound itself?
|
safety pen through the tube.
|
|
|
How long can staples be insereted?
|
a few days up to as long as 2 weeks
|
|
|
what is a binder in regards to wound care?
|
a type of bandage generally applied to a particular body part such as the abdomen or breast.
|
|
|
What are some purposes of bandages and binders?
|
holding dressings in place, especially when tape cannot be used or the dressing is extremely large. Supporting the area around a wound or injury to reduce pain. And limiting movement in the wound area to promote healing.
|
|
|
What are the six basic techniques for wrapping a roller bandage?
|
circular turn, spiral turn, spiral reverse turn, figure of eight turn, spica turn, and recurrent turn.
|
|
|
Explain a circular turn.
|
used to anchor and secure a bandage where it starts and ends. It simply involves holding the free end of the rolled material in one hand and wrapping it around the area, bringing it back to the starting point.
|
|
|
Explain a spiral turn.
|
partly overlaps a previous turn. The amount of overlapping varies from one half to three fourths of the width of the bandage. Spiral turns are used when wrapping cylindrical parts of the body such as arms and legs.
|
|
|
Explain a spiral-reverse turn.
|
a modification of a spiral turn. The roll is reversed or turned downward halfway through the turn.
|
|
|
Explain a figure of eight turn
|
best when bandaging a joint such as the elbow or knee. This pattern is made by making oblique turns that alternately ascend and descend, simulating the number eight.
|
|
|
explain a spica turn.
|
a variation of the figure of eight turn. It differs in that the wrap includes a portion of the trunk or chest.
|
|
|
Explain a recurrent turn.
|
made by passing the roll back and forth over the tip of a body part. Once several recurrent turns are made, the bandage is anchored by completing the application with another basic turn such as the figure of eight turn. A recurrent turn is especially beneficial when wrapping the stump of an amputated limb or the head.
|
|
|
when are t-binders used?
|
to secure a dressing to the anus or perineum or within the groin.
|
|
|
what's an alternative to using a t-binder?
|
adhesive sanitary napkins worn inside the underwear briefs.
|
|
|
what is debridement?
|
removal of dead tissue
|
|
|
what are the 4 methods for debriding a wound?
|
sharp, enxymatic, autolytic, and mechanical.
|
|
|
What is sharp debridement?
|
the removal of necrotic tissue from the healthy areas of a wound with sterile scissors, forceps, or other instruments.
|
|
|
what is necrotic tissue?
|
non-living tissue
|
|
|
When is sharp debridement preferred?
|
when the wound is infected because it helps the wound to heal qwuickly and well.
|
|
|
How does sharp debridement feel?
|
Painful - may bleed.
|
|
|
What is enzymatic debridement?
|
involved the use of topically applied chemical substances that break down and liquefy wound debris.
|
|
|
what is used to keep an enzymatic debridement solution on the wound?
|
A dressing
|
|
|
When should enzymatic debridement be used?
|
on uninfected wounds or for clients who cannot tolerate sharp debridement
|
|
|
What is autolytic debridement?
|
self dissolution, is a painless natural physiologic process that allows the body's enxymes to soften, liquify, and release devitalised tissue.
|
|
|
When is autolytic debridement used?
|
when a wound is small and free of infection.
|
|
|
What is a huge negative of autolytic debridement?
|
the prolonged time it takes to achieve desired results.
|
|
|
How can you speed up the process of autolytic debridement?
|
install an occlusive or semiocclusive dressing to keep the wound moist.
|
|
|
What is mechanical debridement?
|
involves physical removal of debris from a deep wound. One technique is the application of wet-to-dry dressings.
|
|
|
What are some disadvantages to mechanical debridement?
|
impeded healing from local tissue cooling, disruption of angiogenesis, and increased risk for infection from frequent dressing changes
|
|
|
What is angiogenesis?
|
formation of new blood vessels
|
|
|
What is hydrotherapy?
|
A mechanical debridement technique - therapeutic use of water where the body part with the wound is submerged in a whirlpool tank. Loosens up the debri and then is removed afterwards by sharp debridement.
|
|
|
What is irrigation?
|
mechanical debridement - technique for flushing debris.
|
|
|
When is wound irrigation generally carried out?
|
Before a new dressing is applied
|
|
|
What are some examples of heat and cold packs?
|
ice bag, collar, chemical pack, compress, aquathermia pads, soaks, moist packs, and therapeutic baths.
|
|
|
during what age are heat and cold packs used cautiously?
|
2 years old and below.
|
|
|
What is an ice bag and ice collar?
|
containers for holding crushed ice or small ice cubes.
|
|
|
When are ice collars usually applied?
|
after tonsil removal
|
|
|
What are ice bags applied to?
|
Any small injury in the process of swelling.
|
|
|
What is a chemical pack?
|
Chemicals inside a pack that when struck of crushed become cool.
|
|
|
Where can you typically find a chemical pack?
|
In a first aid kit
|
|
|
What kind of pack is a gel pack?
|
Chemical - can be frozen over and over again - and heated in the microwave
|
|
|
do not douche __ to __ hours a pap test.
|
24 to 48 hours - it may wash away diagnostic cells.
|
|
|
Why shouldn't you douche routinely?
|
Bwecause it removes microbes called Doderlein Bacilli that help to prevent vaginal infections.
|
|
|
What is the maximum temperature for a douche?
|
110 degrees fehrenheit
|
|
|
What are compresses?
|
moist, warm, or cool cloths applied to the skin.
|
|
|
What is a aquathermia pad?
|
an electrical heating or cooling device.
|
|
|
What is referred to as a K-pad sometimes?
|
an aquathermia pad
|
|
|
What is a soak?
|
a technique in which a body part is submerged in fluid to probvide warmth or apply a medicated solution.
|
|
|
What is a pack?
|
a commercial device for applying moist heat. More comforting and therapeutic than dry heat.
|
|
|
What are therapeutic baths?
|
a bath performed for other than hygeine purposes - can help reduce a high fever.
|
|
|
how long does a soak usually last?
|
15 to 20 minutes
|
|
|
how hot can a pack be applied to skin?
|
as hot as the patient can tolerate.
|
|
|
Who shouldn't you use a pack on?
|
Someone unconcious because they cannot percieve temperature.
|
|
|
what is a sitz bath?
|
soak of the perianal area. They help reduce swelling and inflammation and promote healing of wounds after hemorrhoidectomy - surgical removal of engorged veins inside and outside the anal sphincter - or a episiotomy, which is an incision that facilitates vaginal birth.
|
|
|
What are some common places pressure ulcers are formed while laying supine?
|
occiput, dorsal thoracic area, elbow, rim of ear, sacrum and coccyx, and heel.
|
|
|
What are some common places pressure ulcers are formed while laying on your side?
|
side of head, shoulder, perineum, ischium, trochanter, anterior knee, and malleus.
|
|
|
Where is the occiput?
|
back of head
|
|
|
where is the dorsal thoracic area?
|
upper back
|
|
|
Where is the sacrum and coccyx?
|
lower back / upper buttocks
|
|
|
Where is the ischium?
|
hip
|
|
|
Where is the malleus?
|
ankle
|
|
|
How many stages are there for pressure ulcers?
|
4
|
|
|
What occurs in stage 1 of a pressure ulcer?
|
intact but redenned skin
|
|
|
What occurs in stage 2 of a pressure ulcer?
|
red and accompanied by blistering or a skin tear.
|
|
|
what occurs in stage 3 of a pressure ulcer?
|
shallow skin crater that extends to the subcutaneous tissue. May be accompanied by serous drainage or purulent drainage caused by wound infection. Still painless.
|
|
|
what occurs in stage 4 of a pressure ulcer?
|
life threatening - tissue is deeply ulcerates, exposing muscle and bone. May have a foul odor. The infection easily spreads throughout the body, causing sepsis - a potentialls fatal systemic infection.
|
|
|
What are some nursing dianosis in regards to a patient with a wound?
|
acute pain, impaired skin integrity, ineffective tissue perfusion, impaired tissue integrity, and risk for infection,
|
|
|
What is different for wound healing in an 80 year old compared to a 30 year old?
|
Takes twice as long to heal.
|
|
|
What are the changes that make older adults' wounds take longer to heal?
|
diminished collagen and blood supply and decreased quality of elastin. Manifested by long term contact with ultraviolet rays from the sun.
|
|
|
What are risk factors for developing pressure ulcers?
|
inactivity, immobility, malnutrition, emaciation, diaphoresis, incontinence, vascular disease, localized edema, dehydration, and sedation.
|
|
|
How does diabetes affect wound healing?
|
Makes it longer
|
|
|
Why are some older adults more at risk for thermal injury?
|
because of altered temperature perception. Bath no more than 100 degrees.
|
|
|
How would depression, poor appetite, and cognitive impairments interfere with wound healing?
|
Poor nutrition.
|
|
|
If a resident is incontinent, what makes them more succeptable to skin breakdown?
|
the feces or urine will interfere with air circulation aiding the death of the skin tissue.
|
