Nursing Module 8 Lecture

Front 1

Primary lesion

Back 1

First lesion to appear on skin in response to a causative agent-usually has a recognizable structure

Front 2

Secondary lesion

Back 2

Changes can occur in primary lesion and result in this type of lesion. These changes occur in epidermal layer and caused by several factors including scratching,rubbing,meds,treatments,client med condition or disease process

Front 3

4 types of wound exudate

Back 3

serous
sanguineous
serosanguineous
purulent

Front 4

serous drainage

Back 4

clear,watery plasma

Front 5

sanguineous drainage

Back 5

red

Front 6

serosanguineous drainage

Back 6

mixture of serous and sanguineous drainage,consists of plasma and red blood cells and is pink and watery

Front 7

purulent drainage

Back 7

pus, a protein-rich liquid product of the liquefaction of necrotic tissue. It is made up of cells and cellular debris and is usually caused by an infection. It is thick and yellow, green, tan or brown

Front 8

Drainage from surgical wound

Back 8

Initially sanguineous. Over several days, it changes to sersanguineous and then serous

Front 9

Pressure ulcer

Back 9

any lesion caused by ischemia from unrelieved pressure that leads to necrosis of underlying tissues. Develop when soft tissure is compressed between a bony prominence and an external surface.

Front 10

How to prevent pressure ulcer

Back 10

monitor client
cleanse the skin
increase circulation
decrease microorganisms
remove excess moisture
decrease friction and excoriation
provide nutrition
position client properly
prevent shear
decrease pressure

Front 11

open wound

Back 11

disruption or break in skin
penetration by sharp object or instrument

Front 12

closed wound

Back 12

trauma caused by blow with blunt object

Front 13

clean wound

Back 13

wound free of infectious organisms
surgical incision not entering or affected by secretions from respiratory,gastrointestinal or genitourinary tracts

Front 14

contaminated wound

Back 14

wound with microorganisms
penetration of skin by dirt bacteria

Front 15

penetrating wound

Back 15

wound with break through epidermis,dermis and underlying tissues; may enter organs
penetration by object or instrument (usually accidental)

Front 16

abrasion

Back 16

superficial injury caused by rubbing or scraping of skin against another surface
friction injury resulting from fall or rubbing against bed linens

Front 17

laceration

Back 17

open wound with jagged edges
penetration of skin by sharp object

Front 18

contusion

Back 18

closed wound; may be swollen, discolored and painful
blunt trauma, such as being hit by object

Front 19

partial-thickness wound

Back 19

extends through the first layer of skin (epidermis) and into but not through the second layer of skin (dermis)

Front 20

full-thickness wound

Back 20

extend through both epidermis and dermis and may involve subcutaneous tissue, muscle and possibly bone

Front 21

3 phases of wound healing

Back 21

inflammatory phase
proliferative or reconstruction phase
maturation or remodeling phase

Front 22

Inflammatory phase of wound healing

Back 22

begins at time of tissue injury and lasts 3-4 days
inflammation characterized by heat,erythema,edema, pain
leukocytes migrate to wound
monocytes migrate to wound & clean bed of bacteria and and cellular debris

Front 23

Proliferative or reconstruction phase of wound healing

Back 23

lasts 4-21 days
collagen fills wound bed, new blood vessels develop, granulation tissue formed by fibroblasts

Front 24

Maturation or remodeling phase of wound healing

Back 24

much maturation occurs by 3-4 weeks, maximum may not occur until 2 years
phase characterized by reorganization of collagen fibers, wound remodeling and maturation of tissues to approximate skin's original strength

Front 25

3 types of wound healing

Back 25

primary intention
secondary intention
tertiary intention

Front 26

primary intention

Back 26

clinician approximates wound edges or margins and secures them using sutures, staples, or steri-strips
occurs in the first 14 days of injury
wound bed free of hematoma,debris, or exudate, then fills in with minimal granulation tissue, and the scar is usually thin or flat

Front 27

secondary intention

Back 27

prolonged
skin or wound edges can't be approximated, as in a pressure ulcer or a wound that is large or infected
all dead and infectious tissue must be removed and the wound must fill with granulation tissue.
wound contraction plays a greater role
generally involves greater tissue loss, higher risk for infection, prolonged healing and a large scar

Front 28

tertiary intention

Back 28

delayed or primary closure
occurs in wounds that may be contaminated, infected or draining exudate.
May be left open intentionally for 3-5 days to let healing begin by allowing contaminated or infected matter to drain out.
Once infection clears & granulation has begun,wound closed with sutures,staples or steri-strips

Front 29

Stages of pressure ulcers

Back 29

Stages I-IV

Front 30

Stage I pressure ulcer

Back 30

observable, pressure-related alteration of intact skin whose indicators as compared with adjacent or opposite area of body, may include changes in one or more of the following:
skin temperature
tissue consistency (firm/boggy)
sensation
appears as defined area of persistent redness in lightly pigmented skin

Front 31

Stage II pressure ulcer

Back 31

Partial-thickness skin loss involving the epidermis,dermis or both. Ulcer is superficial and presents as abrasion, blister or shallow crater

Front 32

Stage III pressure ulcer

Back 32

full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend to but not through underlying fascia. Present clinically as a deep crater with or w/o undermining of adjacent tissues

Front 33

Stage IV pressure ulcer

Back 33

Full-thickness skin loss with extensive destruction, tissue necrosis or damage to muscle,bone or supporting structures (tendon,joint capsule)

Front 34

Developmental factors in wound healing

Back 34

infants and children heal faster than older adults
older adults may be less mobile and have fragile,slowly healing skin
As a person ages, wound healing phase can be prolonged because of decresed inflammatory responses.
Changes in vascular,immune and respiratory systems can impair wound healing

Front 35

Psyiological factors in wound healing

Back 35

Immunosuppression
Incontinence
Hypoxemia
Diabetes
Neurological impairment
procedures
Medications
Infection
Hemorrhage
Fistula
Dehiscence and Evisceration

Front 36

Environmental factors in wound healing

Back 36

Client environment should support clean,dry intact condition
Skin integrity affected by skin dryness, friction from bed linens, moisture from incontenince, perpiration,emesis and wound drainage.

Front 37

hemorrhage

Back 37

bleeding from wound bed or site

Front 38

fistula

Back 38

abnormal passage between two internal organs or between and organ and external skin surface.
Forms because healing tissues don't close.

Front 39

dehiscence

Back 39

separation of wound edges

Front 40

evisceration

Back 40

protusion of internal organ such as a bowel loop through the incision. Wound eviscerations are medical emegencies

Front 41

What to do for evisceration

Back 41

1.stay calm

2. ask colleague to obtain supplies and notify physician while you stay w/ client

3.help client into semi-fowler's position with knees slightly flexed after gatching foot of bed. This position will ease pressure on wound, prevent further tearing of the wound edges and reduce risk of further evisceration
4. cover protruding intesting with sterile dressing moistened saline to prevent wound contaminaiton and keep abdominal contents moist

5. monitor client closely, assess VS and Pulse ox readings

6. Establish intravenous access to provide fluids and prepare client for surgery

7. continue to provide emotion support

Front 42

Which nutrients essential to wound healing?

Back 42

Vitamins C,A,B complex
Iron
copper
zinc

Front 43

Lab work to look for if client has non-healing wounds

Back 43

culture-type of infection

WBC-elevated may suggest systemic infection

Prealbumin and Albumin levels-low levels indicate poor nutrional status which slows wound healing; albumin best indicator of long-term nutritional status

Radiological studies-for suspected infection of wound over bony prominence, rules out osteomyelitis. Standar radiograph or bone scan can be used to detect infection

Front 44

Intervention to promote wound healing: Provide adequate nutrion

Back 44

Malnutrition inhibits wound healing and may increase risk for wound infection
Wound healing depends o availability of adequate protein, vitamins, an minerals.

Front 45

Intervention to promote wound healing: Cleaning wound

Back 45

Wound bed must be clean and free of infection. Bacteria, devitalized tissue and exudate must be removed to promote healthy granulation tissue. Benefits of clean wound must be weighed against potential trauma to wound bed.

Front 46

Intervention to promote wound healing: Maintain moist wound bed

Back 46

moisture enhances wound reepithelialization, helping a wound heal faster and with less scar tissue

Front 47

Intervention to promote wound healing: dressing wound

Back 47

optimal dressings absorb drainage and provide aseptic environment that provides barrier against further trauma

Front 48

Intervention to promote wound healing: draining wound

Back 48

drains prevent fluid from collecting between surfaces of wound, which would separate wound surfaces and prevent them from growing together to heal wound

Front 49

Intervention to promote wound healing: debriding wound

Back 49

removes dirt of dirt, foreign matter and dead tissue from wound.removing this tissue promotes wound healig

Front 50

Describe technique when doing wound culture

Back 50

-Preliminary actions
-Rinse or irrigate wound thoroughly with sterile normal saline before obtaining culture (cleansing the wound before culturing will remove surface bacteria)
-Swab the entire wound bed using zigzag technique and rotating swab starting at top of wound and proceeding to bottom of wound. Swab wound edges using 10pt. coverage. (Using this technique will cover entire wound bed.
-Place swab in culture tube and send the labled specimen to lab. (Prompt delivery of swab specimen will facilitate prompt culturing of the swab.)