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41 Cards in this Set

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Example of primary intention wound healing process?
Surgical incision
Example of secondary intention wound?
burn, pressure ulcers
Are secondary intention wounds covered to heal or left open?
Left open until its filled with scar tissue
What complications are seen due to a slipped suture, dislodged clot, infection?
Hemorrhage
A bluish discoloration, a collection of blood under the skin?
Hematoma
Fever, tenderness, pain at wound site, with inflamed appearance are signs of?
Infection
Total seperation of wound layers, protrusion of visceral organs through a wound opening is called?
Evisceration
What nsg intervention for eviscerated wound? Why?
1. place sterile towels soaked with sterile saline.
2. to decrease bacterial invasion and prevent drying of tissue.
A partial or total seperation of wound layers is called?
Dehiscence
Where is a dehiscence wound seen and why would it occur?
1. abdominal wound
2. After a strain, coughin, vomiting
What patient teaching for a patient after abdominal surgery?
1. Important to splint abdominal wound when coughing.
An abnormal passage between two organs or between an organ and the outside of the body?
Fistula
What are complications of a fistula?
1. increase risk of infection
2. F/E imbalances due to fluid loss (Crohn's disease)
Nortan Scale is based on 5 risk factors?
1.Physical condition
2.Mental condition
3.Activity
4.Mobility
5.Incontinence
Whats the total score? of the nortan scale and what would indicate increase risk?
1. 5-20
2. the lower the score the higher the risk.
The braden scale is composed of 6 subscales?
1. Activity 2. mobility 3. sensory perception, 4. nutrition, 5, moisture, 6. friction and shear.
What is total score of braden scale? and indicates high risk
1. 6-23
2. lower score
clear, watery plasma from a wound is called?
Serous
thick yellow, green, tan or brown drainage is called?
purulent
pale, red, watery: mixture of red fluid drainage?
Serosangineous
bright red: indicates active bleeding
Sangineous
what do you document when describing a wound?
Color, ordor, consistency of drainage
If a wound is infected will the healing process be slow or fast?
Slow
what should pressure ulcers be cleaned with?
Normal Saline (non cytotoxic)
What is a common method used to remove debris from a wound?
irrigation
The removal of non viable, necrotic tissue is called?
Debridement
Name 4 methods of debridement?
1. Mechanical
2. Autolytic
3. Chemical
4. Surgical
The use of wet to dry saline gauze dressing is what type of method of debridement?
mechanical debridement
How is wet to dry dressing administered?
1. moist gauze place into wound.
2. dressing is allowed to dry completely before it is removed
This type of debridement uses synthetic dressings over a wound to allow eschar to be self-digested?
autolytic debridement
How is autolytic debridement administered?
1.use dressings that support moisture
2.if wound is dry, use a moist dressing
3. if excessive exudate, use a dressing that will absord moisture but will maintain some moisture
What is an example of dressing used for autolytic debridement?
transparent film
hydrocolloid dressings
this type of debridement uses topical enzymes, preparation such as Dakin's solution or sterile maggots?
Chemical debridement
what will topical enzymes do to a wound?
-break down necrotic tissue
-either digest or dissolve tissue
This type of debridement is the removal of nonviable tissue by using a scissors, scalpel, or a sharp instrument?
Surgical debridement
A wound will heal in what type of environment?
Moist because supports movement of epithelial cells and facilitates wound closure.
What are complications if a wound has excessive exudate?
-supports bacterial growth
-slows healing process
What blood level will decrease delivery of oxygen to the tisssues and lead to further ischemia?
Hemoglobin
in a emergency situation what are nursing interventions for a wound?
1.stabilize cardiopulmonary function
2. clean the wound
3. protect wound from further injury
How should a nurse control bleeding of a laceration?
1. apply direct pressure on the wound with a sterile or clean dressing
2.place adhesive bandage to allow edges to close and form clot
3. elevate affected part if bleeding continues
Why should a puncture wound be allowed to bleed?
to remove dirt and other contaminants
ex. saliva from a dog bite.