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