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27 Cards in this Set
- Front
- Back
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Partial-thickness
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loss of tissue of epidermis and partial dermis
heals by REGENERATION |
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Full-thickness
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total loss of skin layers and some deep tissues
heals by SCAR FORMation |
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Primary Intention
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wound edges of clean surgical incision remain close together
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Secondary Intention
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wounds left open, allowed to heal by scar formation (pressure ulcer, conatimnated surgical/traumatic wound)
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Tertiary Intention
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delayed primary intention, surgical wounds are not closed immediately but left open for 3-5 days, allowing for edema/infection to diminish, then stapled or sutured
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Important for patient to understand:
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wounds heal in an organized fashion; ongoing assesments aid in determining wound progress/treatments
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Performing wound irrigation:
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gently introducing the ordered fluid into the wound to prevent tissue injury
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Factors that influence wound healing:
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Age-reprod. of epidermis slows
Inadequate nutrition-delays tissue repair/increase infection risk OBESE-less vascularization Hematocrit <20, hemoglobin below 10g/100ml DIABETES-reduced collagen synth LONG TERM CHEMO/STEROID Theapy/IMMUNOSUPPRESIVE DRUGS |
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Open wounds must be kept in a _____environment;
Closed would must be protected from_____ |
moist;
microorganisms, stress |
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Phases of wound healing (full-thickness)
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HEMOSTATSIS-blood vs constrict; clot formation, growth factors released
INFLAMMATION-vasodialtion, macrogphages PROLIFERATION-epithelization, new granulation tissue formed, collagen synth REMODELING-collagen remodeled |
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Asses:
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location, dimensions, undermining, drainage, tissue type, exudate, odor, wound edges, pain
UNIFORM APPROACH |
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Delegation
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assesment CANNOT be delegated
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Lightly palpate along the incision to feel a ________.
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healing ridge
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Healing ridge
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accumulation of new tissue, positive sign
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If necrotic tissue does not allow _____ of the _____ of the wound, the stage _____be determined
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visualtion, base, CANNOT
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When using a syringe for wound irrigation, it stays ____ cm above the wound.
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2.5
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Avoid fluid retention in the wound by positioning the patient on the ____ to encourage the flow of the irrigant _____ from the wound
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side, away
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Use a ___ml syringe with a ____gauge needle to facilitate ___________for cleansing
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3, 19, optimal pressure
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Wound irrigation promotes
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wound healing through removing debris, decreasing bac. counts, and looseing/removing necrotic tissue
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Solutions used for irrigation
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normal saline, warm water, commercially available wound cleansers
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______technique is used for irrigating ____wounds; _____tech. used for _____wounds
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Sterile, surigical
Clean, chronic |
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Assessment (wound irrigantion)
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Review dr orders (open wound irrigation requires order, type of solutions)
Perform wound assesment(provides basis for comparing baseline to determine progress) Assess patients history of allergies to antiseptics, meds, tapes, dressings etc |
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Planning (wound irrigation)
EXPECTED OUTCOMES |
Patient states acceptable level of comfort on pain scale after irrigation
Wound begins to demonstrate signs of wound healing, wound is free of drainage, inflam. Skin integrity is maintained, no redness, edema, inflam. |
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Planning(wound irrigation)
DELEGATIOn |
Sterile wound CANNOT
cleansing of chronic CAN |
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Steps in wound irrigation (important)
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Position to permit gravitational flow of irrigation solution over wound, wound is vertical to basin(top to bottom of wound and from clean to contaminated prevents further infection)
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Irrigating wound with wide opening:
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35ml syringe, attach 19gauge Angio cath or needle
hold cath 2.5cm(1 in) above Use continous pressure, flush wound (clear solution indicates removal of debris) |
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Irrigation of deep wound, small opening
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attach soft cath
(expect would to take longer to empty since its small) insert tip of cath into opening about 1.3cm(.5 in) (prevents tip from touching inner fragile wall) slow, continous pressure, flush (promotes healing by loosening debris) shower for 5-10min with shower head 12 in away dry edges |
