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Nursing 101
Safety/Infection Control, Comfort/Sleep,Integumentary: wound care/healing
Question | Answer |
---|---|
Types of Cultures | Aerobic-Growing only in the presence of oxygen Anaerobic-Growing only in the absence of oxygen |
Types of wound healing | primary, secondary, tertiary |
Primary | Wounds with minimal tissue loss, Edges are approximated, Wound healing occurs with minimal granulation tissue and scaring |
Secondary | Wounds with extensive tissue loss Edges are not approximated Tissue replacement and scarring is greater Increased risk of infection |
Tertiary | Wounds that are left for 3-5 days Then are closed aka “delayed primary intention |
Assessing a wound | wound edges: together, color, smell, location, sizes, |
Wound edges Red | inflammation |
Wound edges White | arterial insufficiency |
Wound edges Blue | Severe arterial insufficiency |
Wound edges Black | necrosis |
Wound edges Brown | venous insufficiency |
Serous | Clear |
Purulent | Thick, Yellow, Blue, Green |
Sanguineous | Bloody |
SeroSanguineous | Pink Clear with streaks Phases of Wound Healing |
Factors that affect wound healing | lifestyle: smoking and, nutrients, movement, incon. Meds, infection and other disease |
Caring for a client with a wound drain Nursing Responsibilities | *Keep linen to a minimum *Assess skin very often *Use the right product * Therapeutic Beds * turn q hour |
Diabetic Foot Care | *Inspection *Nail care *Client Education |
Wound culture Purpose | *Determine the presence of infection *Identify the causative organism |
Stage 1 | Nonblanchable erythema of intact skin |
Stage 2 | Partial-thickness skin loss involving epidermis and possibly dermis |
Stage 3 | Full-thickness skin loss involving damage or necrosis or subcutaneous tissue that may extend down to, but not through,the underlying fascia. |
Stage 4 | Full-Thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures such as a tendon or joint capsule |