Wound Assessment and Care r/t Nursing
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| show | Wound effects only epidermis. New skin is formed and no scar is present.
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| show | Wound involves minimal tissue loss with well approximated edges. Minimal scarring. Ex: Clean surgical scar.
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| Secondary intention healing | show 🗑
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| show | Wound is contaminated/ clean-contaminated. Follows secondary intention healing. When there is no edema, infection or debris, two surfaces of granulation tissue are sutured together. Strict aseptic technique - prone to infection. Less scar than secondary.
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| show | 1.Hemostasis: vessels constrict limiting hemo. Platelets aggregation & Clotting mechanism. 2.Inflammation:edema, erythema, pain, warmth, WBC migration. macrophages engulf debris & pathogens. Scab formed.
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| show | New cells fill the wound. Fibroblasts form collagen for strenth. Blood & lymph vessels are re-formed, resulting in formation of granulation tissue. Epithelialization begins.
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| Maturation phase "epithelialization" (2nd or 3rd week until healed) | show 🗑
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| show | may indicate a clotting issue,infection,slipped suture,internal bleeding
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| Dehiscence (major complication) | show 🗑
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| Evisceration (major complication) | show 🗑
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| show | abnormal passage between two body cavities or a body cavity + the skin that is created by an abscess.
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| Infection (major complication) | show 🗑
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| show | consists of serum. Staw colored fluid w/ watery consistency that separates out of blood when a clot is formed. Uusally present in a clean wound.
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| sanguineous | show 🗑
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| show | combination of bloody and serous drainage. Common in new wounds.
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| Purulent exudate | show 🗑
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| Predisposing for evisceration/ dehiscence | show 🗑
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| Stage I Pressure Ulcer | show 🗑
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| show | Involves partial-thickness skin loss of the epidermis, dermis or both. Abrasion, blister, or shallow crater.
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| Stage III Pressure Ulcer | show 🗑
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| show | Full thickness skin loss with extensive destruction, necrosis, or damage to muscle, bone or support structures. Presence of undermining and sinus tracts common.
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| Eschar | show 🗑
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| show | Daily skincare, warm water(not hot) for high risk pts. Use soap only as needed. Lotion if dry. Keep linen free of wrinkles. Adq calories & protein. Reposition q2h using the rule of 30 degrees. Therapeutic mattresses and cushions. Family teaching.
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| RYB color code system (wound mgmt) RED | show 🗑
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| RYB color code system (wound mgmt) YELLOW | show 🗑
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| RYB color code system (wound mgmt) BLACK | show 🗑
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| Sharp debridement | show 🗑
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| Wound care with drains | show 🗑
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| Mechanical debridement. | show 🗑
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| Enzymatic Debridement | show 🗑
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| show | use of an occlusive moisture retaining dressing and the body's own mechanisms for ridding itself of necrotic tissue. Activites: Apply dressing & observe fluid. Change q72h; cleanse wound at dressing changes.
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| Woven Gauze | show 🗑
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| show | for cleaning and wiping the skin or providing a layer of protection
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| show | Protection
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| Transparent film | show 🗑
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| show | Wafers, pastes, powders. hydrophilic. Adhesive. Keeps wound moist.Moldable for tight spots, absorbant, promote autolysis. Good for stasis ulcers or stge II pressure ulcers. Not for infected wounds. anaerobic bacterial growth.
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| show | sheets, granules or gels with high water content. Jelly consistency; Nonadhesive. Mimimal absorbtion.. Softens slough or eschar. Can be used in infected wounds. may maserate periwound skin.
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| show | mod-lg exudate.Beads, pwd, paste, ribbon, alg. 2nd dressing req.
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| Heat therapy Indications | show 🗑
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| show | Observe for faintness due to drop in BP (vasodilation).
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| show | Very Young
Very old
Sensory impairment
high risk for injury: fingers, hands, face, perineum, feet
Application to small area of intact skin is better tolerated
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| Moist heat | show 🗑
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| Cold Therapy Indications | show 🗑
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| show | May increase blood pressure. May cause shivering. Prolonged exposure may cause tissue damage.
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| show | Avoid direct contact with skin
Apply hot/cold intermittently
No more than 15 min at a time
check skin for redness, blistering, cyanosis or blanching
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| show | superficial scrape of top layers of the skin
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| abscess | show 🗑
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| show | Closed wound caused by blunt trauma. AKA bruise/ ecchymotic.
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| Crushing | show 🗑
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| show | open, intentional wound caused by a sharp instrument
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| show | torn open. Wound w/ jagged margins
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| show | open woudn in which the agent causing the wound lodges in body tissue
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| puncture | show 🗑
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| show | wound with an entrance & exit site
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| Factors affecting healing | show 🗑
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| show | decreases amt of pressure required to occlude blood flow to an area. Risk for ischemia
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| Anti-inflammatories | show 🗑
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| Steroids | show 🗑
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| Anticoagulants | show 🗑
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| show | delay healing. toxicity
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| show | increase sun sens
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| show | dry out the skin.
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| for aerobic wound culture | show 🗑
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| show | Internal Bleeding
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| show | Tightly adhering hydrocolloid dressing
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| show | ice
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| show | Vitamin C
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