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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| Primary intention healing | show 🗑
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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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| Inflammatory phase "cleansing" (days 1-5) | show 🗑
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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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| Hemorrhage/Hematoma (major complication) | show 🗑
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| Dehiscence (major complication) | show 🗑
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| show | total separation w/ protrusion of viscera. surgical emergency. Cover opening w/ sterile saline soaked sterile towels, notify the surgeon, and prep pt for surgery.
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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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| show | contaminated/traumatic wound s/sx: 2-3 days;
clean surgical wound s/sx: 4-5 day post op.
s/sx: edema, erythema, warmth, pain, fever above 100.4, odor, purulent drainage, color change in drainage.
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| serous exudate | show 🗑
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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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| show | Usually in inflammatory phase before collagen reinforced. Assoc w/ abd. wound, obesity (Fat does not heal quickly), malnutrition, inadq muscle closeure, or infection. Triggered by coughing, vomiting& change in position.
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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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| Stage IV Pressure Ulcer | show 🗑
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| Eschar | show 🗑
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| Preventing Pressure Ulcers | show 🗑
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| show | Granulation.
RN goal=Protect the wound
Activites=Keep the wound moist and covered
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| show | Moist, devitalized tissue (slough)
RN goal=cleanse the wound
Activites=irrigation and dressings. Poss debridement
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| RYB color code system (wound mgmt) BLACK | show 🗑
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| show | use of a sharp instrument to remove devitalized tissue. Provides immediate improvement of the wound bed & preserves granulation tissue.
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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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| Autolysis | show 🗑
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| show | Fine to coarse mesh. Absorbent. For packing wounds, wicking exudate or debridement.
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| Nonwoven gauze | show 🗑
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| show | Protection
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| Transparent film | show 🗑
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| Hydrocolloids | show 🗑
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| hydrogels | show 🗑
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| Absorption dressings | show 🗑
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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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| show | caused by force leading to compression or disruption of tissues. Assoc w/ fx. Minimal/no break in skin.
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| incision | show 🗑
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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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| show | open wound caused by a sharp onject. Often a collapse of tissue around entry point. Prone to infection
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| show | wound with an entrance & exit site
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| show | age (older=longer healing time)
impaired mobility/sensation, nutrition, hydration, poor circulation, medications, moisture, fever (increased metabolism, unavail for wound healing), contamination/infection.
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| BP meds Healing | show 🗑
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| Anti-inflammatories | show 🗑
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| show | inhibit wound healing
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| show | may cause extravasion of blood into sub q tissue. min pressure/injury can cause a hematoma
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| show | delay healing. toxicity
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| antibiotics, psychotherapeutic drugs, chemotherapy | show 🗑
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| herbal products (tea tree oil, lavender) | show 🗑
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| for aerobic wound culture | show 🗑
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| show | Internal Bleeding
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| Preferred dressing for dry yellow slough | show 🗑
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| Tx for fx ankle | show 🗑
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| Nutrient to promote collagen synthesis & capillary wall integrity | show 🗑
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Created by:
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