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MS1 Exam Three > Wound Care > Flashcards

Flashcards in Wound Care Deck (33)
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1
Q

Types of Healing

A
  1. Primary intention healing
  2. Secondary intention healing
  3. Tertiary intention healing
2
Q

Primary intention healing

A
  • tissue surfaces approximated (brought together)
  • minimal or no tissue loss
  • minimal granulation tissue and scar
  • surgical incision as an example
3
Q

Secondary intention healing

A
  • Edges cannot or should not be approximated (brought together)
  • repair time longer, more scarring and risk for infection
4
Q

Tertiary intention healing

A

“delated primary intention”

  • left open for 3-5 days and then closed
  • allows edema to resolve exudate to drain
  • closed with sutures, staples, or adhesive skin closures
5
Q

Phases of Wound Healing

A
  1. Hemostasis Phase
  2. Inflammatory Phase
  3. Proliferative Phase
  4. Maturation Phase (Remodeling)
6
Q

Hemostasis Phase

A
  • cessation of bleeding
  • vasoconstriction and formation of clot
  • scab inhibits infection
  • epithelial cells migrate into wound to prevent entry of microorganisms
7
Q

Inflammatory Phase

A

Blood supply increases

  • erythema and edema
  • exudate cleanses wound
  • neutrophils first 24 hrs
  • replaced by macrophages
  • phagocytosis
  • crucial healing
8
Q

Proliferation Phase

A

Day 3-4 to 21 days

  • Fibroblasts synthesize collagen that adds strength to wound
  • Capillaries grow across wound, bring fibrin
  • Granulation tissue forms
  • Light red or pink
9
Q

Maturation Phase

A
  • Remodeling*
  • From day 21 to 1-2 yrs
  • fibroblasts continue to synthesize collagen
  • wound site is remodeled and contracted
  • scar becomes stronger
  • too much collagen?
10
Q

Complications

A
  • Hemorrhage
  • Infection
  • Dehiscence
  • Evisceration
11
Q

Hemorrhage

A
  • May bleed uncontrollably
  • apply pressure
  • surgery may be needed
  • Hematoma under wound, may obstruct blood flow to area
12
Q

Infection

A
  • microbes compete for oxygen and nutrition (impairs wound healing)
  • change in wound color, pain, drainage
  • may occur druing injury, surgery, post-op
  • confirmed by culture
  • may have fever, increase WBCs
  • immunosuppressed increase risk
13
Q

Dehiscence

A
  • Partial or total rupture of sutured wound
  • cover with sterile saline gauze
  • patient to bed with knees bent
  • notify doctor
14
Q

Evisceration

A
  • protrusion of internal viscera through an incision
  • usually occurs 4-5 days post-op
  • cover with large sterile dressing
  • patient in bed with knees bent
  • notify surgeon immediately
15
Q

Risk factors for evisceration

A
  • obesity
  • poor nutrition
  • trauma
  • failure to suture
  • coughing
  • vomiting
  • straining
16
Q

Prevention

A
  • protein
  • CHOs
  • Lipids
  • Vit A and C
  • Iron
  • Zinc
  • Copper
17
Q

Lifestyle Preventative measures

A
  • regular exercise leads to better circulation

- smokers at risk for delayed healing

18
Q

Medications not good for wound healing

A
  • anti-inflammatory (need inflammatory response for wound healing)
  • antineoplastic (cancer drugs, same thing)
  • prolonged antibiotics (prone to infection from resistant bacteria)
19
Q

Exudate

A
  • serous (clear, light yellow)
  • serosanguineous (light pink)
  • sanguineous (bloody red)
  • purulent (yellow green, puss)
20
Q

Elderly patients Considerations

A

-at risk for imparied wound healing due to:

  • impaired liver fx
  • nutritional deficiencies
  • chronic illness
  • vascular changes
  • delayed inflammatory response
  • slowed collagen synthesis
21
Q

Diagnostic Tests

A

wound culture and sensitivity

22
Q

Surgery

A
  • Emergency: life threatening/ repair tissue or vessels
  • Non-emergency: ineffective healing/debridement for infected or necrotic tissue
  • necrotic tissue removed
  • wound flushed with saline
  • abscess (incision and drain)
  • Escharotomy to remove eschar
23
Q

What is the difference between necrotic tissue and eschar?

A

?

24
Q

Pharmacologic Therapy

A
  • Antibiotics
  • Topical gels or injectable meds with growth factors
  • opioids and NSAIDs
25
Q

Non-Pharm Therapy

A
  • nutrition
  • compression
  • vacuum-assisted closure
  • hyperbaric oxygen therapy
  • stem cells
  • maggots
  • alternative
26
Q

Nursing Care

A
  • Assessment
  • Maintain moist wound healing
  • promote optimal nutrition and hydration
  • prevent infection
  • position to minimize pressure on the wound
27
Q

EBP

A
  • Hydrocolloid dressings best for dry wounds
  • impermeable to oxygen, moisture, and bacteria
  • Maintain moist environment
  • Support autolytic debridement
  • dry wound with no drainage - transparent film
  • exudative wound - absorptive dressings
28
Q

Drain purpose

A

allow excessive fluid, purulent drainage to drain; assists with granulation tissue formation

29
Q

Drain labels

A
  • type of drain
  • date
  • initials
30
Q

nursing care of drains

A

maintain suction as needed, assess and document drainage

31
Q

Wound V.A.C.

A

Vacuum Assisted Closure

  • continuous or intermittent negative pressure
  • removes fluid and exudate
  • prepares the wound for healing and closure
32
Q

Wound V.A.C. complications

A
  • hemorrhage from suction with anticoagulant therapy

- wound infection from dressing pieces left in wound

33
Q

Wound V.A.C. Care

A
  • eval pts for risk of bleeding
  • stop VAC if bright red blood seen - apply pressure and notify MD
  • Perform proper dressing change