215-4 wound care

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elevatedsound7
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197385
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215-4 wound care
Updated:
2013-02-04 14:50:03
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215 wound care
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215 wound care
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  1. maslows needs base to top are
    • physiological
    • safety and security
    • love and belonging
    • self-esteem
    • sefl actualization
  2. the layers of skin
    • epidermis
    • dermis
    • subcutaneous
  3. what is the nursing role in wound care
    • prevention
    • promote tissue repair and regeneration
  4. enhance a wound care pt nutritional status by
    • protein rich foods
    • water
    • vitamin dense
  5. an acute wound is one that
    heals within 30 days
  6. chronic wound is
    wound that persists beyond usual healing time of greater than 30 days
  7. Healthy people 2020 is
    government wants to decrease pressure sore prevalence in nursing home patients 50% by 2020.
  8. what is the Braden scale
    scale that determines the risk for pressure sores
  9. stage 1 pressure ulcer =
    epidermis is red and is non-blanchable
  10. stage 2 pressure sore =
    injury to epidermis and derimis (actual break in skin) blister
  11. stage 3 pressure sore =
    ulcer goes beyond the dermis  to subcutaneous tissue.
  12. stage 4 pressure sore =
    ulcer extends to muscle or bone
  13. unstageable pressure soar =
    eschar covered, cannot stage until unroofed
  14. osteomyelitis
    infection of bone
  15. primary intention
    • wound is clean
    • little loss of tissue
    • edges well and approximated
    • heals rapidly with minimal scarring
    • (surgical wound
  16. secondary intention
    • wound heals from bottom up
    • large wound with tissue loss
    • healing takes longer
    • wound not readily approximated
  17. tertiary intention
    • time delay wound is sutured or closed
    • more scarring
    • risk for infection an inflammatory reaction
  18. hemostasis phase is
    • vasoconstriction
    • deposit of fibrin
    • clot formation
  19. proliferation phase is
    • collagen - adds strength
    • capillaries -  increase blood supply
    • new tissue built to fill wound space
    • granulation tissue
  20. during proliferation phase what should you be wanting for pt
    adequate nutrition, oxigenation
  21. maturation phase =
    • scar is formed
    • can take years
  22. Goal with red wound =
    • protect it
    • it is granulation tissue
    • at proliferation phase
  23. yellow wound care =
    clean wound
  24. black wound care =
    debride
  25. autolytic debridement =
    using bodies own enzymes to debride a wound
  26. factors that influence wound healing
    • age
    • circulation and oxygenation
    • wound condition
    • overall health status
    • meds (steroids)
    • nutrition
  27. nursing process begins with
    assessment
  28. sanguineous woun drainage =
    bloody
  29. serosanguineous=
    combination of clear and bloody drainage
  30. first step in obtaining a woud culture =
    clean wound to remove old drainage
  31. wound culture should be done with what technique
    aseptic
  32. what is nursing diagnosis for pt with wounds
    • impaired skin integrity
    • disturbed body image
    • acute/chronic pain
    • self-care deficit
  33. wound care considerations
    • location and size of wound
    • type and depth of wound
    • presence of infection
    • need for debridement
    • amount and type of drainage
  34. non stick dressings are used -
    • prevent dressing from adhering to wound
    • ie petrolatum dressing or tefla
  35. gauze used for what in wound care
    • packing
    • most common
  36. petrolatum dresing or Telfa =
    nonstick dressing
  37. transparent dressing used for
    • small wounds or tubes
    • occlusive but with visualization
    • tegaderm
  38. hydrocolloids are
    • remain on for 3-7 days
    • absorbs drainage
    • occlusive and adhesive
    • conforms and cushions
    • duoderm
  39. duoderm =
    hydrocolloid dressing
  40. hydrogels
    • o2 permiable
    • maintains moisture
    • may remain 8-48 hrs
    • used with minimal exudate
    • aquasorb
  41. aquasorb =
    hydrogel
  42. alginates are
    • derived from seaweed
    • moderate to heavy drainage
    • retentive gel on contact with exudate
    • sorbsan, aquacel, nuderm
  43. sorbsan, aquacel, Nu-derm
    alginates
  44. indications of hyperbaric treatment
    diabetic foot ulcers, arterial ulcers, radiation necrosis
  45. when cleaning wound avoid?
    iodine, hydrogen peroxide, acidic solutions
  46. preferred cleaning solution for wounds =
    saline
  47. complications of wound healing
    • hemorrhage
    • hematoma
    • infection
    • dehiscence
    • evisceration
    • fistula
  48. in surgical wounds hemorrhage usually occurs
    within first 48 hours post op
  49. infection in wounds usually occur
    within 2-11 days
  50. dehiscence =
    partial or total disruption of sutured wound 
  51. treatment for dehisence =
    keep wound covered with moistened sterile dressing, notify MD, limit activity
  52. eviseration =
    protrusion of viscera through incisional area.
  53. tx of eviseration
    cover wound with STERILE saline soaked dressing, call MD STAT, low fowlers position, saty with pt.
  54. fistula =
    abnormal tube passage that can develope between to organs or from one organ to the outside of body
  55. what to discuss in home care D/C planning
    • good handwashing
    • nutrition and fluids
    • spplies to purchase

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