providing wound care and treating pressure ulcers

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honey
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198392
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providing wound care and treating pressure ulcers
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2013-02-07 02:15:12
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chapter 38
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providing wound care and treating pressure ulcers
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  1. dyspnea
    difficulty breathing
  2. integument
    skin
  3. skin & mucous
    skin and mucous membrane are protective barriers for the body against infection.
  4. necrosis
    fatal injury to cells
  5. the only type of tissues that can regenerate
    skin, mucous membranes, bone marrow, muscles, liver, kidney, and lung tissues.
  6. inflammatory phase
    the inflammatory phase begins immediately after injury and last about 4 days.
  7. unable to generate
    heart muscle and nerve cells
  8. platelet aggregation
    clumping
  9. fibrin
    insoluble protein essential to clotting
  10. hemostasis
    arrest of escaping blood by clotting or vessel compression
  11. phagocytosis
    engulfing of microorganisms or foreign particles
  12. erythema
    redness
  13. wound stage 2:
    proliferation stage begins on the third or fourth day after injury and last 2-3 weeks.
  14. lysis
    brake down
  15. macrophages
    monocytes that are phagocytic
  16. collagen
    fibrous structural protein of all connective tissue
  17. wound final stage
    healing maturation, begins about 3 weeks after injury.
  18. keloid
    permanent raised enlarged scar
  19. adhesions
    fibrous bands that hold together tissues that are normally separated
  20. first intention
    closure
  21. approximate
    close together
  22. laceration
    torn ragged or mangled wound
  23. apipose
    fatty
  24. needed for wound healing
    protein, carbohydrates, lipids,vitamins A & C,thiamine, pyridoxine and riboflavin minerals zinc, iron copper.
  25. hemorrhage
    intense bleeding from a wound
  26. sanguineous
    bloody
  27. immunocompromised
    with poorly functioning immune system
  28. internal hemorrhage is extensive
    hypovolemic shock may occur with a fall in blood pressure, rapid thready pulse, increased rate of respiration, restlessness, diaphoresis, and cold clammy skin.
  29. how do you know its an infection?
    • *increased pain at the wound site.
    • *redness around wound
    • *warmth in the surrounding tissues
    • *purulent(pus) exudate
  30. adipose
    fatty
  31. purulent
    pus
  32. abscess
    • accumulation of pus made up of debris from phagocytosis when microorganisms have been present.
    • *white yellow pink green
  33. microorganisms most frequently present in wound infection
    staphylococcus aureus
  34. exudate
    fluid accumulation containing cellular debris
  35. cellulitis
    • inflammation of the tissue surrounding the initial wound.
    • (red and induration)
  36. fistula
    abnormal passage or communication usually formed between two internal organs or leading from an internal organ to the surface of the body.
  37. sinus
    is a fistula leading from a pus filled cavity to the outside of the body.
  38. best way to prevent wound infection
    is to maintain strict asepsis when performing wound care.
  39. to prevent microorganisms in your mouth or saliva from possibly landing in the wound
    reframe from talking while dressing the wound
  40. dehiscence
    is the spontaneous opening of an incision
  41. eviscertion
    is the protrution of an internal organ through the incision
  42. serosanguineous
    serum in blood mixture
  43. there are three basic wound types
    • red:wounds are clean and ready to heal
    • yellow:wounds have a layer of yellow fibrous debris or exudate and often become infected
    • black:wounds need debridement (removal of all foreign or unhealthy tissue from a wound) of the eschar (sloughing dead tissue usually caused by a thermal injury or gangrene) to heal.
  44. penrose drain
    flat rubber tube
  45. drainage devices
    • empty the device when it is two thirds full
    • should be drain and compressed every four hours
  46. debridement
    • chemical debridement: wound with necrotic tissue that is responding to other treatment.
    • auto debridement: a longe r process that uses the body enzymes to break down nonviable tissue in the wound. dressing is warm moist that could encourage bacteria.
    • mechanical debridement: physical removal of wound debris by irrigation or hydotherapy with a whirlpool or ultra sound mist.
  47. dressings
    • prevent microorganisms from intering or exiting.
    • absorbs drainage
    • pressure to control bleeding
    • support stabilize tissues and reduce the discomfort from the wound.
  48. superficial wounds
    heal faster moist then dry.
  49. hydrocolloid dressing
    • not recommended for heavy drainage wounds
    • 3-5 days
  50. binders
    • wide elastic fabric bands
    • decrease tension around a wound or suture line, increase patient comfort, decrease lactation after birth or hold dressing in place.
  51. treat pressure ulcers
    • 250-500ml of solution and irrigate using a syringe with a small catheter to reach underneath areas and tunnels.
    • Note: for infected ulcers a noncclusive dressing is always used.
  52. approximation
    degree of closure
  53. assess wounds
    • acute wounds assess every 8 hrs.
    • chronic once a day.
    • temp greater than 101f(38.3c); a WBC count greater then 10,000/dl and a feeling of malaise may indicate infection.
  54. common nursing diagnosis
    • impaired skin integrity related to surgical incision(trauma)
    • risk for infection related to nonintact skin or impaired skin integrity.
    • acute pain related to infection.deficient knowledge related to careĀ  of wound
    • anxiety related to need to perform wound care.
  55. planning
    dressing require a doctors orders and irrigation may only be done with a order.
  56. cold
    using cold solution lowers the wound temp, which slows healing.
  57. hydrocolloid
    • are only applied to uninfected wounds.
    • they keep the wound moist and block microorganism entry.
  58. irrigation(flushing a wound)
    with dr order only.
  59. granulaion tissue
    connective tissue with multiple small vessels.
  60. wounds
    • parcial-thickness( heal by epithelialization)
    • full-thickness injuries(heal by contraction)
  61. 3 phases of wound healing
    • inflammation
    • proliferation
    • maturation
  62. necrotic tissue
    interferes with wound healing
  63. surgical wounds
    heal by first intention because there is little tissue loss at the surface.
  64. wounds with tissue loss
    heal by second intention
  65. cardinal signs of inflammation
    • selling
    • erythema
    • pain
    • heat
    • loss of function
  66. wound healing
    exercise enhances blood circulation bringing oxygen and nutrition to a wound
  67. complications of healing
    hemorrhage, infection,dehiscence and evisceration
  68. chronic wounds
    negative pressure via vacuum assisted closure may be used for chronic wounds that are not healing.
  69. wound drains
    placed to provide an exit for blood and fluid.
  70. to activate a wound suction device
    the body of the device is compressed and the outlet is closed.
  71. draining a wound helps prevent
    the formation of an abscess or fistula.
  72. clean wounds
    should only be irrigated with normal saline antimicrobial solutions damage granulation tissue.
  73. sloughing
    natural shedding of dead tissue
  74. debridement
    removing foreign and unhealthy tissue from wound
  75. eschar
    sloughing death tissue(gangrene)

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