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cassiekay10
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206271
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fund
Updated:
2013-03-10 22:46:55
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wounds
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7-10
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  1. contusion
    closed, discolored wound caused by blunt trauma -- bruise
  2. abraision
    superficial open wound -- scrapes, scratches, rub-type
  3. puncture wounds
    open results when sharp item, needle, nail wire, pierces skin
  4. penetrating wounds
    similar to puncture, object remains in wound
  5. leceration
    open wound made by accidental cutting or tearing of tissue
  6. pressure ulcers
    wound resulting from pressure or friction
  7. contamination of wounds categories 5
    clean, clean-contaminated, contaminated, infected, and colonized
  8. clean def
    wound not infected
  9. clean-contaminated
    surgically made wound, not infected, direct contact w narmal flora in resp tract, urin tract, or gi, potential to become infected
  10. contaminated
    surg wound or wound caused by truama that has been grossly contaminated by breaking asepsis
  11. infected
    wound that the infectious process has already established, evidenced by high numbers of microorganisms and either purulent drainage or necrotic tissue
  12. colonized
    differs from infected in that it has a high number of microorganisms present but wo signs of infection
  13. pressure ulcers known as 2
    decubitus ulcer or bedsore
  14. bedsore occurs when
    external pressure is exerted on soft tiss, esp over bony prom, for a prolonged period of time
  15. ischemia
    reduced blood flow in areas where tissues and capillaries are compressed
  16. advanced ischemia
    necrosis of cells
  17. ulcers can be result of 2
    friction or shearing
  18. most common bedsore sites
    sacrum, butt, greater troch, elbows, heels, ankles, occiput, and scapula
  19. risk factors for pressure ulcers 5
    elderly, amaciated or malnourished, incont, immobile, impaired circulation or chronic metabolic conditions
  20. staging of pressure ulcers 6
    deep tiss inj, 1, 2, 3, 4, unstageable
  21. deep tissue injury
    area over bony prom, differs from surrounding tiss in temp, text, firmness, discomfort level
  22. stage 1
    erythema, remains for at least 15 - 30 min after relieving pressure and it will not blanch when you gently touch it w fingertip
  23. stage 2
    occurs when there is partial thickness loss of dermis
  24. stage 3
    full-thinkness loss involving damage to epidermis, dermis, and subcutaneous tiss, but not involving muscle or bone. undermining or tunneling can occur
  25. stage 4
    full-thickness tiss loss, involved deep tiss necrosis of muscle, fascia, tendon, joint capsule, and sometimes bone
  26. unstageable
    involves full thickness tiss loss but are impossible to accurately state due to the wound bed being completely obscured by eschar or excessive slough
  27. prevention of pressure ulcers
    • 1 assess pallor, erythema, jaundice, bruising
    • 2 assess turgor
    • 3 peposition every 2h
    • 4 clean and dry
    • 5 linens wrinkle free
    • 6 lotion dry skin
    • 7 use draw sheet or lift
    • 8 adequate nutrition and fluids
  28. stasis ulcer
    develop when venous blood flow is sluggish, generally in lower extremeties, allowing deoxygenated blood to pool in the veins
  29. draining sinus tracts
    channel or tunnel that develops bw two cavities or bw an infected cavity and the skin surface -- fistula
  30. fistula known as
    draining sinus tract
  31. surgical incisions
    intentionally made w sharp instruments, linear w more sharply defined edges than most wounds. good approximation bw 2 edges
  32. inflammatory process of wound healing
    phase occurs when wound is fresh and includes both hemostasis and phagocytosis
  33. hemostasis
    body stops the bleeding associated w fresh wound
  34. phagocytosis
    wbcs macrophages engolf and digest invading microorganisms and the remaining fragments of damaged cells
  35. signs of inflammation 4
    warmth, redness, pain, edema
  36. do not medicate w drugs that block inflammation because they
    interfere with bodys natural process and delays healing
  37. reconstruction phase
    when wound begins to heal, lasting about 21 days after inj -- proliferation phase
  38. reconstruction phase steps
    fibroblasts produce collagen that forms scar tiss and helps strenghten wound. cap produce new networks to supply oxygenated blood and nutrients
  39. granuolation tissue
    extremely fragile red and semitransparent new tissue
  40. maturation phase
    remodeling phase, would contracts and scar strenghtens
  41. maturation steps
    healing ridge develops can last years, refined collagen produced, firm and less elastic, extra support
  42. keloid
    overproduction of collagen, thick, raised scar
  43. first intention wound wound closure
    wound is clean w little tiss lossm, edges are approximated and wound is sutured close - surg inc.
  44. second intention
    greater tiss loss and wound edges are irregular and cannot be brought together. - pressure ulcer or traumatic wound, will be left open to gradually heal by filling in w granulation tiss, leaving wide scar
  45. third intention
    wound left open for a time to allow granulation tiss to form then sutured closed, - draining wound- when draining is done wound sutured
  46. 11 factors affecting wound healing
    age, chronic illness, diabetes, hypoxemia, lifestyle, lymphedema, medications, mult wounds, nutrition and hydration, radiation, wound tension
  47. evisceration
    guts come out of stomach
  48. complications of wound healing3
    infection, wound dehiscense and evisceration, hemorrhage
  49. dehiscense
    seperation of outer layers of wound after surgery
  50. measurement of wound
    amnt & color or drainage, assess size, if open - assess base or bed
  51. amount and color of drainage on old dressing
    mark drainage if no order to change dressing
  52. assess size of wound
    lenth, width, depth
  53. if open, assess base or bed of wound
    color of tiss, texture of tiss, gran tiss, aschar, sinus tracts (tunnelling?), undermining (widening inside)
  54. sinus tracts
    tunnel
  55. undermining
    widening inside
  56. ryb classifications
    • r red protect
    • y yellow cleanse
    • b black debride
  57. red wounds
    in proliferative stage of healing and are the color of normal gran tiss, wounds need protection by nsg interventions that include gently cleansing used of moist dressing, application of a transparent or hydrocolloid dressing, changing dressing only as needed
  58. yellow wound
    oozing from tiss covering wound, purulent. to cleanse, nsg interventions include irrigating the owund, using wet-to-moist dressings, using nonadherant, hydrogel or other absortive dressings consulting w md for use of topical antimicrobial mediation to decrease bact growth
  59. black wounds
    thick eschar may be brown gray or tan, must be debrided, may be surg removed w scissors or scapel, or by mech debridemtn, scrubbing or wet to dry dressing, be chemical debridement using ointments w enzymes agents, afterwards treated as yellow and as healing progresses, a red
  60. when more than one color is present
    the most color is treated
  61. heat and cold brings a
    local or sustemic change in body temp for therapuetic purposes
  62. heat and cold modified by
    method, duration of aplication, degree of temp, pt age and phys cond, amount of body surface covered
  63. nurses aim in applying heat/cold
    • 1 promote healing
    • 2 facilitate comfort
    • 3 use knowledge and skill in carrying out application
    • 4 follow safety measure
  64. effects of heat
    dilates peripheral blood vessels
  65. vasodilations
    increases blood flow -- increases o2 and nutrients to the area -- venous congestion is decreased. reduces viscosity of blood and increased capillary permeability improved the delivery of leukococytes, and nutrients and removal of wastes and prolongs clotting time -- heat reduces muscle tension -- promotes relaxation and helps to relieve muscle spasms and joint stiffness -- relieve pain
  66. systemic effects of heat
    increased cardiac imput, sweating, muscle pain, dysmenorrhea, chronic pain
  67. effects of applying cold
    constricts peripheral blood vessels -- reduces blood flow to tiss and decreasing the local release of pain-producing substances -- reduces the formation of edema and inflammation, -- decreased metabolic needs and cap w decreased cap permeability w increased coagulation of blood at site -- facilatiate control of bleeding and reduce edema formation
  68. rebound phenomenon
    heat produces max vasofialtion in 20 to 30 mins, if heat cont after that time - tiss congestion and vasoconstriction occors
  69. with cold rebound
    max vasoconstriction ovvurs when the skin reaches 14 degress c (60f) the vasodilation occurs
  70. nsh process determining heat/cold
    • pt phys and mental status:
    • 1 health hx and phys exam
    • 2 hx of cv or peripheral vascular dis, sensory impair, confusion, decreased consciousness
    • 3 level of consciousness or orientation
  71. never apply heat/cold to
    open wound, hemorrhage, infl edema, inflamed area, tumor, testes, adb of preg, metallic implants
  72. cold should not be used for
    open wounds or pts w impaired peripheral circualtion or allergy to cold
  73. assessment of bd area includes
    sensation, color/apperance, circualtion (pulses, blanching, temp, color)
  74. tiss w decreased or absent pulses
    pale or cyanotic, feels cold has decreased circultion -- increases risk for inj form heat or cold
  75. check heating/cooling elements for
    leaks, distribution and constancy of temp
  76. undesired responces to heat
    redness, blistering, pain, hypotenstion and changes in consciousness,
  77. undesired responses to cold
    pallor, cyanosis, numbness, pain
  78. rx for heat application should include
    body area to be treated, frequency and legth of time for application
  79. irrigation
    instillation of fluid into a cavity or opening
  80. purpose of irrigation
    • clean/restore patency
    • instill meds
  81. sterile technique
    • bladder
    • kidney
    • pelvis
    • eye
    • open wounds
  82. clean tech
    • throat
    • ear
    • vag
    • bowel
    • stomach
  83. pt has surgry in any area tech used is and because
    sterile because of impaired skin integrity
  84. safety
    • gloves, gown
    • use gentle pressure
  85. if pt compains of discomfort
    reduce pressure
  86. medication irrigation
    use correct concentration, meds cause irritation
  87. temp of irragations
    room temp, extremes could cause burns, drop in bd temp, shock
  88. 3 pt teaching
    • procedure and what to expect
    • time for questions
    • therapeutic comminication
  89. obserations of irrigations
    • drainage or exudates
    • amount
    • color
    • consistency
    • odor
  90. documentation irrigation
    • areas of irrigation
    • type/amount solution used
    • time
    • pt response
    • all fluids returned, if fails - record it and amount retainted on intake sheet
  91. 9 general procedures fro irrigations
    • check order for type, amnt, temp, and sol
    • clean or sterile
    • wash hands
    • id and gather equipment
    • id pt
    • explain procedure
    • provide privacy
    • need any padding???
    • put on prot equipment
  92. sanguineseous
    containing blood
  93. serous
    clear pale yellow serum
  94. purulent
    thick yellow or green puss - sign of infection
  95. billious
    bile made by bd help break down fats for digestion -- dark green color and is present after gallbladder surgery
  96. serosanguineous
    both blood and clear drainage -- pink color
  97. seropurulent
    both clear and pus present
  98. purpose of bandages and binders
    protect underlying wound or dressing, provide pressure, support, or immobilization
  99. bandages made of
    muslin or elasticized fabric
  100. check pt how long to ensure comfort of bandage
    30 mins
  101. cms
    circulation, motor, sensation
  102. nsg dressing assessmetn
    • id purpose, review chart
    • id body part
    • effectiveness of previous
  103. planning
    • PLAN
    • WASH HANDS
    • OBTAIN DEVICES
    • PLAN FOR INTERVALS TO CHECK CMS
  104. implementation dressing
    • right pt?
    • explain purpose
    • provide privacy
    • clean gloves, remove soilded
    • assess wound
    • use tech apply new
    • examine for neatness
    • essess extremeties for cms
  105. eval of dressing
    • pt comfort
    • effectiveness
    • safety
  106. documentation dress
    • time
    • type bandage
    • area
    • assesment cms
    • length of tiem was off
    • cond of skin
    • re application
  107. roller gauze
    hold dressings in place on limbs, 1/5 in, 1 in, 2 in, 3 in wideths -- not stretch, soft, strong, comfortable -- easily molded sterile and non sterile
  108. kling
    soft, mesh like -- avail in 2, 3, and 4 in widths, extremities, head, and tors0 --part of primary dress or used to hold other dress in place sterile or nonsterile -- keep in functional position
  109. elastic bandage
    ace wrap -- provide constant pressure over area or support inj joint -- lower extremity facilitate venous return -- extremity elastic hose, elastic sleeve, or sequential compression device can be used instead
  110. circular method
    secures dress or covers confined area
  111. spiral and reverse spiral
    provide comfort to a wider area , begen distally and wind proximally
  112. figure 8
    used over joint easy flexion
  113. recurrent fold
    bandage distal portions of extrem or stump, best pressure
  114. binder generally used on trunk to
    hold dress in place or support tissues
  115. binders can be placed
    chest, abd, or pelvic area
  116. abd binders made from
    firm elastic fabirc w velcro fasteners across front
  117. stretch net binders used for
    hold dress in place,l not support -- washed easy, air circulation, stretch to shape
  118. t binders
    hold perineal dressing or pack in place, single female, double male, elastic, muslin, or disposable
  119. wet to dry dress
    debride wound surface -- moist gauze absorbs drainage, dry adheres to surface, surface debris removed w dressing
  120. wet to dry comfort
    uncomfortable, moistening negates purpose
  121. sterilization
    kills all pathogens and spores
  122. disinfections
    kills pathogens but not spores
  123. things that cannot be steri
    iv pumps or electircal equip
  124. autoclaving
    steam pressure w heat ranging from 250-s70 degrees, sterilize
  125. boiling
    10 mins kills non-spore forming organisms but not spores
  126. ionizing radiation
    kills pathogens of sutures, some plastics, and biological mat
  127. chemical disinfection
    kill path on equipment and supplies that cannot be heated, cidex - sterilize rubber-based catherters for urological
  128. gaseous disinfection
    kills pathogens on supplies and equip that are heat sensitive or must remain dry
  129. penrose drain
    soft latex rubber tubing material, one end is placed in bottom of wound and other opens to outside of bd trhu small surgical stab wound, sterile safety pin attachied to penrose drain to prevent sliding down into wound
  130. closed wound suction
    placed during surgery, drainage tube w mult openings, attachec to vaccuum unit, hemovac, jp drain, used after breast, hep or perineal surg
  131. 4x4, 2x2, 3x3
    folded gauze pads
  132. fluffs
    absorb drainage, pack wounds
  133. abds
    combinations -
  134. telfa
    nonadherent, synthetic material attached to one side,
  135. moisture vapor permeable mvp transparent film
    thin sheet plastic, called by brand names, one side ahdesive, allows gases to move thru, provide moist surface encouraging epitherlialization of wound surface, small wounds and iv sites
  136. hydrocolloid drainage
    duoderm, soft wafer, epithethelilization and healing, impermeable, used over stage 2 one week
  137. polyurethane foam
    used around tubes or drains to hold them awy from skin and prevent abrasion
  138. mont straps
    tie across large/bulky dress, avoids skin irritation caused by repeated tape removal, eyelets, twill tape to secrue,
  139. drainage bags
    disposable, allows measurement, control odor,

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