Care of Wounds

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Care of Wounds
2014-12-13 12:25:37

Nursing 110, Module IV, Unit B
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  1. What is a wound?
    A break in the normal integrity of skin & tissues

    Ranges from paper cut on finger to third-degree burns all over body
  2. Wound Healing is the the body responding to ____________
  3. What is the difference between an open & closed wounds.

    Give examples of each
    • Open Wounds
    • A portal of entry for microorganisms to enter
    • Can be accidental injury or surgical
    • Surgical incisions, paper cuts, burns

    • Closed Wounds
    • No portal of entry
    • There is evidence of trauma
    • Not on purpose (surgical)
    • Hematoma, sprains, bruises
  4. A wound caused by superficial damage to skin no deeper than epidermis is called an _______           

    It is less severe than a ______  

    Mild ones are known as grazes or scrapes (no scarring, bleeding)           

    Traumatic ones remove all layers of the skin are called ________


  5. Laceration
    Wound that is produced by the tearing of soft body tissue

    Often irregular and jagged & contaminated with bacteria and debris from whatever object caused the cut
  6. A Contusion is another term for a ______
  7. Differentiate healing by primary, secondary, and tertiary intention

    Give examples of each
    • Primary
    • Intentional wounds with minimal tissue loss Usually surgical wounds

    • Secondary
    • Large, open wounds requiring tissue replacement
    • Often contaminated
    • Edges not well approximated

    • Examples
    • Burns
    • Severe trauma wounds
    • Surgical wounds that become infected

    • Tertiary
    • Wound is left open for days
    • To allow edema or infection to resolve
    • Drain before closing

    • Examples
    • Severe animal bites
  8. Fluid that accumulates in a wound
    Contains serum, cell debris, bacteria, & white blood cells
    Accumulation causes swelling & pain
  9. Name the four phases of wound healing
    • Hemostasis
    • Inflammatory Stage
    • Proliferation Phase
    • Maturation Phase
  10. Scar
    Avascular collagen tissueDoes not sweat, grow hair, or tanStrong but less elastic that uninjured tissue
  11. Collagen-rich tissue which forms at the site of an injury
    Granulation Tissue
  12. What is 1st stage of wound healing

    • Occurs immediately after injury
    • Blood vessels constrict & clotting begins
  13. What is 2nd stage of wound healing
    Inflammatory Stage

    • Lasts 4-6 days following hemostasis     
    • Acute inflammation’s

    Leukocytes arrive to ingest bacteria & cellular debris

    Macrophages release growth factors for epithelial cells & new blood vessels

    May have generalized body response (mild fever, elevated leukocytes, malaise)
  14. The four components of inflammation are
    pain, heat, redness, & swelling
  15. What is 3rd stage of wound healing
    • Proliferation Phase
    • or Fibroblastic Regenerative Phase
    • or Connective Tissue Phase

    • Lasts several weeks
    • Fibroblasts secrete collagen
  16. What is the 4th stage of wound healing?
    • Maturation Phase
    • or the Remodeling Phase

    • Begins at 3 weeks after injury
    • Can continue for months or years

    • Collagen that was haphazardly deposited in sound remodels
    • Healed wound becomes stronger, more like surrounding tissue
  17. Desiccation means
  18. Maceration means
  19. What are some local factors that affect wound healing?

    List and explain why
    • Pressure
    • Interrupts the blood supply to region

    • Trauma, Edema
    • Adding more damage to wound

    • Desiccation or Maceration
    • Causes cellular death

    • Build-up of necrosis tissue
    • Prevents oxygen from getting to cells

    • Infection
    • Immune system now has to fight infection, overburden
    • Foreign substances in Wound
    • Wounds need to be free of foreign debris to heal
    • Bone debris, glass particles, dirt, dead skin
    • Sutures are considered foreign bodies
  20. What are some systemic factors that affect wound healing?

    List and explain why
    • Circulation
    • Circulating blood carries leukocytes, platelets, & antibodies to the wound

    Circulating blood carries debris & wastes of healing away from wound

    • Oxygenation
    • Chronic respiratory disorders, smokers

    • Health Condition
    • Especially those affecting circulation or oxygenation

    • Weight
    • Large amounts of subcutaneous tissue is not very vascular
    • Obesity impedes healing

    • Nutrition
    • Age
    • Medications & Procedures
  21. What medical procedures & medications would
    delay wound healing?
    Corticosteroids & post-op radiation increase risk of infection & delay healing

    Chemotherapy (causes neutropenia)

    Immune Suppressants (Humira)  

    Prolonged antibody therapy (from super infection treatment)
  22. What are the nutritional needs for wound healing?
    Protein, Carbs

    • Vitamin B (enzyme activities)
    • Vitamin A & C (collagen)
    • Vitamin K (prothrombin production)

    Zinc, Copper, Iron, Magnesium
  23. What is a wound infection?
    What are the symptoms?
    A wound infection is when bacteria invading wound

    Symptoms appear within 2-7 days after (injury, surgery, etc.)

    • Purulent drainage & increased drainage
    • Pain, redness, swelling around wound
    • Increased body temperature
    • Increased WBC count

    Patient is often already home at this point
  24. bone infection is called

  25. Pathogenic organisms present in blood or tissues
  26. Dressing should be checked
    Frequently first 48 hours after injury or surgery (or both)

    No less than 8 hours after
  27. List some causes of Hemorrhage
    Slipped suture

    Dislodged clot at wounds site


    Erosion of blood vessel by foreign body (i.e. a drain)
  28. Dehiscence & Evisceration
    • Dehiscence
    • Partial or total separation of wound layers
    • Resulting from stress on wound not yet healed
    • If occurs, manage as open wound

    • Evisceration
    • Wound completely separates with protrusion of viscera thru incision area
    • Most serious complication of dehiscence
    • Is a emergency requiring surgical repair
  29. What to do if evisceration occurs
    • Place patient in low Fowler’s position
    • Cover exposed abdominal contents
    • Do not leave patient alone
    • Notify physician
  30. Fistula
    • Abnormal passage from internal organ to
    • outside of the body

    • Can be created intentionally
    • Arteriovenous fistula for dialysis

    Often results from infection

    • Develops into abscess (collection of infected fluid not
    • drained)

    • Fluid puts pressure on surrounding tissues
    • Creates unnatural passage
  31. Name some symptoms of hemorrhage
    • Low BP
    • Rapid respiration
  32. Tetracycline cannot be used on _____

    kids younger than 8

    • Impedes bone growth
    • Stains teeth that are growing in
  33. Azithromycin, Clarithromycin, Clindamycin, Erythromycin, Vancomycin

    Are examples of _________ spectrum antibiotics


    They are gram positive / negative specific
  34. How are antibiotics given


    • Orally
    • Give on empty stomach or 1-2 hours after meals

    • IM
    • Administer deeply into large muscle & rotate sites
  35. New or secondary infections that occur during antibiotic therapy are called ________

    Name some examples
    Super Infections

    • Yeast infection / thrush
    • Vaginitis
    • Black furry tongue
    • Stomatitis
  36. Abdominal Binder
    • Garment applied in the OR immediately
    • after abdominal surgery

    Provides Compression, pressure and support to incision site

    • Helps to improve blood circulation and
    • oxygen levels at the operative site

    Increases healing and reduces swelling

    • Slowly gives strength to the weaker
    • abdominal muscles

    • Patient is able to get out of bed sooner
    • and walk around more easily

    Used after hysterectomy, caesarian incision
  37. Serous Drainage

    Looks ________

    Is composed of_______
    Clear & Watery

    Clear serous portion of the blood & serous membranes
  38. Sanguineous Drainage

    Looks _______

    Is composed of ________
    • Looks like blood
    • Bright red drainage indicates fresh bleeding
    • Darker drainage indicates older bleeding

    of large numbers of red blood cells
  39. Seros-Sanguineous Drainage

    Looks _______

    Is composed of ________
    Light pink to blood tinged

    Mixture of serum & red blood cells
  40. Purulent Drainage

    Looks _______
    Smells like _______
    Is composed of ________
    • Various colors depending on causative
    • organism (dark yellow, green)
    • Looks like pus (thick)

    Musty, foul odor

    • white blood cells
    • liquefied dead tissue debris
    • Dead & live bacteria
  41. Abscess
    A collection of pus in any part of the body           

    Causes swelling and inflammation around it
  42. A protective covering placed over a wound
    (Wound) Dressing
  43. A (wound) dressing does what?
    • Provide physical, psychological, & aesthetic
    • comfort
    • Prevent, eliminate, or control infection
    • Absorb drainage
    • Maintain a moist wound environment
    • Protect the wound from further injury
    • Protect the skin surrounding the wound
    • Remove necrotic tissue (if appropriate)
  44. What does applying heat to skin do?
    • Increases vasodilation
    • Which increases bloodflow
    • Which increases oxygen to area           

    Reduces muscle tension, stiffness, muscle spasms
  45. Heat application is used in what situations?
    • Infection
    • Surgical wounds
    • Inflamed tissue
    • Chronic pain
    • Arthritis
    • Joint muscle pain
  46. Prolonged Heat Exposure (applied to skin) causes what?

    How to prevent these symptoms?
    • Sweating
    • Increases cardiac output
    • Hypotension

    Heat should be on / off every 20minutes
  47. What does applying cold to skin do?
    Constrictions peripheral vascular vessels which increases coagulation

    Reduces muscle spasms

    Reduces pain producing substances (histamines, serotonin)

    Reduces edema & inflammation
  48. Prolonged cold exposure (applied to skin) causes what?

    How to prevent these symptoms?
    • Increases BP
    • Causes shivering, goose bumps
    • Skin should be no lower than 15° Celcius

    Should be applied on / off every 20 minutes