mgccc nursing

Card Set Information

Author:
Anonymous
ID:
45917
Filename:
mgccc nursing
Updated:
2010-10-29 10:54:30
Tags:
Fain\'s lecture on skin integrity wound care day
Folders:

Description:
day 2 of skin integrity and wound care
Show Answers:

Home > Flashcards > Print Preview

The flashcards below were created by user Anonymous on FreezingBlue Flashcards. What would you like to do?


  1. contaminants
    the introduction of pathogens or infectious material into or on normally clean surfaces
  2. infection
    microbes invade body tissue
  3. Managing Infection
    • -protect from fecal & urinary contamination
    • -cleanse and debride
    • -trial of topical antibiotic
    • -diagnose soft tissue infection and osteomyelitis
    • -systemic antibiotics for systemic infection
    • -urgent medical attention for sepsis
  4. standing orders
    will see alot of standing orders in long term facilities (ex:nursing home) not so much in acute care
  5. sepsis
    systemic inflammatory response to infection
  6. symptoms of sepsis
    • fever
    • tachycardia
    • 50% of pts diagnosed w/ sepsis die.
  7. Wound cleansing
    • -cleanse wounds initially and at each dressing change
    • -saline irrigation is a safe and appropriate method for cleansing most ulcers
    • (hydrogen peroxide can be used, but not not in most instances)
  8. Factors that affect wound healing
    • -meds
    • -radiation
    • -anti-inflammatory drugs
    • -chemotherapeutic agents (cytocid medications)
    • -immunosupressive agents
    • -smoking
    • -social circumstances
    • -mobility
  9. Intrinsic/stystemic factors
    • -health status
    • -age factors
    • -circulation & oxygen
    • -nutritional status
    • -wound condition
    • -meds and health status
  10. Psychological effects of wounds
    • -pain
    • -anxiety
    • -changes in body temp
  11. nutritional assessments
    • -dietary intake
    • -height and weight
    • -weight change
    • -lab values
    • -hydration status
  12. essential nutrients
    • -carbs
    • -fats
    • -proteins
    • -vitamins (a, c, e, zink)
    • -fluids
  13. normal phases of wound healing
    • hemostasis (immediate)
    • inflammation (4-6 days)
    • proliferation (few weeks)
    • remodeling (years)
  14. -assessment
    • -does this pt have the ability to heal?
    • -consider overall goals of care
    • -etiology of wound
    • -factors that contribute to impaired healing
  15. FACT
    Most wounds heal in a moist environment
  16. wound healing
    • -all layers of tissue below the epidermis are moist
    • -without a moist surface, wound healing will take longer
    • -providing a moist environment will heal most wounds 3 times faster
  17. types of topical wound dressings
    • -hydrocolloid wafer dressings
    • -dydrogel dressings
    • -alginate dressings
    • -transparent adhesive dressings
    • -foam dressings
    • -absorption dressings
    • -gauze dressings
    • -composite dressings
    • -bilogic dressings
    • -other (negative pressure)
  18. Advantages of Hydrocolloid dressings
    (ex: duoderm & tegasorb)
    • -to protect skin at risk from friction or shear
    • -to maintain a moist wound environment
    • -to facilitate autolytic debridement
  19. Precautions of Hydrocolloid dressing
    • -do not recommend for infected wound
    • -maceration of periwound skin not possible
    • -not appropriate for heavy exudating wound
  20. Hydogel dressings
    (ex: vigilon, aquasorb)
    • description:
    • -non adhesive
    • -maintain moist healing environment
    • -avalible in 3 sizes
    • -requires secondary cover such as gauze or thin film dressing
  21. hydrogel advantages
    • -rehydrates dry wounds
    • -provides moist wound healing
    • -reduces pain associated with the wound
    • -ideal for loose packing
  22. hydrogel indications
    • -to facilitate debridement
    • -to maintain moist wound healing
    • -to fill in "dead space" or pack wound
    • -as a primary dressing on a partial thickness wound
  23. Hydrogel utilization
    • -change every 24-72 hours
    • -cleanse or irrigate wound prior to dressing application
    • -observe periwound skin for signs of maceration
    • -requires use of secondary dressing
  24. Alginate dressings
    (ex: sorban & algiderm)
    • description:-
    • -non-adhearent highly absorbent dressing
    • -drssing forms a soft, gelatinous mass when they come in contat with wound fluid
    • -derived from seaweed (good for use on infected wounds)
  25. alginate dressings
    • -will decrease the frequency of dressing changes decreasing trauma and manipulation of wound
    • -will lower costs of wound care
    • -ideal for loose packing in deep wounds
  26. wound assessment
    • -must be accurate and done at regular intervals
    • -includes evaluation of wound and surrounding skin
    • -used to drive treatment decisions
    • -provides baseline data to evaluate repair process
  27. Documentation
    • -location
    • -stage
    • -size (LxWxD in cm)
    • -sinus tract
    • -undermining
    • -exudate
    • -necrotic tissue
    • -granulation tissue
    • -signs/symptoms of infection
    • -periwound skin
  28. Document Size
    Length x width x depth
  29. Documenting size
    -partial thickness wounds will not have any depth to measure, so they will be measured as L x W only
  30. Undermining
    • when wound is actually larger than the opening
    • (you always want to measure the portion that is undermining)
  31. Sinus tract
    like a cave-narrow and goes downward into the wound-these need to be packed
  32. Remember.....
    • -educate! (nutrition, hydration, etc.)
    • -prevent! (turn pt every 2 hrs)
    • -there will always be a need for more than 1 type of dressing.
    • -continually reassess the wound (need to know improvement status, etc.)
  33. Assessing Wound
    • -if its dry, moisten it
    • -if its moist, absorb it
    • -if its deep, fill it
    • -if its shallow, cover it

What would you like to do?

Home > Flashcards > Print Preview