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PNUR 101 - Wound Care Info
Wound Care info from binder
32
Medical
06/01/2009

Additional Medical Flashcards

 


 

Cards

Term
Name the purposes of a dressing
Definition

Absorbs drainage

Applies pressure (pressure promotes homeostasis and eliminates dead space)

Splints or immobilizes the wound

Protects the wound from contamination

Provides comfort

Provides a protective environment

Provides an environment that aids healing

 

Term
Name factors that impair wound healing
Definition

Age

Malnutrition

Obesity

Smoking

Drugs

Diabetes mellitus

Radiation therapy

Wound stress

Term
How does age impair wound healing?
Definition
Circulatory changes with aging as well as a slower response, less elastic scar tissue, and potential decreased immune status all can affect healing.
Term
How does obesity impair wound healing?
Definition
Decreased circulation due to fewer blood vessels in fat. Adequate circulation is needed for healing to occur.
Term
How does smoking impair wound care?
Definition
Decreased the hemoglobin (carries oxygen) in the blood and constricts blood vessels
Term
How do drugs impair wound care?
Definition
For example steroids reduce the inflammatory response: chemotherapy decreases numbers of white blood cells; prolonged use of antibiotics can result in a superinfection due to bacteria developing resistance
Term
How does Diabetes mellitus impair wound care?
Definition
Poor circulation resulting in decrease tissue perfusion.
Term
How does radiation therapy impair wound care?
Definition
fragile, poorly oxygenated tissue
Term
How does wound stress impair wound care?
Definition
vomiting, abdominal distention, sudden unexpected tension on incision
Term
What are the phases of wound healing?
Definition

Hemostasis

Inflammation

Reconstruction

Maturation

Term
What happens during the Hemostasis phase of wound healing?
Definition
Blood platelets adhere to the walls of the injured vessel and a clot begins to form. Fibrin in the clot holds the wound together and bleeding stops
Term
What happens during the Inflammation phase of wound healing?
Definition
Leukocytes begin to engulf debris including bacteria, fungi, viruses, and toxic proteins. If there is no infection present, the leukocytes decrease in number and the inflammation recedes. If infection is present, it may be accompanied by increasing inflammation as well as the presence of pus and fever. In a non-infected wound, the sides of the wound meet and new cells and cappilaries fill the wound and seal it within 24 to 48 hours. 
Term
What happens during the reconstruction phase of wound healing?
Definition
Fibroblasts produce collagen and a scar forms. This stage begins 3 to 4 days after injury and lasts 2 to 3 weeks. During this phase, wound disruption (dehiscence) is most likely to occur if healing is not occuring or if there is unusual stress or tension on the wound.
Term
What happens during the Maturation phase of wound healing?
Definition
Fibroblasts exit the wound and the wound continues to strengthen. This can continue for up to one year. During this phase, keloid formation is possible, expecially in African Americans or dark-skinned people.
Term
What are the classic signs of inflammation?
Definition

Heat

Redness (erythema)

Edema

Pain

Term
What is a Keloid?
Definition
Overgrown scar tissue
Term
Type and size of dressings is dependent on several factors. List those factors.
Definition

Location of the wound

Amount of drainage

Presence of infection

Function of the dressing

Frequency of dressing changes (Montgomery straps are useful for a dressing that needs frequent changes)

Term
Name the types of dressings
Definition

Gauze (absorbs moisture)

Nonadherent gauze (nonstick such as Telfa pads)

Transparent adhesive film (prevents entry of bacteria, but allows entry of oxygen to the wound and allows observation of the wound)

Hydrogel dressings

Hydrocolloid dressings

Alginate dressings

Wound vac

Term
What are the wound dressing application methods?
Definition

Dry sterile dressing

Wet to dry dressing

 

Term
What are the uses and benefits of Dry sterile dressing
Definition

Used to protect a wound that is healing by primary intention and has little or no drainage.

Does not debride

May be used with topical agents

May stick to wound so nurse may need to moisten with sterile normal saline to remove it.

Term
What are the uses and benefits of Wet to dry dressing
Definition

Purpose is to debried the wound (remove the eschar and unhealthy or ncrotic tissue)

Wound is packed with a dressing moistened with solution (usually normal saline or a mild detergent such as Dakins' solution; avoid using hydrogen peroxide or betadine as both of these can be damaging to tissues when used as packing materials)

The dressing is allowed to dry, then removed so tht the dead tissue is removed by the dressing.

Avoid appplying dripping wet dressing and do not allow wet dressing to overlap onto skin.

wet to moist dressing may be used instead of wet to dry in order to decrease trauma to the wound and provide a more gentle debridement without damaging healthy tissue. Wet to dry method should definitely be avoided when granulation tissue is forming.

Term
What are the principles of wound packing?
Definition

Loosely pack the wound with moistend dressing.

Fill all dead spaces in wound. (this may require the use of a cotton-tipped applicator)

Do not let packing material drag to touch the surrounding skin.

Pack the wound until you reach the surface; do not pack higher than the wound.

Term
Describe Transparent dressings (like Tagaderm and Opsite)
Definition

Clear, adherent, non-absorptive dressing permeable to oxygen and water vapor, but not to water.

Provides a moist environment to promote epithelial cell growth.

Used for superficial wounds (stage 1 and 2 wounds that are not infected)

Protects from shearing.

Decreases discomfort.

Conforms to body contours.

Apply wrinkle free, but not stretched over skin.

Lasts up to 7 days; change it when the drainage extends beyond the wound edge.

Term
Describe Hydrogel dressings (like Vigilon and Clearsite)
Definition

Available in sheets and gels.

Contain a high precentage of water.

Some have a cooling effect to help decrease pain.

Use for stage 2 to 4 wounds.

Used in wounds that require moisture to heal (for example, a wound with granulation tissue or a wound with necrotic tissue that needs softening)

Change every one to three days.

Term
Describe Hydrocolloid dressings (like Duoderm)
Definition

Made of gelling agents.

Adhesive wound surface.

Apply by covering the wound at least 1 1/2 inches beyond wound margin.

Use for wounds that are stage 1 to 2 or a shallow stage 3 wound, but not on infected wounds or those with exposed bone or tendon.

The dressing forms a gel as it interacts with the wound surface.

This is an occlusive dressing - prevents the wound from contaminants.

The gel maintains a moist wound environment to promote healing.

Change every 3 to 7 days.

Term
Describe wound vacuum-assisted closure (wound vac)
Definition

Useful in chronic wounds with large amounts of drainage.

Provides negative pressure to the wound and promotes healing.

An open foam sponge is placed in wound and promotes healing.

Tube within the foam is connected to negative pressure (suction)

Excess wound fluid is removed.

Granulation is stimulated.

Bacteria is decreased.

Term
Describe Alginate dressing (like Calcium alginate)
Definition

Created from a seaweed derivative.

Available in sheets or ropes.

Highly absorbent (can absorb 8-10 its weight in drainage)

Provide a moist environment for healing.

Used for wounds with large amounds of drainage. (stage 3 or 4)

Pack the dressing lightly into the wound and apply a secondary dressing over the alginate dressing.

when packing is removed, gelled material may look like pus; don't confuse it with pus.

Change every 3 to 5 days or per manufacturers' recommendation.

Term
Describe Enzymes in relation to wound dressing (like accuzyme and santyl)
Definition

Ointments used to debride necrotic tissue.

May cause burning sensation.

Must remove or cross-hatch dry eschar for enzyme to contact the wound.

Usually apply a thin layer to wound bed and cover with normal saline dressing.

Used in adjunct to mechanical or surgical debridement.

Inactivated by silvadene/heavy metals, hydrogen peroxide, antiseptics, detergents.

Change 1 to 2 times daily.

Term
Describe growth factors for wound dressing. (like Regranulex)
Definition

Ointment that is made from growth factors derived from blood.

Useful with diabetic ulcers and pressure ulcers.

Term
What are the two drainage systems in wound care?
Definition

Open drainage

Closed drainage

Term
Name the open drainge systems for wound care.
Definition

Penrose drain

T-tube (may be used in the common bile duct following gall bladder surgery)

Term
Name the closed drainage systems in wound care.
Definition

Wound vac

Hemovac

Jackson-Pratt