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Tissue Healing
wound type and care
78
Nursing
Undergraduate 1
09/23/2011

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Cards

Term
Abrasion
Definition
a wound consisting of superficial damage to the skin
Term
Aminoglycosides:
Definition
Potent bactericidal antibiotics however reserved for life threatening or overwhelming infections, Inhibit protein synthesis of bacteria, Potential for ototoxicity and nephrotoxicity (dosage based on body weight & renal function monitored), 1940’s
Prototype Amikacin (Amikin)
Term
Assessment of Inflammation:
Definition
Look for Color, Redness

Listen for Client’s perception pain & discomfort

Feel for Warmth
Term
Assessment of Inflammation:
Definition
Look for Color, Redness

Listen for Client’s perception pain & discomfort

Feel for Warmth
Term
Avulsion
Definition
in general refers to a tearing away.
Term
Bacteremia
Definition
Bac in blood
Term
Bacteriostatic
Definition
stops Bac reproduction
Term
Cellulitis
Definition
common skin infection caused by bacteria.
Term
Cephalosporins:
Definition
Inhibition of cell walls and bactericidal, 6-18% cross sensitivity with PCN
History In 1945, after penicillin had been introduced into medicine, an antibiotic-producing species of Cephalosporium was isolated from a sewage outfall in Sardinia. Four years later in Oxford, this organism was found to produce several antibiotics, one of which was penicillin with a new side-chain, penicillin N. Discovered in 1953, refined in 1959, mass production 1960’s.
Term
Debridement
Definition
the medical removal of a patient's dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue.
Term
Dehiscence
Definition
busting stitches
Term
Describe the stages of the localized inflammatory process
Definition
Stage I Vascular and cellular response stage Initial vasoconstriction then dilation with Histamine release
example trauma of dreaded PAPER CUT initially no bleeding then watch out

Stage II Exudate Inflammatory exudate (dead cells and clotting factors to produce barrier, cleared by Lymphatic system (sewer treatment system of circulation)

Stage III Reparative stage Regeneration or fibrous scar tissue forms
Term
Ecchymosis
Definition
the medical term for a subcutaneous purpura larger than 1 centimeter or a hematoma, commonly called a bruise. It can be located in the skin or in a mucous membrane.
Term
Erythromycin
Definition
A macrolide antibiotic that is bacteriostatic by inhibiting protein synthesis, but can be bactericidal in higher concentrations,
GI absorption compromised with food, concern with Liver function
Prototype Erythromycin
The other three are Azithromycin (Zithromax) Clarithromycin (Biaxin), troleandomycin (Tao)
Term
Erythromycin History:
Definition
Abelardo Aguilar , a Filipino scientist, sent some soil samples to his employer Eli Lilly in 1949. Eli Lilly’s research team, led by J. M. McGuire, managed to isolate Erythromycin from the metabolic products of a strain of Streptomyces erythreus (designation changed to "Saccharopolyspora erythraea") found in the samples.
Term
Eschar
Definition
scab
Term
Evisceration
Definition
disembowelment
Term
Explain major principles used in the application of bandages and binders.
Definition
Term
Factors in the development/treatment of decubitus ulcers
Definition
Pathophysiology
Stages of development
Risk factors
High risk areas bony prominences
Term
Frequency of Assessment for DU; CRITICAL CARE
Definition
24-48 HOURS
Term
Frequency of Assessment for DU; Home Care
Definition
every RN visit
Term
Frequency of Assessment for DU;ACUTE CARE
Definition
every 48 hours
Term
Frequency of Assessment for DU;ECF
Definition
every 48 hours during the first week, weekly for the first month and then monthly or quarterly unless status changes,
Term
Grading of decubitus ulcer
Definition
1. damage to epidermis & dermis
2.epidermis & dermis destroyed
3.damage to subcutaneous layer
4.damage to bone
Term
Granulation of tissue
Definition
the perfused, fibrous connective tissue that replaces a fibrin clot in healing wounds. Granulation tissue typically grows from the base of a wound and is able to fill wounds of almost any size it heals.
Term
Hematoma
Definition
a localized collection of blood outside the blood vessels,[1] usually in liquid form within the tissue.
Term
Hemostasis
Definition
a process which causes bleeding to stop, meaning to keep blood within a damaged blood vessel (the opposite of hemostasis is hemorrhage).
Term
Incision
Definition
cut by sharp object, scalpel
Term
Initial Emergency Treatment for wounds
Definition
Direct pressure
Elevation
Pressure points
Tourniquet
Stabilize extremities
Stabilize impaled object
Term
Irrigations
Definition
gentle removal of debris
Term
Issues for the tetracycline antibiotics group:
Definition
Can stain developing teeth
Inactivated by Ca2+ ion, not advised to be taken with milk or yogurt
Inactivated by aluminium, iron and zinc, not to be taken at the same time as indigestion remedies
Inactivated by common antacids and over the counter heart burn medicines.
Skin photosensitivity, not advised to be exposed to the Sun or intense light
Drug-induced lupus, and hepatitis
Tinnitus
Term
Keloid
Definition
is a type of scar, which depending on its maturity, is composed mainly of either type III (early) or type I (late) collagen. It is a result of an overgrowth of granulation tissue (collagen type 3) at the site of a healed skin injury which is then slowly replaced by collagen type 1.
Term
Laceration
Definition
irregular tear-like wounds caused by some blunt trauma.
Term
Manual cleaning
Definition
Clean from clean to dirty, slightly more vigorous
Term
Measures to promote wound healing
Definition
Cleaning the wound Preoperative skin preparation & Irrigations
Term
Nursing Interventions Pharmacology/Allergies
Definition
Systemic reaction potentially anaphylaxis
Term
Nursing Interventions Pharmacology/RESISTANCE:
Definition
microorganism able to resist the effects of a specific antibiotic
Term
Nursing Interventions Pharmacology/Sensitivity
Definition
localized response such as diarrhea
Term
Nursing Interventions Pharmacology/Tolerance
Definition
Receptor site tolerance the clinical effect is reduced As the duration of exposure continues
Metabolic (pharmacologic) tolerance prolonged exposure to the drug changes the body’s metabolic response to the drug, increasing the drug clearance, Example with barbiturates unable to maintain blood concentration over time
Term
Nursing Interventions/Measures to promote wound healing/Initial Emergency Treatment for wounds
Definition
Controlling bleeding after A, B, C’s,
Direct pressure to limb, elevation, pressure points, tourniquet(bleeding), stabilize impaled object
Term
Nursing Issues which relate to tissue healing.
Definition
Risk for infection,
Risk for infection transmission,
Risk for altered peripheral tissue perfusion,
Impaired skin integrity, Knowledge deficit
Term
Nursing Management of Antibiotic Therapy/
Subjective Assessment
Definition
Fatigue, Anorexia, General Health
Term
Nursing Management of Antibiotic Therapy/Analysis, Issues
Definition
Evaluation of presentation
Term
Nursing Management of Antibiotic Therapy/Evaluation
Definition
Evaluation of collaborative plan, Complications Allergic Reaction, Super-infection
Term
Nursing Management of Antibiotic Therapy/Intervention;Nursing
Definition
Consistent safe administration of meds, evaluation and collection of drainage specimens, evaluation and collection of drainage specimens.
Term
Nursing Management of Antibiotic Therapy/Objective Assessment
Definition
Labs C&S (PRIOR TO STARTING ANTIBIODICS), CBC (WBCs), Provider’s assessment & Plan Presentation of Infection – chills, temperature over time, Weight changes, drainage characteristics
Term
Nursing Management of Antibiotic Therapy/Plan
Definition
Collaborative plan for treatment
Education; Client & Significant others aware of plan, i.e. duration of medication, expected improvement
Term
Open/closed wound
Definition
A wound is a break in the continuity of a tissue of the body, either internal or external. Wounds are classified as open or closed. An open wound is a break in the skin or in a mucous membrane. A closed wound involves underlying tissues without a break in the skin or a mucous membrane.
Term
Osteomyelitis
Definition
an infection of the bone or bone marrow.[
Term
Penicillins, (PCN)
Definition
Inhibition of cell wall synthesis, Prototype Amoxicillin,
Common sensitivity,
History 1896, 1928, 1940’s post WWII,
Term
Phases of Healing Process
Definition
Inflammatory first 3-4 days increased circulation and nutrients to site

Proliferative 3-4 to 21days raised healing

Maturation 21 days to 1-2 years scar becomes thinner & whiter
Term
Pressure points
Definition
press to stop bleeding, pulse points
Term
Primary intention
Definition
When wound edges are brought together so that they are adjacent to each other (re-approximated)
Minimizes scarring
Most surgical wounds heal by primary intention healing
Wound closure is performed with sutures (stitches), staples, or adhesive tape
Examples: well-repaired lacerations, well reduced bone fractures, healing after flap surgery
Term
Purpura (from Latin: purpura, meaning "purple")
Definition
is the appearance of red or purple discolorations on the skin that do not blanch on applying pressure.
Term
Purulent
Definition
pus
Term
Quinolones, (or fluoroquinolones)
Definition
broad spectrum synthetic bactericidal
(gram negative & gram positive) The Bayer Company produces Ciprofloxacin (Cipro®). Its discovery stemmed from researchers in the 1960s looking for an alternative treatment to malaria. 
Prototype Ciprofloxacin (Cipro)
Term
S O A P I E
Definition
Subjective
Objective
Analyze
Intervention
Evaluation
Term
Sanguineous
Definition
containing blood
Term
Scale for Assessment of Risk for Developing Pressure Sores
Definition
Braden Scale
Term
Secondary Intention
Definition
healing with granulation tissue
Surgeon may pack the wound with a gauze or use a drainage system
Granulation results in a broader scar
Healing process can be slow due to presence of drainage from infection
Wound care must be performed daily to encourage wound debris removal to allow for granulation tissue formation
Examples: gingivectomy, gingivoplasty, tooth extraction sockets, poorly reduced fractures.
Term
Serosanguineous
Definition
containing serum and blood
Term
Specific data which should be obtained when assessing any wound
Definition
Appearance, Drainage, pain, Signs of Infection, & Collecting culture from wound
Term
Specific data which should be obtained when assessing any wound/Analysis
Definition
Healing
Progressing
Deteriorating Infection Local
Systemic
Term
Specific data which should be obtained when assessing any wound/Evaluation
Definition
Based on earlier findings
Term
Specific data which should be obtained when assessing any wound/Implementation
Definition
Based on earlier findings
Term
Specific data which should be obtained when assessing any wound/Objective
Definition
Assessment of location,
Potential cause
Size
Shape
Tunneling
Undermining
Color
Exudate Color
Consistency
Amount
Oder
Surrounding skin
Margins/boarders
Temperature
Term
Specific data which should be obtained when assessing any wound/Plan
Definition
Implementation Obtain Culture & Sensitivity
Evaluate Medications
Education
Term
Specific data which should be obtained when assessing any wound/Subjective:
Definition
Assessment of pain and discomfort
Term
Stages of the Inflammatory Process/ 1
Definition
Vascular and cellular response stage
Initial vasoconstriction then dilation with Histamine release
example trauma of dreaded PAPER CUT initially no bleeding then watch out
Term
Stages of the Inflammatory Process/ 2
Definition
Exudate; Inflammatory exudate (dead cells and clotting factors to produce barrier, cleared by Lymphatic system (sewer treatment system of circulation)
Term
Stages of the Inflammatory Process/3
Definition
Reparative stage Regeneration or fibrous scar tissue forms
Term
State two purposes of cleaning a wound.
Definition
Irrigations & Manual cleaning

Wound drains
Term
Tetracycline:
Definition
the first broad spectrum antibiotic released in the United States. This inhibits the bacteria’s protein synthesis by blocking amino acid transfer and is bacteriostatic for gram negative and gram negative organisms. Oral dose on an empty stomach with full glass of water.
Term
Wound Drainage/ Sanguineous
Definition
Bright Red Blood (Red Merlot)
Term
Wound Drainage/ Sero-sanguineous
Definition
Pink Yellow "Blush Rosa"
Term
Wound Drainage/ Serous
Definition
Yellow Clear "White Chardonnay"
Term
Wound Dressings/3
Definition
Dry

Wet to Dry

VAC (Vacuum Assisted Closure)
Term
Wound drains
Definition
Allow for internal approximation of surgical wound
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