Term
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Definition
- Protection
- Temperature REgulation
- Psychosocial
- Sensation
- Vitamin D production
- Immunological
- Absorption
- Elimination |
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Term
| Factors affecting skin integrity |
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Definition
Developmental Considerations
- younger than 1 thin skin
- older skin integrity
STate of health -
- thin and obese subject to skin
- Fluid loss through fever, vomit or diarrhea reduces the fluid volume of the body
- Excessiver perspiration
- Jaundice
- Disease of the skin
- Diabetes slow healing
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Term
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Definition
- Incision
- Contusion
- Abrasion
- Laceration
- Puncture
- Avulsion - tearing a structure from normal anatomic position possible damage to blood vesels
- Microbial - secretion of exotoxins or endotoxins
- Chemical
- Thermal
- Irridation
- Pressure Ulcer
- Venous Ulcer - injury to poor venous return from underlying conditions such as incompetent valve and obstruction
- ARterial ulcer - injury and underlying ischemia resulting from underlying conditions
- Diabetic Ilcers - |
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Term
| Classifications of Wounds |
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Definition
Intentional and Unintetional
Open and Closed
Acute and Chronic |
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Term
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Definition
Hemostasis - clotting platelets, exudate - liquid cut
Inflammatory Phase - lukocytes and macrophages
Proliferation Phase - connective tissue phase
Maturation phase - collagen remodeling - scar |
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Term
| Factors affecting wound healing |
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Definition
dessiccation - (dehydration)
maceration (overhydration)
necrosis (death of a tissue)
Local factors
Pressure, dessication, maceration, trauma, edema, infection, necrosis
Systemic factors - age, circulation and oxygen, nutritional status, wound condition, meds and health statuse, immunosuppresion
Other complications
Infection
Hemorrhage
Dehiscence - total separation of wound layers
Evisceration - complete separation
Fistula - abnormal passage from an internal organ to the outside of the body, or from one organ to another - often a result of infectionl |
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Term
| Factors in Pressure Ulcers |
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Definition
External pressure
Friction and Shear |
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Term
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Definition
Immobility
Nutrition and Hydration
Moisture
Incontinence
Skin Hygiene
Diabetes Mellitus
Diminished Pain Awareness
Fracture
History of Corticosteroid itherapy
Immunosuppression
Multisystem TRauma
Poor circulation
PRevious Pressure Ilcer
Significant OBseity or Thinees |
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Term
| STages of Pressure UIcers |
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Definition
Stage 1 - Red skin over bony prominence
Stage 2 - Partial thickness loss of dermis, pink wound without slough shiny or shallow. Present as intact or open blister
Stage 3 - Full thickness tissue loss or directly palpable. Slough may be present but doesn't obscure may involve tunneling.
stage 4 - tissue loss with exposed bone tendon or muscle is visible. Exchar or slough may be present may have tunneling
Unstagageabe- bottom of lucer covered by slough and eschar in wound bed. |
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Term
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Definition
Sensory Perceptoin - completely limited, very limited, slightly limited
Moisture - const moist, very moist, occ moist, rarely moist
Activity - bedfast, chairfast, walks occ, walks freq
Mobility - commpletely immobile, very limited, slightly limitied, no limitation
nutrition - very poor, probalby inadequate, adequate, excellent
friction and sheer - problem, pot prob, no apparent prob |
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Term
| Nutritional risk for ulcer |
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Definition
Albumin <3.2 (normal 3.5 - 5
Prealbumin - <19 normal is 16-40
body weight > 15%
total lymp count <1800 norm is 1000 - 40000
hemo A1C> 8% normal <6%
glucose > 120 mg norm 70-120 |
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Term
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Definition
Red = protect
Yellow = cleanse
Black = Debride |
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Term
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Definition
Serous drainage - composed of primarily of clear serous portion of the blood from serous membrane- clear and watery
Sanguineous drainage - llarge number of red blood cells - bright red is fresh bleeding where as dark is older blood
Serosanguineous drainage - mix of the first two pink to blood
Purulent drainage - white blood cell, liquified tissue debris and dead and alive bacteria. musty color |
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Term
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Definition
Penrose -provides sinus tract - after incision and drainage of abscess in abd surgery
T Tube - for bile drainage - after gallbladder surgery
Jackson Pratt - decrease dead space by collecting drainage - after breast removal ab surgery
Hemovac - decrease deead space by collecting drainage - after abdominal ortho surgery
Gauze - allow healing from base of wound - infected wounds after removal of hemorrhoids |
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Term
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Definition
Disturbed body Image
Deficient Knowlege related to Wound Care
Acute Pain
Chronic Pain
Impaired Tissue Integrity
REadiness for Enhanced Knowledge
Impaired Skin Integrity
Activity Intolerance
Self Care Deficit
Risk for Impaired Skin Integrity
Risk for Trauma |
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Term
Nursing Wounds
Outcome Identirication and Planning |
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Definition
Maintain skin integrity
Demonstrate self care measures to prevent pressure ulcer development
Demonstrate self care measures to promote wound healing
Demonstrate evidence of wound healing
Demonstrate increase in body weight and muscle size if appropriate
REmian free of infection at the site of the wound or pressure ulcer
Remain free of sings and symptoms of infection
Verbalize the pain managent regime relieves pain to an acceptable level
Be discharged to home within established parameters
Demonstarte appropriate wound care measures before discharge
Verablize understanding of signs and symptoms |
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Term
Nursing Wounds
Interventions |
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Definition
Bedrest Care
Incision Site Care
Woudn Care
Pressure Management
Pressure Ulcer Prevention
Skin Surveliance |
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Term
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Definition
| removal of devitalized tissue |
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Term
| Types of dressings/products |
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Definition
Tramsparent films - allow O2 exchange, self adhesive, waterproof protect against contamination, maintain moist environment, allow visualization of wound,
Hydrocolloid dressing - occlusive or semiocclusive - limiting exchange of oxygen between wound and environment. Minimal to moderate absorption of drainage maintain wound environment, moist environment, provide cushion, protect against contamination, may be left in place for 3 to 7 days
Hyudrogels - maintain a moist wound environment, minimal absorption of drainage, facilitate auolytic debridement, do not adhere to wound reduce pain most require a secondary dressing to secure
Alginates - absorb exudate, maintain a moist wound environment, facilitate autolytic debridement, requires secondary dressing, can be left in place for 1 to 3 days
Foams - maintain moist wound environment, do not adhere to wound, insulatee wound, highly absorbent, can be left in place 7 days
Antimicrobials - refudce infection and prevent infection
Collagens - maintain a moist wound environment, do not adhere to wound, not compatible with topical agents, non adherent,
Composites - combine two omre more physically distinct products in a single dressing. Allow exchagne of oxygen between wound and environment may facilitate autolytic debridement provide physical bacterial barrier and absorptive layer. semiadherenet |
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Term
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Definition
heat and cold are applied to a specific part or all of patients body for local or systemic change
heat - dilates vessels, increases tissue metabollism, reduces blood viscosisty and increases capillary permeability, reduces muscle tension, and reileves pain.
cold - constricts bvessels, reduces muscle spasms, promotes comfort, decreases formatoin of edema, and ddecreases local release of pain producing subsmtances. controls bleeding.
heat 20 - 30 mins only as after that time vasoconstirction occurs.
cold 15C or 60F vasodilation begins. |
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Term
Nursing Dx
Hot cold Therapy |
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Definition
Ineffective thermoregulation
ineffective tissue perfusion
actue pain
chronic pain
risk for injury
risk for trauma |
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Term
Nursing
Outcome
Hot Cold Therapy |
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Definition
Verbalize increased comfort
Demonstrate evidence of wound healing decreased muscle spasm decreased edema increased comfort
Verbalize and demonstrate safe hot or cold application |
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Term
Nursing
Intervention
Hot cold therapy |
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Definition
Heat
Dry Heat - Hot water Bags, Electric HEaing Pad, Aquathermia PAd, Hot Packs,
Moist Heat - warm compress, sitz bath, warm soak
Cold
Dry Cold - ice bag, Cold Pack
Moist Cold - cold compress |
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Term
Nursing
Evaluation
Hot Cold THerapy |
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Definition
Verablize increased comfort
Verbalize increased ability to sleep and rest
Demonstrate evidence of wound healing
Demonstrate a decrease in symptom of muscle spasm inflammation and dedema |
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