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Surgical Nursing Exam 1
Wound Healing and Management, Pain Management
124
Veterinary Medicine
Undergraduate 4
10/07/2010

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Term
What are the four stages of wound healing?
Definition
Inflammatory, debridement, repair, maturation
Term
2 components of the inflammatory stage
Definition
hemorrhage, inflammation
Term
Importance of hemorrhage
Definition
flushes contaminatnts from wound, clot formation minimizes blood loss, provides minimal tensile strength, scab for protection, fibrin matrix provides the temporary foundation for fibroblasts to build on
Term
Importance of inflammation
Definition
chemotaxis calls neutrophils and monocytes for debridement - increased blood flow and vascular permeability - sets the stage for the rest of the healing process
Term
What is the debridement stage characterized by?
Definition
WBC infiltration - exudation (pus, purulence, suppuration)
Term
purpose of neutrophils
Definition
increase inflammation, which increases chemotaxis - phagocytosis
Term
purpose of monocytes
Definition
produce important growth factors for epithelialization, angiogenesis, and fibroplasia.
Term
2 simultaneous processes of the repair stage
Definition
Fibroplasia (dermis) and Epithelialization (epidermis)
Term
Describe what is happening with fibroplasia of the dermis.
Definition
Fibroplasts infiltrate the area, collagen deposition and remodeling, angiogenesis, granulation tissue, wound contraction
Term
Describe what is happening with epithelialization.
Definition
Mitosis of the basal cell layer = proliferation of the epithelium, collagenase, pruritus
Term
After how many days of wound healing does the peak repair take place?
Definition
5-21
Term
When would epitheliaztion be delayed?
Definition
open wounds
Term
After how many days does the maturation stage occur?
Definition
60-360 days postwounding
Term
What is taking place during the maturation stage?
Definition
Fewer fibroblasts remain for continued remodeling and contraction.
Term
What is the effect of physical stress at the site?
Definition
Gentle stretching minimizes but strengthens scar tissue
(must not be done after 60 days due to keloid formation)
Term
Is a mature scar weaker or stronger than normal skin? Why?
Definition
15-20% weaker - no elastin
Term
What is a keloid and why does it form?
Definition
Progressively enlarging scar due to increased collagen deposition in the dermis, still covered by epithelium. Keloids form when stretching occurs after 60 days.
Term
at what point does support become unnecessary for a wound?
At what point is their optimal strength?
Definition
10 days.
15 days.
Term
What is the optimal time for suture removal? Why might this need to be delayed?
Definition
10 days
Inflammation or steroid therapy may delay healing
Term
How many days postwounding are there the greatest fibroblast numbers?
Definition
5-21
Term
What is proud flesh and what species it common in?
Definition
Overexuberant granulation tissue (fibroblasts) - epithelial growth cannot keep up with fibroplasia - horses
Term
What initiates the extrinsic coagulation pathway?
Definition
thromboplastin mediated (cellular guts)
Term
What initiates the intrinsic coagulation pathway?
Definition
Collagen exposure to blood - excites platelets
Term
What is the PT test?
Definition
Prothrombin time - plasma is mixed with tissue thromboplastin and calcium. Clot time depends on factor 7 and common pathway factors
Term
What is the BMBT test?
Definition
Buccal Mucosal Bleeding Time -
Nonspecific test that primarily evaluates intrinsic (i.e. platelet adhesion and activation)
Platelet defects/deficiency, vWB disease, capillary fragility = prolonged bleeding time
Factor defects = rebleeding from site
I mm incision made into inner lip – siphon excess blood with gauze – record time it takes for the clot to form – normally takes 1 – 5 min
Term
What does the platelet count evaluate?
What are the major concerns with performing this test?
Definition
Platelet adhesion and activation - phlebotomy needs to be PERFECT
Term
What is the ACT test and what factor does it evaluate? What causes a prolonged ACT?
Definition
Activated coagulation time - measures coagulation time of blood added to diatomaceous earth - evaluates factor 11 - severe thrombocytopenia and intrinsic coagulopathies
Term
What factor does the APTT test evaluate?
Definition
Factor 11
Term
What is a fibrinogen assay and why is it used to evaluate hemostasis?
Definition
Fibrinogen is the most abundant factor in normal plasma - concentrations increase with inflammation and decrease when it is used, such as a DIC - total solids is measured before and after cooking
Term
What is the most reliable assay to evaluate warfarin/second generation coumarin toxicity and why?
Definition
PT test - evaluates activation of vitamin K dependent factors
Term
What is cox-1 responsible for?
Definition
Normal functions of platelet aggregation, protection of GI mucosa and renal perfusion
Term
What is cox-2 responsible for?
Definition
Synthesis of inflammatory mediators
Term
What kind of drugs are the following?
Acetaminophen (Tylenol®)  (non-NSAID)
Ibuprofen (Motrin®, Advil®) 
Aspirin
Phenylbutazone (Butazolidin®, “Bute”)
Ketoprofen (Ketofen®, Orudis®)
Flunixin (Banamine®)
Etodolac (EtoGesic®)*
Meloxicam (Metacam® )*
Deracoxib (Deramaxx®)*
Firocoxib (Previcox®)*
Carprofen
Definition
NSAIDS
Term
selective cox-2 inhibitors - "cox-1 sparing" or minimal cox-1 inhibition
Definition
Etodolac (EtoGesic®)*
Meloxicam (Metacam® )*
Deracoxib (Deramaxx®)*
Firocoxib (Previcox®)*
Term
selective cox-2 inhibitor - little to no cox-1 inhibition
Definition
carprofen (Rimadyl)
Term
Which clinical (inexpensive & fast) coag. diagnostic could/should be done in a preoperative patient known to or suspected of having received NSAIDs? (i.e. in ANY clinical setting)
Definition
BMBT
Term
Consequences of excessive hemorrhage
Definition
Inhibition of clot formation in the wound
Hypovolemia
Anemia
Hypoproteinemia
Term
Tools to contain hemostasis intraoperatively
Definition
Gauze
Hemostatic forceps
Ligatures
Electrocautery
Laser
Tourniquet
Commercial hemostatic agents
Term
Should you blot or wipe with gauze? Should it be dry or semisaturated?
Definition
Blot - wiping is abrasive and disturbing to the clot.
Semi-saturated - fibroblasts and platelets will stimulate clot formation.
Term
How does the crushing action aid in hemostasis?
Definition
Exposes more collagen and releases clotting factors, physically stops blood flow
Term
Difference between monopolar and bipolar electrocautery
Definition
Monopolar = single electrode handpiece. Touch to hemostat to isolate tissue/vessel.
Bipolar = forcep handpiece - current runs from one tip to the other.
Term
Advantage of a laser
Definition
precision
Term
How often must you release a tourniquet to reprefuse tissues?
Definition
no longer than every 30 min
Term
Commercial products used in intraoperative hemostasis:
Gelfoam
Definition
absorptive, synthetic material that swells with blood and exerts pressure within the wound
Term
Surgicel
Definition
cellulose material that becomes a gelatinous mass when exposed to blood/body fluids - provides scaffold for clot formation. Similar to calcium alignate
Term
Hemablock
Definition
Polysaccharide beads/fibers
Absorbant materal integrated into a clot - activates platelets and clotting factors
Term
3 ways to manage hemorrhage postoperatively
Definition
Drains, compression bandages, cryotherapy
Term
What is cryotherapy? Why is it used for postoperative hemorhagge control?
Definition
application of low temperatures to remove heat from an area ofthe body - causes vasoconstriction, which decreases blood flow and limits edema formation
Term
3 types of wound healing
Definition
1st intention - primary closure
2nd intention - granulation
3rd intention - delayed surgical closure
3rd intention -
Term
What is a 'clean' wound, 'clean-contaminated' wound, 'contaminated' wound, or 'infected/dirty' wounds?
Definition
clean = surgical incisions under ideal conditions
clean contaminated = surgical incisions with potential of contamination or open wound with healthy granulation tissue
contaminated = acute traumatic wounds, major break in surgical asepsis, acute inflammation
dirty wound = traumatic wound older than 4-6 hrs - perforated hollow organ - visible gross contamination - purulent
Term
What is the golden period?
Definition
less than 4-6 hours after a wound has been made - when primary closure should take place
Term
Why would we use second intention healing?
Definition
avoid formation of an abscess - allow debridement to occur - significant contamination or insufficient amount of skin to close
Term
How could 2nd intention healing affect function of a limb/muscle?
Definition
excessive scarring decreases mobility
Term
What is the main goal of bandaging?
Definition
Provide the optimal micro-environment for healing
Term
6 things to consider for bandaging
Definition
CDMTPP
Contamination, debridement, moisture, temperatue, pressure, pain
Term
Purpose of lavage
Definition
decontamination and debridement
Term
What is the optimum psi for lavage? What happens if you use too much pressure?
Definition
10-15 psi
If greater than 15 is used, contaminants are driven into the wound
Term
Required properties of lavage fluid
Definition
sterile, isotonic, buffered
Term
What concentration of chlorhexidine or povidone iodine is the best for the final rinse of a lavage?
Definition
0.05 - 0.2%
Term
how long does chlorhexidine have residual activity and how is it able to do this?
Definition
12-24 hrs; binds to tissues with minimal 2 min contact time
Term
What are the disadvantages of using povidone iodine?
Definition
Even when diluted appropriately, may still inhibit neutrophil activity. Potential systemic toxicity if used on large wounds. No tissue binding - diminished by organic matter - short residual activity (4-6 hrs)
Term
Why should we not use hydrogen peroxide?
Definition
Very little antimicrobial activity - drying agent - cytotoxic - thrombosis of capillaries
Term
Why should we not use acetic acid?
Definition
cytotoxic even when diluted, painful
Term
Why should we not use bleach?
Definition
extremely cytotoxic, even when very diluted
Term
advantage of PHMB dressing
Definition
decreases microbial contamination of wound and bandage.
Term
advantage of Film
Foam
Hydrogels
Hydrocolloids
Alginates
Definition
decreases access of environmental contaminants
Term
adherent dressing =
can be used for how many days?
Definition
dry gauze
1-2
Term
nonadherent dressing =
Definition
alginate and hydrogel
Term
How and why would we provide moisture to a dry wound?
Definition
decrease viscosity of thick exudates to increase drainage to secondary layer. Macerates necrotic, dessicated, and healthy tissues. Usually applied wet to dry
Term
What type of bandage should be used to promote autolysis and selective debridement?
Definition
Hydrogels or alignates
amorphous gel over wound is wiped/lavaged away.
Term
What type of bandage can accommodate some exudation, and is good for maintaining granulation or for transition from debridement to granulation? Also good for debridement of deep wounds
Definition
hydrogel
Term
What stage of healing is foam best used for?
Definition
Granulation, except when there is little moisture (will dehydrate wound)
Term
Maceration vs. dessication
Definition
maceration = too wet = friable tissues, easily traumatized, poor wound strength, impedes cellular activity
dessication = too dry = dehydration = cell death - cessation of cellular activity, tissue fractures, increased scarring, prolonged healing time
Term
What amount of moisture is the following meant to handle?
foam
Definition
mild to moderate exudation/serous drainage
Term
Telfa
Definition
Mild serous drainage (can't be left on for too long, can dry and become adherent)
Term
Adaptic
Definition
minimal serous drainage - non draining wound
Term
film
Definition
transparent film used for wounds with ZERO exudate only
Term
Should thick exudates have a wet or dry dressing? What about serous exudates? Why?
Definition
Thick exudates should have a wet bandage to help fluids flow out better. Serous exudates should have a dry dressing
Term
Alignate can absorb ___ times its weight in exudate. For this reason it is great for heavily suppurative wounds.
How long can you leave alginate on a wound?
Definition
20
3-4 days
Term
Why is it important to prevent wound hypothermia?
Definition
slows healing because of vasoconstriction and decreased cellular metabolism and activity. decreased oxygenation and removal of wastes.
Term
What else can we do besides an insulating bandage to keep the wound warm?
Definition
minimize exposure time during bandage changes, warm lavage fluids, warm topical agents/dressings
Term
pressure influence on deadspace
Definition
mimimal pressure can be used to decrease dead space and seroma formation.
Term
pressure influence on edema
Definition
diffuse pressure may be used to stabilize an injury or decrease edema
Term
influence of pressure on blood flow and cellular activity
Definition
decreases with increased pressure
Term
Influence of pressure on - oxygenation
Definition
abdominal/thoracic bandages may inhibit ventilation
Term
Influence of pressure on movement of exudates
Definition
movement into secondary layer inhibited - decreases storage capacity of secondary layer
Term
Why are active drains particularly important for skin grafts?
Definition
Prevent hematoma/seroma formation under the graft and undermined skin.
Gentle suction forces contact between skin and SQ tissue. Applying a bandage would cause too much pressure and lack of blood flow, causing loss of the skin graft
Term
3 main reasons for drains
Definition
decrease dead space, remove fluids, decrease contamination
Term
Why do bite wound injuries weep excessively?
Definition
1)microbial contamination
2) Inflammation of underlying tissues that were crushed/torn
Term
Why is honey used as a topical wound agent?
Definition
antimicrobial due to acidity - osmotic pressure draws fluid
Term
Good choices for topicals
Definition
water soluble/miscible or petroleum-based
Term
Why shouldn't you use powders or corticosteroids?
Definition
powders act as a foreign contaminant in the wound, prolonging debridement.
steroids decrease inflammation, which decreases debridement and repair.
Term
To prevent proud flesh...
Definition
immediate closure if possible
Bacitracin (accelerates epithelialization)
Nonadherent dressing
Light pressure to reduce blood flow and slow fibroplasia
Steroids after 5 days
Term
How should you prep a wound for surgical closure?
Definition
KY for exposed tissue
Dilute chlorhexidine lavage
Chlorhexidine scrub for periwound skin
Term
Why would a stent suture pattern be used?
Definition
Create diffuse pressure, so that the pressure is mostly on penrose tubing, not wound edges
Term
Purpose of 'freshening' the edges of a wound for a skin graft
Definition
blood and clot formations will provide minimal connections between fresh tissue and grafted skin
Term
What is pain and how does it occur?
Definition
a noxious stimulus causes inflammatory mediators to stimulate nociceptors, which travel up neural pathways to the brain
Term
What occurs during modulation
Definition
CNS can either depress or amplify an impulse
Term
What is windup?
Definition
Windup occurs during general anesthesia when NMDA receptors are stimulated, but impulses are not perceived. When the animal wakes up, CNS hypersensitivity occurs and nerve impulses are amplified
Term
Why do animals mask pain?
Definition
natural selection - less likely to become prey if they don't visually exhibit pain
Term
Negative ramifications of pain
Definition
1)Patient suffering
2)Stress increases ACTH, cortisol, and epinephrine. decreases insulin
causes decreased appetite, catabolic wasting, and increased risk of infection
- compromised cardiovascular function - increased inflammation - increased risk of chronic pain - increased fear/anxiety - prolonged recovery
Term
Goals behind perioperative analgesia
Definition
optimize patient recovery and minimize risk of chronic pain.
Balance between controlling pain but not so much that the animal will not pay attention to it.
Term
preemptive analgesia
Definition
administering analgesics before pain is induced
Term
multimodal analgesia
Definition
variety of drugs and mechanisms of action - variety of routes - intervene pain pathway at different areas
Term
ceiling effect
Definition
when a drug has a maximum effect at a certain blood level, the effect will not increase with higher doses due to all the receptors for that drug already being bound.
Term
side effects of NSAIDs
Definition
GI ulceration and hemorrhage, hemorrhage, hepatic & renal toxicity
Term
contraindications/cautions with NSAIDs
Definition
Impaired renal or hepatic function, GI disease, dehydration, hypotension, hemorrhage or impaired hemostasis
Term
symptoms that clients should watch for when prescribed NSAIDs
Definition
anorexia, nausea, vomiting, diarrhea, bleeding (or hematemesis, melena, hematochezia)
coffee grounds
bleeding from incision or bruising
Term
systemic side effects of opioids
Definition
cardiopulmonary depression, emesis and/or defecation, CNS depression, constipation
Term
contraindications/cautions with opioids
Definition
hepatic disease, cardiopulmonary disease, head trauma, pre-existing altered bowel motility
Term
common initial effects of opioid administration
Definition
emesis and defecation
Term
Adverse side effects you should monitor for with opioids
Definition
hypoventilation, bradycardia, prolonged CRT, weak pulses, hypotension,

nausea/emesis, excessive sedation, dysphoria
Term
how frequently should you monitor patients receiving opioids?
Definition
every 15 min-every hour, depending on dose, route, patient, and drug
Term
name some alpha2 agonists
Definition
Xylazine, Dexmedetomidine, Detomidine
Term
same some alpha 2 antagonists
Definition
yohimbine & atipamezole
Term
name some sodium channel blockers (local anesthetics)
Definition
lidocaine, bupivicaine
Term
dissociative agents
Definition
ketamine, HCL
Term
what type of drug is tramadol?
Definition
nonopiate
Term
Short duration of analgesia (30-90 min.)
Profound sedation
Cardiopulmonary effects (severe bradycardia, heart block, hypotension, resp. depression, & emesis)
Exacerbated w/opioids
Possible colic in horses (decreased gut motility)
Dex-butorphanol – good combination for minor procedures
Definition
alpha-2 agonists
Term
affect sensory & motor neurons equally (:. Sensory & motor impairment)
Definition
Na channel blockers
Term
2 min (immediate) onset
Painful, due to acidity (buffer?)
Duration 20 min-1h (2h w/epi)
Buffer to avoid pain on initial injection (see pg 185; 0.8 mL Na bicarb to 10mL lidocaine)
Definition
lidocaine
Term
Na channel blocker; with > lipid solubility & protein binding, rendering prolonged effects compared to lidocaine
20 min. onset
duration 4-6 h. [8 h. w/ epi.)
Poss. sensitivity to drug in larger animals (rats very tolerant; rabbits highly sensitive)
SQ only
Cardiotoxicity – IV route contraindicated!
Definition
bupivicaine
Term
Should be taken with food (may cause nausea)
Mu receptor activity + inhibition of norepinephrine & serotonin reuptake = analgesia
Definition
tramadol
Term
What are non-pharmaceutical, palliative nursing care practices that may relieve discomfort in hospitalized patients?
Definition
Cryotherapy (acute injuries)
Heat therapy (NOT for acute injuries)
Massage
Bandaging
Acupressure
Laser therapy
Other physiotherapies
Padding
Repositioning/turning
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