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Wound Care
Wound Care
80
Nursing
Undergraduate 1
07/27/2011

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Term
a wound is
Definition
damaged skin or soft tissue results from trauma
Term
trauma is a
Definition
general term referring to injury
Term
examples of tissue trauma are
Definition
cuts, blows, poor circulation, strong chemicals, and excessive heat or cold
Term
open wounds are
Definition
ones in which the surface of the skin or mucous membrane is no longer intact
Term
closed wounds are
Definition
when there is no opening in the skin or mucous membrane, occur more often from blunt trauma or pressure
Term
the three sequential phases of wound repair are
Definition
1. inflammation
2. proliferation
3. remodeling
Term
inflammation is when
Definition
the physiological defense immediately after tissue injury lasts approximately 2 to 5 days
Term
the three purposes of inflammation are to
Definition
1. limit the local damage
2. remove injured cells and debris
3. prepare the wound for healing
Term
the first stages of inflammation is
Definition
* immediately following an injury, blood vessels constrict to control blood loss and confine damage
*then blood vessels dilate to deliver platelets that form a loose clot
*the membranes of damaged cells become more permeable, causing release of plasma and chemical substances that transmit a sensation of discomfort
Term
signs and symptoms of inflammation are
Definition
* swelling, redness, warmth, pain and decreased function
Term
second stage of inflammation is when
Definition
leukocytes and macrophages migrate to the site of injury, and the body produces more and more white blood cells to take their place
Term
leukocytes and macrophages are
Definition
types of white blood cells
Term
leukocytosis is
Definition
increased production of white blood cells is confirmed and monitored by counting the number and type of white blood cells in a sample of the clients blood
Term
an increase in white blood cells particularly neutrophils and monocytes is suggestive of an
Definition
inflammatory or in some case an infectious process
Term
phagocytosis is
Definition
a process which neutrophils and monocytes consume pathogens, coagulated blood and cellular debris
Term
incision
Definition
a clean separation of skin and tissue with smooth even edges
Term
laceration
Definition
a separation of skin and tissue in which the edges are torn and irregular
Term
abrasion
Definition
a wound in which the surface layers of skin are scraped away
Term
avulsion
Definition
stripping away of large areas of skin and underlying tissue leaving cartilage and bone exposed
Term
ulceration
Definition
a shallow crater in which skin or mucous membrane is missing
Term
puncture
Definition
an opening of skin, underlying tissue, or mucous membrane caused by a narrow, sharp, pointed object
Term
contusion
Definition
injury to soft tissue underlying the skin from the force of contact with a hard object, sometimes called a bruise
Term
proliferation
Definition
period during which new cells fill and seal a wound, occurs from 2 days to 3 weeks after the inflammatory stage
Term
granulation tissue
Definition
combination of new blood vessels, fibroblasts and epithelial cells, which is bright pink to red, because of the extensive projections of capillaries in the area
Term
collagen
Definition
a tough and inelastic protein substance, produced by fibroblasts causing the adhesive strength of the wound to increase
Term
resolution
Definition
process by which damaged cells recover and re-establish their normal function
Term
regeneration
Definition
cell duplication
Term
scar formation
Definition
replacement of damaged cells with fibrous scar tissue
Term
remodeling
Definition
period during which the wound undergoes changes and maturation, follows the proliferation stage and may last 6 months to 2 years. During this time the wound contracts and the scar shrinks
Term
the speed of wound repair and extent of scar tissue that forms depends on whether
Definition
the wound heals by first, second or third intention
Term
first intention healing is a
Definition
process in which the wound edges are directly next to each other, only a small scar will form and most surgical procedures that are closely approximated will heal this way
Term
second intention healing is when the
Definition
wound edges are widely spread apart, margin of the wound are not in direct contact the granulation tissue needs additional time to extend across the expanse of the wound, a conspicuous scar results
Term
third intention healing
Definition
the wound edges are widely separated and are later brought together with some type of closure material, results in a broad deep scar, to speed healing them may contain drainage devices or be packed with absorbent gauze.
Term
the key to wound healing is
Definition
adequate blood flow to the injured tissue
Term
dehiscence
Definition
separation of wound edges
Term
evisceration
Definition
wound separation with protrusion of organs
Term
if evisceration occurs
Definition
the nurse puts sterile dressings moistened with normal saline over the protruding organs and tissue and notifies the physician immediately
Term
the primary goal of surgical or wound healing is to
Definition
reapproximate the tissue to restore its integrity
Term
a pressure ulcer is
Definition
a wound caused by prolonged capillary compression that is sufficient to impair circulation to the skin and underlying tissue. the primary goal in managing pressure ulcers is prevention
Term
a dressing is
Definition
a cover over a wound
Term
Montgomery straps
Definition
strips of tapes with eyelets
Term
transparent dressings are
Definition
clear wound coverings that allow the nurse to view a wound without removing the dressings, commonly used to cover IV sites
Term
Hydrocolloid dressings are
Definition
self adhesive opaque air and water occlusive wound coverings, that keeps wounds moist and can be left in place for up to one week, allow at least a one inch margin of healthy tissue around the wound
Term
when to change dressings
Definition
when a wound requires assessment or care and when the dressing becomes loose or saturated with drainage
Term
drains
Definition
are tubes that provide a means for removing blood and drainage from a wound. they promote wound healing by removing fluid and cellular debris, current trend is to place them so that they exit from a separate location beside the wound. this approach keeps the wound margins approximated and avoids a direct entry site for pathogens
Term
open drains are
Definition
flat flexible tubes that provide a pathway for drainage toward the dressing
Term
capillary action
Definition
movement of a liquid at the point of contact with a solid, which in this case is the gauze dressing
Term
closed drains
Definition
are drains that terminate in a receptacle, closed drains are more efficient because the pull fluid by creating a vacuum or negative pressure
Term
sutures are
Definition
knotted ties that hold an incision together, generally are constructed from silk or synthetic materials such as nylon
Term
staples are
Definition
wide metal clips. that do not encircle a wound like sutures but form a bridge that holds the two wound margins together. they do not compress the tissue if the tissue should swell
Term
adhesive or steri-strips also known as butterfly strips are used to
Definition
hold a weak incision together temporarily, sometime used for superficial lacerations
Term
a bandage is
Definition
a strip or roll of cloth wrapped around a body part
Term
a binder is
Definition
a type of bandage generally applied to a particular body part sch as the abdomen or breast
Term
t-binders are used to
Definition
secure a dressing to the anus or perineum or within the groin
Term
debridement is
Definition
the removal of necrotic tissue from the healthy areas of a wound with sterile scissors, forceps, or other instruments. this method is preferred if the wound is infected because it helps the wound to heal quickly and well, it is painful and the wound my bleed afterwards
Term
enzymatic debridement is
Definition
the use of topically applied chemical substance that break down and liquefy wound debris, it is appropriate for uninfected wounds or for clients who cannot tolerate sharp debridement
Term
autolytic debridement is
Definition
self-dissolution, is painless natural physiologic process that allows the body's enzymes to soften and liquefy and release devitalized tissue. it is used when a wounds is small and free of infection.
Term
mechanical debridement
Definition
involves physical removement of debris from a deep wound. one application is wet-to-dry dressings. the wound is packed with moist gauze which is removed 4-6 hours later, dead tissue adheres to the meshwork of the gauze and is removed when the dressing is changed
Term
hydrotherapy
Definition
therapeutic use of water, in which the body part with the wound is submerged in a whirlpool tank. the agitation of the water which contains an antiseptic, softens the dead tissue. loose debris that remains intact is later removed by sharp debridement
Term
irrigation is
Definition
a technique used for flushing debris, is used when caring for a wound and also for cleaning an area of the body such as the eye, ear and vagina
Term
douche
Definition
is a procedure for cleansing the vaginal canal sometimes necessary to treat an infection
Term
ice collars are used
Definition
after tonsil removal and ice bags to any small injury in the process of swelling
Term
compresses are
Definition
moist warm or cool cloths applied to the skin
Term
aquathermia pads
Definition
electrical or heating or cooling devices (k-pad)that contains hollow channels through which heated or cooled distilled water circulates, it is used alone or as a cover over a compress
Term
a soak is
Definition
a technique in which a body part is submerged in fluid to provide warmth or apply a medicated solution, lasts 15-20 minutes
Term
a pack is
Definition
a commercial device for applying moist heat
Term
therapeutic baths are
Definition
those preformed for other than hygiene purposes, they help to reduce a high fever or used to apply medicated substances to the skin to treat skin disorders or discomfort
Term
sitz baths
Definition
reduce swelling and inflammation and promote healing of wounds
Term
pressure ulcers appear over
Definition
bony prominences of the sacrum, hips and heels. if compression reduces the pressure in local capillaries to less than 32 mm Hg for 1-2 hours the cells die from lack of oxygen and nutrition
Term
stage 1 of pressure ulcers
Definition
characterized by redness but skin is still intact
Term
stage II of pressure ulcers
Definition
ulcer is red and accompanied by blistering or a skin tear which may lead to colonization and infection of the wound
Term
stage III of a pressure ulcer
Definition
skin has a shallow crater that extends to sub Q tissue. it may be accompanied by serious drainage or purulent drainage caused by wound infection, it is relatively painless despite the severity of the ulcer
Term
stage IV of a pressure ulcer
Definition
are life threating, the tissue is deeply ulcerated exposing muscle and bone, the dead or infected tissue may produce foul odor. the infection easily spreads through out the body causing fatal systemic infection
Term
sepsis
Definition
potentially fatal systemic infection
Term
prevention of pressure ulcers
Definition
1. identify clients with risk factors for pressure ulcers
2. implement measures that reduce conditions under which pressure ulcers are likely to form
Term
Fowlers position
Definition
promotes wound drainage from an abdominal incision
Term
the nurse encloses the soiled dressing within a latex glove
Definition
after changing a clients dressing
Term
the nurse compresses the bulb reservoir and closes the vent when
Definition
emptying a jackson pratt to re-establish negative pressure within the drainage device
Term
why does a nurse apply wet-to-dry dressings over skin ulcers
Definition
to remove dead cells and debris
Term
the best evidence that a wound is healing is
Definition
when the cavity appears pink
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