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wound care


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What precautions are used when implementing wound care?
standard precautions
What would a nurse avoid when caring for a healing wound?
avoid frequent cleaning.
Risk factors that contribute to pressure ulcers ?
inadequate nutrition
fecal and urinary incontinence
decreased mental status
diminished sensations
excessive body heat
advanced age
chronic medical conditions
hard support surfaces, repeated injury, incorrect application of protective devices
Partial thickness
confined to the dermis and epidermis
heals by regeneration
full thickness
involving the epidermis, dermis, subcutaneous tissue, and possibly bone and muscle.
require connective tissue repair
cause= sharp instrument

characteristics= open, deep or shallow
causes= blow from a blunt instrument

characteristics= closed wound, skin appears ecchymotic d/t damaged blood vessels
causes= surface scrape, intentional or unintentional

characteristics= open wound involving the skin
causes= penetration of the skin and often the underlying tissue by a shape instrument, intentional or unintentional.

characteristics= open wound
causes= tissues torn apart, often from an accident

characteristics= open wound, rough edges
penetrating wound
penetration of the skin and the underlying tissues, usually unintentional

characteristics= open wound
reactive hyperemia
body mechanism. extra blood floods an area to compensate for the preceding period of impeded blood flow results in a bright red flush appearance
reactive hyperemia is caused by ?
How long does reactive hyperemia last?
1/2 to 3/4 as long as the duration of blood impeded blood flow.
If reactive hyperemia is relieved in 1/2 to 3/4 the time as blood impediment, will there be tissue damage to the area ?
An example of shearing force.
sitting in the Fowler's position for extended periods of time.
An example of friction.
sheets rubbing against skin.
Primary intention healing


primary union or first intention healing
tissue surfaces have been approximated.
minimal or no tissue loss.
formation of minimal granulation tissue and scarring.
An example of primary intention healing
surgical incision
Secondary intention healing
considerable tissue loss
edges cannot be approximated
An example of secondary intention healing .
pressure ulcers
How does secondary intention healing differ from primary intention healing?
repair time is longer
the scarring is greater
the susceptibility to infection is
Phases of wound healing ?
inflammatory phase
proliferative phase
maturation phase
inflammatory phase
initiated immediately
last 3-6 days
two major processes= hemostasis and phagocytosis
Proliferative phase

second phase
day 3 or 4 to day 21 postinjury
collagen= strength to the wound
sutures collagen= healing ridge
unsutures= invisible
granulation tissue- bleeds easily
eschar=dried plasma protein and dead cells
Maturation Phase

third phase
from day 21 to 2 years after injury
collagen fibers are more organized
wound is remodeled and contracted
never as strong as original
keloid development is some individuals
Pressure Ulcer Scale for Healing
National Pressure Ulcer Advisory Panel
measures length, depth, width, and amount of drainage, and tissue type.

the score is used as an indicator of healing.
Three types of exudate
serous exudate
pyogenic exudate
sanguineous (hemorrhagic) exudate
serous exudate consists of ?
serum from the serous membrane of the body
purulent exudate consists of?
thicker than serous and contains pus
which is composed of leukocytes, liquefied dead tissue debris.

purulent exudate can vary in color of green, blue, yellow
sanguineous (hemorrhagic) exudate consists of?
large amounts of red blood cells
seen in open wounds
Mixed types of exudate are?
Purosanguineous drainage
consists of pus and blood

seen often is new wound that is infected
serosanguineous drainage consists of ?
clear and blood tinged drainage

seen in surgical incisions
Causes of an internal surgical hemorrhage.
dislodged clot
slipped stitch
erosion of a blood vessel
Signs of an internal hemorrhage ?
distention of the area
possible sanguineous drainage from the surgical drain
After surgery, the risk of a hemorrhage is greatest ?
first 48 hours
What are the nurses action when a client is hemorrhaging?
apply pressure dressings to the area
monitor vital signs
call the physician
Severe infection causes?
elevated white blood cell count
When is surgical infection most likely to occur?
2 to 11 days postoperatively
partial or total rupturing of a sutured wound.

usually involves an abdominal wound
evisceration. when does it occur? what clients are at risk?
protrusion of the internal viscera through an incision
likely to occur 4 to 5 days post-op
obesity, poor nutrition, multiple trauma, failure of suturing, coughing, vomiting, and dehydration increase the risk
What should the nurse do in the event the client states " something has given away" ?
apply sterile dressing
place client in bed with knees bent
notify surgeon
Pressure points with the client in a supine position?
heels ( calcaneus)
back of the head
Pressure points if the client is in a side lying position?
knee=medial & lateral condyle
greater trochanter
side of the head
Pressure points with the client in the prone position?
genitalia (men)
breast (women)
cheeks and ears
Pressure points with the client is a Fowler's position?
What are the nutritional needs of a client who has a wound that is healing?
rich in+ Protein
vitamins A & C
iron, zinc, and copper
Areas most likely to have problems with skin break down?
skin folds ex:under the breast
areas that are frequently moist=perineum
areas that receive extensive pressure ex:trochanter and coccyx
Assessing common pressure sites
1.natural or fluorescent light
2. a room that is not too cold or hot
3.inspect for whitish or reddened area
4. inspect for areas of abrasions or excoriations
5. palpate surface temperature
6. palpate over bony prominence and areas of edema
yellow wounds=liquid to semi-liquid slough may be accompanied by purulent drainage.
remove nonviable tissue
apply wet to dry dressing
irrigating the wound
using absorbent dressing material= impregnated nonadherent, hydrogel dressing, or exudate absorber
consult DR. about the use of an antimicrobial gel.
red wounds= late regenerative phase
protect to avoid disturbance
1. gently cleansing w/o pressure
2. avoid dry gauze or wet-to dry dressings
3. apply a antimicrobial agent
4. apply gauze or transparent film, or hydrocolloid dressing
5. change infrequently
black wounds= covered with thick nerotic tissue aka eschar
require debridement
when eschar is removed the wound is treated as a yellow wound then a red wound
How does a nurse treat a wound if more than one color is present?
treats the more serious color first.
black, yellow, then red
treating pressure ulcers
reposition q 2 hours
clean the ulcer w/ q. dressing change
use surgical asepsis
do not use alcohol
if infected get a sample of drainage
use pressure relief devices
teach client to move often
provide range of motion exercises
What are some special considerations that require caution when using heat and cold applications?
Neurosensory impairment
Impaired mental status
Impaired circulation
Immediately after injury or surgery
open wounds
Would cold therapy be used on an open wound?
No because cold decreases blood flow: which will slow down healing
Would heat therapy be affective immediately after surgery?
No. heat increases bleeding.
Would heat or cold therapy be used on a client who has diabetes, peripheral vascular disease, or congestive heart failure?
NO, because they would not have the ability to dissipate heat via blood circulatory system= tissue damage.
People with impaired mental status would require ____________________by the nurse
during heat or cold therapy?
monitoring to ensure safe therapy
When using heat/cold therapy neurosensory impaired persons are at risk for __________________________?
tissue damage
What type of injuries would require heat therapy?
musculoskeletal problems, stiff joints from arthritis, low back pain ,
What type of injuries would require cold therapy?
sports injuries= sprain, strains, and fractures
Obtaining an aerobic culture
clean wound
rotate swap over clean areas of granulation tissue from the sides or base of the wound
aerobic cultures should not be taken from ?
pus or pooled exudate
obtaining an anaerobic wound culture?
clean wound
insert syringe into wound
aspirate 1 ml of drainage
What should the nurse do if the client is complaining of pain at the wound site before obtaining a wound culture?
administer pain relief meds 30 minutes before performing the procedure
What is a disadvantage to sheep skins ?
makes the client hot.
the temperature for heat therapy?
46-52C (115-125F)adults
debilitated or unconscious clients= 40.5 -46C (105-115F)
The purpose of primrose drains ?
to permit the drainage of serosanguineous and purulent drainage.

promote the healing of underlying tissue.
the purpose of Jackson Pratt drains?
connected to a reservoir to maintains constant low suction.
provide accurate drainage measurements
reduces the possible entry of microorganisms.
drainage of purulent and serosanguineous drainage
Occlusive dressings are used on what type of wounds?


burned skin
Advantages to a transparent wound dressings ?
1. acts as temp. skin
2. remain in place until healing is complete or as long as they are intact.
3. transparent= assessed through them
4. occlucive =moisture= retains serous exudate.
5. can be used over a joint.
adhere to skin not to wound
6. client can bath with dressing
7. removed w/o causing damage.
Advantages to hydrocolloid dressings
1. last a long time.
2. are water resistant
If obtaining a wound culture, where would the nurse swab the wound?
rotate the swab back and forth over granulation tissue (viable tissue) from the sides and base of the wound.
Why does the nurse swab over viable wound tissue?
microorganisms that are the cause of the infection are within the viable tissue
For an anaerobic specimen the nurse knows ?
insert 10ml. syringe
aspirate 5 ml. of drainage. attach needle to syringe, expel air
inject the drainage into the anaerobic tube.
send to lab immediately

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