Chapter 14 FON

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Chapter 14 (Surgical Wound Care)

Question Answer
binderstrip or roll of cloth or other material that can be wound around a part of the body in a variety of ways for multiple purposes
dehiscencepartial or complete separation of a surgical incision or rupture of a wound closure
drainagefree flow or withdrawal of fluids from a wound or cavity by some sort of system such as a urinary catheter or T-tube
eviscerationprotrusion of an internal organ through a disrupted wonder or surgical incision.
exudatefluid, cells, or other substances that have been slowly exuded or discharged from body cells or blood vessels through small pores or breaks in cell membrane
granulationsoft, pink, fleshy projection consisting of capillaries surrounded by fibrous collagen that slowly fills the incision during process of healing
irrigationGentle washing of an area with a stream of solution delivered through an irrigating syringe
primary intentiona wound that has been made surgically and has little tissue loss; skin edges are close together and minimal scarring results
puncturestab wound for a drainage system
purulentproducing or containing pus
sanguineouspertaining to blood
serosanguineousthin, red exudate composed of serum and blood
serousthin, watery exudate composing the serum portion of blood
T-tubeDrainage tube into the duct to maintain a free flow a drainage tube into the duct to maintain a free flow
tertiary intentionhealing that occurs by primary intention with delayed suturing of a wound in which two layers of granulation tissue are sutured together.
vacuum-assisted closureMachine which applies negative pressure to wounds
woundany injury to the body's tissues that involves a break in the skin
What are factors that affect healing?age, nutritional status, physical wellbeing, and medication therapies.
How are surgical wounds classified?Based on the level of contamination
The risk for an infection in a clean surgical wound is less than _________ %5
Wounds that are contaminated have a significantly elevated risk of infection, nearing _________%.27
What are the four phases of wound healinghemostasis, inflammatory phase, reconstruction, and maturation
What is hemostasis?Stops bleeding when blood platelets stick to the walls of injured vessel which causes a clot to form. Fibrin then holds the wound together.
What occurs in the inflammatory phase?there is a initial increase in flow of blood elements (antibodies, electrolytes, plasma proteins) and water out of blood vessels and into the vascular space which causes the signs of inflammations. Leukocytes appear and attack bacteria, fungi, viruses and toxic proteins. Cells in injured tissue move, divide, and form new cells. Blood clot dissolve and wound fills; the sides of wound usually meet in 1-2days. @ end new cells and capillaries fill wound from underlying tissue to the skin surface. Seals the wound and protects it.
What is a keloid?Overgrowth of collagenous scar tissue at the site of a wound, forms during this maturation phase. Color ranges from red to pink to white.
What occurs in the reconstruction phase?Fibroblasts produce collagen, a glue-like protein substance that adds tensile strength to the wound and the tissue.
When does the reconstruction phase begin?3rd or 4th day of injury and lasts 2-3 weeks
Collage formations increases rapidly between postoperative days _ and _.5 and 25
How does the wound look during the reconstruction phase?Irregular, raised, purplish, immature scar.
Wound dehiscence most frequently occurs during which phase of wound healing?Reconstruction phase
Although tissue heals at varying speeds, which wounds wounds regain strength faster? Internal or external?Internal wounds regain strength faster than skin wounds.
What occurs during the maturation phase?Approx 3 weeks after surgery, fibroblasts exit the wound. Keloid forms during the maturation phase.
What are the 3 processes of wound healing?Primary intention(primary union), secondary intention(granulation), or tertiary (third) intention
A wound in which skin edges are close together and little tissue is lost, such as those made surgically, heal by _____ intention where minimal scarring resultsprimary
When does primary intention healing begin?inflammatory phase of healing; in surgery, this is usually during closure of the wound
When a wound must granulate during healing then it is healing by ______ intention.secondary
When skin edges are not closed together (approximated) or when pus has formed, then the healing is done by ______ intentionsecondary
When the surgeon provides a means for the purulent exudate to release through a drainage system or by packing the wound with gauze what happensSlowly, the necrotized tissue decomposes and escapes and the city begins to fill with granulation tissue
what is secondary intention?when a wound myst granulate during healing, occurs when skin edges are not approximated or when pus has formed
What occurs during a tertiary intention?the practitioner leaves a contaminated wound open and closes it later, after the infection is controlled, by suturing two layers or granulation tissue together in the wound.
Foods rich in _____, ______, _____, and _____ assist in wound repairproteins, vitamins A, vitamins C, and Zinc.
What are some sources of proteinmeat, peanut butter, and legumes.
What are some sources of Vitamin Adark leafy vegetables and yellow or orange fruits and vegetables
What are some rich sources in Vitamin CStrawberries, tomatoes, spinach, and cruciferous vegetables, including broccoli, cauliflower, and cabbage
What are some sources for Zincfortified cereals, red meat, and seafood.
When should you offer fluidshourly
How much mL should be encouraged to take in 24 hours2000 to 2400 mL in 24 hours
I&OIntake and output
what is splintingtechniques to reduce the stress placed on incision
After surgery, you must inspect the surgical wound how often?Inspect the dressing hourly during the first 4 hours after the procedure. Then, inspect dressings every 2 to 4 hours for the first 24 hours
What must a nurse do to prevent undetected hemorrhaging?The nurse myst inspect both the dressing or incisional area and the area under the patient.
Incision coverings take the form of ____, _____, or ______ dressingsgauze, semiocclusive, and occlusive
What is the difference between gauze, semi occlusive and occlusive dressings?gauze dressings permit air to read the wound; semi occlusive dressing permit oxygen but not air impurities to pass; and occlusive dressings permit neither air nor oxygen to pass.
A ___ dressing prevent deeper tissues from drying out by keeping the wound surface moist.dry
If the dressing removal is anticipated to be painful, provide analgesic at least _________ minutes before exposing a would30
When are wet-to-dry dressings most commonly used?wound management. Most appropriate for wounds that do not have significant amounts of ischemic or necrotic tissue or large amounts of drainage or exudate.
How should you remove tape from an incisionBy gently taking off tape by moving it towards the incision and gently using thumb to retract skin away from tape (counetrtraction)
What are the commonly used wetting agents for dressingsnormal saline solution and lactated Ringer's solution, isotonic solutions that aid in mechanical debridement
When is Acetic Acid used for wet to dryEffective against Pseudomonas aeruginosa but is toxic to fibroblasts in standard dilutions.
When is Sodium hypochlorite solution (Dakin's) usedto help debridement in a wound with necrotic debris and is an effective deodorant solution.
When is Povidoneiodine usedrapid-acting antimicrobial agent for cleansing intact skin.
What should you label on wetting solutionsDate and time of opening and should be discarded 24 hours after opening and replaced with fresh solution to prevent microorganism growth
What are transparent dressingsthin, self-adhesive see-through film dressing. Can be semi occlusive or occlusive. There's a synthetic permeable membrane that acts as a second temporary skin.
What are the advantages of a synthetic membrane in transparent dressings?Adheres to undamaged skin to contain exudate and minimize wound contamination. Barrier to external fluids and bacteria but still allow wound to breathe. Promotes a moist environment which speeds epithelial cell growth.
Principles of basic wound irrigation1) clean from least to most contaminated 2) When irrigating, solutions flow from least to most contaminated
what does AHCPR recommend pressure for irrigation?4 to 15 psi
AHCPRHealth Care Policy and Research
When using a syringe, how far should you keep it from a wound when being cleansed?1 inch
In wound care, the area being cleansed is considered ____ and the surrounding skin surfaces are considered ____ without respect to whether the wound is infectedclean; contaminated
What can you do to irrigate if a wound is deep but narrowyou may attack a soft catheter to the syringe to maintain sterile technique while allowing fluid to enter the wound.
What may a wound bleeding indicate?slipped suited, dislodged clot, coagulation problem, or trauma to blood vessels or tissue.
What are the less obvious signs of internal bleedingrestlessness; rapid, thready pulse; decreased blood pressure; decreased urinary output; and cool, clammy skin.
Internal abdominal bleeding, if allowed to continue, may cause the abdomen to feelRigid and distended
If evisceration follows dehiscence, how must you treat patient?Put patient in low Fowler's position, with knees flexed to reduce pressure on the wound. Keep patient on NPO(nothing by mouth) and covered the wound and contents with warm, sterile saline solution dressings. Notify surgeon immediately.
According to the CDC, when is a wound considered infectedWhen it contains pus drainage