Chapter 14 wound care

jthitphaneth's version from 2016-01-06 23:06

Section 1

Question Answer
woundrefers to and injuries to the body's tissues that involves a break in the skin.
incisiona cut produced surgically by a sharp instrument that creates an opening into an organ or space in the body
puncturestab wound for a drainage system
primary intentionminimal scarring results, wound made surgically had little tissue loss. skin edges are closely approximated together
secondary intentionwhen a wound must granulate during healing, occurs when skin edges are not close together or when pus has formed
purulentproducing or containing pus (think, yellow, green, tan, or brown)
exudatefluid, cells, or other substances that have been slowly exuded, or discharged, from cell or blood through small pores or breaks in call membrane
granulationtissue, or soft, pink, fleshy projections that consist of capillaries surrounded by fibrous collagen
tertiary intentiondelayed primary intention. Occurs with delayed suturing of a wound in which two layers of granulation tissue are sutured together.
sanguineouscomposed of or pertaining to blood (bright red: indicates active bleeding)
serosanguineousthin and red, composed of serum and blood (pale, red, watery: mixture of serous and sanguineous)
serousthin and watery composed of the serum portion of blood (clear, watery plasma)
inflammatory responsea tissue reaction to injury
factors that impair wound healing are..age, malnutrition, obesity, impaired oxygenation, smoking, drugs, diabetes mellitus, radiation, wound stress
infectious processa condition caused by the invasion of the body by pathogenic microorganisms
irrigationis gentle washing of an area with a stream of solution delivered through an irrigating syringe
drainagethe removal of fluids from a body cavity, wound, or other source of discharge by one or more methods.
vacuum- assisted closure (wound VAC) the wound VAC functions by applying negative pressure to wounds
bandagea strip or roll of cloth or other materials that can be wound around a part of the body in a variety of ways for multiple purposes
bindera bandage that is made of large pieces of material to fit a specific body part (elastic, cotton,muslin, or flannel)
basic bandage terms:circular, spiral, spiral-reverse, recurrent
dehiscenceseparation of surgical incision or rupture of wound closure, typically an abdominal incision
eviscerationthe protrusion of an internal organ through a wound or surgical incision, especially in the abdominal wall.
abscesscavity that contains pus and is surrounded by inflamed tissue, formed as a result of suppuration in a localized infection
adhesionband of scar tissue that binds together two anatomic surfaces normally separated; most commonly found in abdomen
cellulitisinfection of the skin characterized by heat, pain, erythema, and edema
dehiscenceseparation of a surgical incision or rupture of a wound closure
eviscerationprotrusion of an internal organ through a wound or surgical incision
extravasationpassage or escape into the tissues; usually of blood, serum, or lymph
hematomacollection of extravasated blood trapped in the tissues or in an organ that results from incomplete hemostasis after surgery or injury
T-tubea drainage tube that maintains a free flow of bile. Used for Pt's that underwent an open cholecystectomy until edema subsides.
circular bandage circular turns are used to cover small body regions such as a digit or wrist and are used to anchor bandaging materials
spiral bandageused to cover cylindrical body parts where contour of part does not vary significantly in size (slender wrist and forearm)
spiral- reverse bandageused to cover inverted cone-shaped body parts such as calf or thigh (provide coverage for joints and immobilization)
Recurrent bandageprovides cap-like coverage for scalp or amputation stump
inflammatory phase (wound healing)an initial increase in blood elements and water flow out of the blood vessel into the vascular space
hemostasis (wound healing)termination of bleeding as soon as injury occurs. Fibrin clot forms to hold edges together
reconstruction phase (wound healing)collagen formation occurs, wound dehiscence most frequently occurs during this phase
maturation phase (wound healing) fibroblasts begin to exit the wound. keloids may form during this phase
surgical woundthe surgeon's goal is the enter the cavity involved, repair the injured or diseased area and minimize trauma as quickly as possible.
dressing change for surgical wound:every 2 to 4 hours for the first 24 hours
incision coverings:gauze, semiocclusive, occlusive
gauzepermits air to reach the wound
semiocclusivepermits O2 but not air impurities to pass
occlusivepermits neither air, O2 or H20 to pass
open drainagedrainage that passes through and open-ended tube into a receptacle or out onto the dressing. I.e. penrose drain
closed drainagesystem of tubing and other apparatus attached to the body to remove fluid in airtight circuit that prevents environmental contaminants from entering the wound or cavity. I.e. JP bulb
suction drainageUse of a pump or other mechanical device to help extract a fluid. I.e. Hemovac

Section 2

Question Answer
complementary therapiesare treatments used in addition to conventional health care regimens recommended by a person's health care provider
alternative therapiesoften include the same interventions as complementary therapies but frequently become the primary treatment modality that replaces allopathic medicine
allopathic medicinetraditional or conventional Western medicine
Holistic nursing addresses and treats the mind-body-spirit of the patient
herbal therapyas medical treatment goes back thousands of years. Not viewed as drugs
pharmaceuticalsdrugs, was increased and their use became commonplaced
asian ginseng (panax ginseng)improves overall health and well-being. helps with atherosclerosis, bleeding disorders, colitis, diabetes, depressant cancer
aloe vera (aloe ferox, aloe barbadensis) has laxative properties. helps with burns and skin irritation
cayenne (capsicum sp.)general cardiovascular health: reduces cholesterol level; topical application produces analgesia, control bleeding
comfrey (symphytum offcinale)cell proliferant, stimulates quick healing of strains and slow-healing wounds (for external use only)
echinacea stimulates immune function; excellent blood cleanser; upper respiratory infections; wound healing
ginger nausea,vomiting,motion sickness, appetite improvement, impotence, liver toxicity, burn
ginkgoimproves memory, increases circulation to the extremities and the brain
kavaanxiety, stress, and restlessness, insomnia, wound healing
lavenderantiseptic, antidepressant, sedative relaxation, minor cuts, psoriasis, fragrance
chiropractic therapydoctors of chiropractic medicine undergo extensive training in manipulation of the musculoskeletal system
Qilife force
Meridians channels of energy
acupunctureis a method of stimulating certain points (acupoints) on the body by the insertion of special neddles to modify the perception of pain, normalize physiologic functions, or treat or prevent disease
chamomileuse for pain, gastric intestinal spasms, stress, insomnia
eucalyptusrespiratory problem
lemoncolds and flu, mental stimulation diuretic, antiinflammatory
peppermintance, stomach upset general stimulant
rosemaryinternally: mental stimulant; alleviating stress. externally: myalgias, neuralgia, puritus, migraines
tea treeantiseptic skin irritations, viral illness, respiratory infection
acupressure entails the use of gentle pressure at similar points on the body. used primarily for prevention and relief of symptoms of muscle tension.
therapeutic massagemassage performed by trained professionals to manipulate the soft tissues of the body and assist with healing.
aromatherapyentails the use of pure essential oils, produced from plants, to provide health benefits
reflexologythe manipulation of specific reflexes removes stress, enabling the release of disharmonies removed by a physiologic change in the body
imageryvisualization techniques, the conscious mind is used to create mental images to evoke physical changes in the body, create a sense of improved well- being, and enhance self- awareness
relaxationthe state of a generalized decrease in cognitive, physiologic, or behavioral arousal. Also defined as the process of arousal reduction. This process elongates the muscle fibers and reduces the neural impulses sent to the brain and thus decreases the activity of the brain and other body systems.
relaxation strategies:music, rhythmic breathing, progressive relaxation, color exchange, modified autogenic relaxation, sensory pacing
focusingthe ability to identify, differentiate, maintain attention on, and return attention to simple stimuli for an extended period
passivitythe ability to stop unnecessary goal-directed and analytic activity
receptivityability to tolerate and accept experiences that are sometimes uncertain, unfamiliar, or paradoxic
animal -assisted therapy (AAT)involves the use of trained animals to enhance an individual's physical, emotional, and social well-being
yogatypically, these changes include improved health and energy, reduced stress, feelings of well-being, and the healing of disease
taiji (T'ai chi) was originally developed as a martial art in seventeenth- century China.
biofeedbacka noninvasive method that and individual can employ to learn control of the body to manage certain conditions
Pt's tend to think of CAM therapies as gentler and less invasive than traditional medical treatments :
Some herbs interfere with the actions of medications, a thorough health history is important :
In acupuncture and acupressure, needles or pressure is applied to specific points on the body :
pressure to feet in the form of massage is performed in reflexology :
magnet therapy is thought to improve circulation to specific area, promote healing, increase energy and decrease pain :

Section 3

Question Answer
noxious injurious to physical health
nature of pain:a complex, abstract, personal subjective experience. It is an unpleasant sensation caused by stimulation of the sensory nerve endings
definition of painand unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage
referred painis felt at a site other than the injured or diseased organ or part of the body
acute pain (fight or flight response)is intense and of short duration, usually lasting less than 6 months. Provides a warning of actual or potential tissue damage
chronic paingenerally characterized as pain lasting longer than 6 months. Signals that tissue damage has occured
synergisticactions of two or more substances or organs achieve an effect that cannot be achieved by an individual substance or organ
gate control theory (Melzack 1983)suggests tha pain impulses are regulated and even blocked by gating mechanisms located along the central nervous system
endorphinspotent polypeptides composed of many amino acids, found in the pituitary gland and other areas of the CNS
Pain assessment guide:H:ow does your pain feel? , I:ntensity (0-10) , L:ocation , D:uration , A:ggravating and alleviating factors?