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maslows needs base to top are
- physiological
- safety and security
- love and belonging
- self-esteem
- sefl actualization
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the layers of skin
- epidermis
- dermis
- subcutaneous
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what is the nursing role in wound care
- prevention
- promote tissue repair and regeneration
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enhance a wound care pt nutritional status by
- protein rich foods
- water
- vitamin dense
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an acute wound is one that
heals within 30 days
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chronic wound is
wound that persists beyond usual healing time of greater than 30 days
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Healthy people 2020 is
government wants to decrease pressure sore prevalence in nursing home patients 50% by 2020.
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what is the Braden scale
scale that determines the risk for pressure sores
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stage 1 pressure ulcer =
epidermis is red and is non-blanchable
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stage 2 pressure sore =
injury to epidermis and derimis (actual break in skin) blister
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stage 3 pressure sore =
ulcer goes beyond the dermis to subcutaneous tissue.
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stage 4 pressure sore =
ulcer extends to muscle or bone
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unstageable pressure soar =
eschar covered, cannot stage until unroofed
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osteomyelitis
infection of bone
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primary intention
- wound is clean
- little loss of tissue
- edges well and approximated
- heals rapidly with minimal scarring
- (surgical wound
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secondary intention
- wound heals from bottom up
- large wound with tissue loss
- healing takes longer
- wound not readily approximated
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tertiary intention
- time delay wound is sutured or closed
- more scarring
- risk for infection an inflammatory reaction
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hemostasis phase is
- vasoconstriction
- deposit of fibrin
- clot formation
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proliferation phase is
- collagen - adds strength
- capillaries - increase blood supply
- new tissue built to fill wound space
- granulation tissue
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during proliferation phase what should you be wanting for pt
adequate nutrition, oxigenation
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maturation phase =
- scar is formed
- can take years
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Goal with red wound =
- protect it
- it is granulation tissue
- at proliferation phase
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yellow wound care =
clean wound
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black wound care =
debride
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autolytic debridement =
using bodies own enzymes to debride a wound
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factors that influence wound healing
- age
- circulation and oxygenation
- wound condition
- overall health status
- meds (steroids)
- nutrition
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nursing process begins with
assessment
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sanguineous woun drainage =
bloody
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serosanguineous=
combination of clear and bloody drainage
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first step in obtaining a woud culture =
clean wound to remove old drainage
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wound culture should be done with what technique
aseptic
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what is nursing diagnosis for pt with wounds
- impaired skin integrity
- disturbed body image
- acute/chronic pain
- self-care deficit
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wound care considerations
- location and size of wound
- type and depth of wound
- presence of infection
- need for debridement
- amount and type of drainage
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non stick dressings are used -
- prevent dressing from adhering to wound
- ie petrolatum dressing or tefla
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gauze used for what in wound care
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petrolatum dresing or Telfa =
nonstick dressing
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transparent dressing used for
- small wounds or tubes
- occlusive but with visualization
- tegaderm
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hydrocolloids are
- remain on for 3-7 days
- absorbs drainage
- occlusive and adhesive
- conforms and cushions
- duoderm
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duoderm =
hydrocolloid dressing
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hydrogels
- o2 permiable
- maintains moisture
- may remain 8-48 hrs
- used with minimal exudate
- aquasorb
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alginates are
- derived from seaweed
- moderate to heavy drainage
- retentive gel on contact with exudate
- sorbsan, aquacel, nuderm
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sorbsan, aquacel, Nu-derm
alginates
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indications of hyperbaric treatment
diabetic foot ulcers, arterial ulcers, radiation necrosis
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when cleaning wound avoid?
iodine, hydrogen peroxide, acidic solutions
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preferred cleaning solution for wounds =
saline
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complications of wound healing
- hemorrhage
- hematoma
- infection
- dehiscence
- evisceration
- fistula
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in surgical wounds hemorrhage usually occurs
within first 48 hours post op
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infection in wounds usually occur
within 2-11 days
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dehiscence =
partial or total disruption of sutured wound
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treatment for dehisence =
keep wound covered with moistened sterile dressing, notify MD, limit activity
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eviseration =
protrusion of viscera through incisional area.
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tx of eviseration
cover wound with STERILE saline soaked dressing, call MD STAT, low fowlers position, saty with pt.
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fistula =
abnormal tube passage that can develope between to organs or from one organ to the outside of body
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what to discuss in home care D/C planning
- good handwashing
- nutrition and fluids
- spplies to purchase
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