fund

closed, discolored wound caused by blunt trauma -- bruise

superficial open wound -- scrapes, scratches, rub-type

open results when sharp item, needle, nail wire, pierces skin

similar to puncture, object remains in wound

open wound made by accidental cutting or tearing of tissue

wound resulting from pressure or friction

clean, clean-contaminated, contaminated, infected, and colonized

wound not infected

surgically made wound, not infected, direct contact w narmal flora in resp tract, urin tract, or gi, potential to become infected

surg wound or wound caused by truama that has been grossly contaminated by breaking asepsis

wound that the infectious process has already established, evidenced by high numbers of microorganisms and either purulent drainage or necrotic tissue

differs from infected in that it has a high number of microorganisms present but wo signs of infection

decubitus ulcer or bedsore

external pressure is exerted on soft tiss, esp over bony prom, for a prolonged period of time

reduced blood flow in areas where tissues and capillaries are compressed

necrosis of cells

friction or shearing

sacrum, butt, greater troch, elbows, heels, ankles, occiput, and scapula

elderly, amaciated or malnourished, incont, immobile, impaired circulation or chronic metabolic conditions

deep tiss inj, 1, 2, 3, 4, unstageable

area over bony prom, differs from surrounding tiss in temp, text, firmness, discomfort level

erythema, remains for at least 15 - 30 min after relieving pressure and it will not blanch when you gently touch it w fingertip

occurs when there is partial thickness loss of dermis

full-thinkness loss involving damage to epidermis, dermis, and subcutaneous tiss, but not involving muscle or bone. undermining or tunneling can occur

full-thickness tiss loss, involved deep tiss necrosis of muscle, fascia, tendon, joint capsule, and sometimes bone

involves full thickness tiss loss but are impossible to accurately state due to the wound bed being completely obscured by eschar or excessive slough

• 1 assess pallor, erythema, jaundice, bruising
• 2 assess turgor
• 3 peposition every 2h
• 4 clean and dry
• 5 linens wrinkle free
• 6 lotion dry skin
• 7 use draw sheet or lift
• 8 adequate nutrition and fluids

develop when venous blood flow is sluggish, generally in lower extremeties, allowing deoxygenated blood to pool in the veins

channel or tunnel that develops bw two cavities or bw an infected cavity and the skin surface -- fistula

draining sinus tract

intentionally made w sharp instruments, linear w more sharply defined edges than most wounds. good approximation bw 2 edges

phase occurs when wound is fresh and includes both hemostasis and phagocytosis

body stops the bleeding associated w fresh wound

wbcs macrophages engolf and digest invading microorganisms and the remaining fragments of damaged cells

warmth, redness, pain, edema

interfere with bodys natural process and delays healing

when wound begins to heal, lasting about 21 days after inj -- proliferation phase

fibroblasts produce collagen that forms scar tiss and helps strenghten wound. cap produce new networks to supply oxygenated blood and nutrients

extremely fragile red and semitransparent new tissue

remodeling phase, would contracts and scar strenghtens

healing ridge develops can last years, refined collagen produced, firm and less elastic, extra support

overproduction of collagen, thick, raised scar

wound is clean w little tiss lossm, edges are approximated and wound is sutured close - surg inc.

greater tiss loss and wound edges are irregular and cannot be brought together. - pressure ulcer or traumatic wound, will be left open to gradually heal by filling in w granulation tiss, leaving wide scar

wound left open for a time to allow granulation tiss to form then sutured closed, - draining wound- when draining is done wound sutured

age, chronic illness, diabetes, hypoxemia, lifestyle, lymphedema, medications, mult wounds, nutrition and hydration, radiation, wound tension

guts come out of stomach

infection, wound dehiscense and evisceration, hemorrhage

seperation of outer layers of wound after surgery

amnt & color or drainage, assess size, if open - assess base or bed

mark drainage if no order to change dressing

lenth, width, depth

color of tiss, texture of tiss, gran tiss, aschar, sinus tracts (tunnelling?), undermining (widening inside)

tunnel

widening inside

• r red protect
• y yellow cleanse
• b black debride

in proliferative stage of healing and are the color of normal gran tiss, wounds need protection by nsg interventions that include gently cleansing used of moist dressing, application of a transparent or hydrocolloid dressing, changing dressing only as needed

oozing from tiss covering wound, purulent. to cleanse, nsg interventions include irrigating the owund, using wet-to-moist dressings, using nonadherant, hydrogel or other absortive dressings consulting w md for use of topical antimicrobial mediation to decrease bact growth

thick eschar may be brown gray or tan, must be debrided, may be surg removed w scissors or scapel, or by mech debridemtn, scrubbing or wet to dry dressing, be chemical debridement using ointments w enzymes agents, afterwards treated as yellow and as healing progresses, a red

the most color is treated

local or sustemic change in body temp for therapuetic purposes

method, duration of aplication, degree of temp, pt age and phys cond, amount of body surface covered

• 1 promote healing
• 2 facilitate comfort
• 3 use knowledge and skill in carrying out application
• 4 follow safety measure

dilates peripheral blood vessels

increases blood flow -- increases o2 and nutrients to the area -- venous congestion is decreased. reduces viscosity of blood and increased capillary permeability improved the delivery of leukococytes, and nutrients and removal of wastes and prolongs clotting time -- heat reduces muscle tension -- promotes relaxation and helps to relieve muscle spasms and joint stiffness -- relieve pain

increased cardiac imput, sweating, muscle pain, dysmenorrhea, chronic pain

constricts peripheral blood vessels -- reduces blood flow to tiss and decreasing the local release of pain-producing substances -- reduces the formation of edema and inflammation, -- decreased metabolic needs and cap w decreased cap permeability w increased coagulation of blood at site -- facilatiate control of bleeding and reduce edema formation

heat produces max vasofialtion in 20 to 30 mins, if heat cont after that time - tiss congestion and vasoconstriction occors

max vasoconstriction ovvurs when the skin reaches 14 degress c (60f) the vasodilation occurs

• pt phys and mental status:
• 1 health hx and phys exam
• 2 hx of cv or peripheral vascular dis, sensory impair, confusion, decreased consciousness
• 3 level of consciousness or orientation

open wound, hemorrhage, infl edema, inflamed area, tumor, testes, adb of preg, metallic implants

open wounds or pts w impaired peripheral circualtion or allergy to cold

sensation, color/apperance, circualtion (pulses, blanching, temp, color)

pale or cyanotic, feels cold has decreased circultion -- increases risk for inj form heat or cold

leaks, distribution and constancy of temp

redness, blistering, pain, hypotenstion and changes in consciousness,

pallor, cyanosis, numbness, pain

body area to be treated, frequency and legth of time for application

instillation of fluid into a cavity or opening

• clean/restore patency
• instill meds

• bladder
• kidney
• pelvis
• eye
• open wounds

• throat
• ear
• vag
• bowel
• stomach

sterile because of impaired skin integrity

• gloves, gown
• use gentle pressure

reduce pressure

use correct concentration, meds cause irritation

room temp, extremes could cause burns, drop in bd temp, shock

• procedure and what to expect
• time for questions
• therapeutic comminication

• drainage or exudates
• amount
• color
• consistency
• odor

• areas of irrigation
• type/amount solution used
• time
• pt response
• all fluids returned, if fails - record it and amount retainted on intake sheet

• check order for type, amnt, temp, and sol
• clean or sterile
• wash hands
• id and gather equipment
• id pt
• explain procedure
• provide privacy
• need any padding???
• put on prot equipment

containing blood

clear pale yellow serum

thick yellow or green puss - sign of infection

bile made by bd help break down fats for digestion -- dark green color and is present after gallbladder surgery

both blood and clear drainage -- pink color

both clear and pus present

protect underlying wound or dressing, provide pressure, support, or immobilization

muslin or elasticized fabric

30 mins

circulation, motor, sensation

• id purpose, review chart
• id body part
• effectiveness of previous

• PLAN
• WASH HANDS
• OBTAIN DEVICES
• PLAN FOR INTERVALS TO CHECK CMS

• right pt?
• explain purpose
• provide privacy
• clean gloves, remove soilded
• assess wound
• use tech apply new
• examine for neatness
• essess extremeties for cms

• pt comfort
• effectiveness
• safety

• time
• type bandage
• area
• assesment cms
• length of tiem was off
• cond of skin
• re application

hold dressings in place on limbs, 1/5 in, 1 in, 2 in, 3 in wideths -- not stretch, soft, strong, comfortable -- easily molded sterile and non sterile

soft, mesh like -- avail in 2, 3, and 4 in widths, extremities, head, and tors0 --part of primary dress or used to hold other dress in place sterile or nonsterile -- keep in functional position

ace wrap -- provide constant pressure over area or support inj joint -- lower extremity facilitate venous return -- extremity elastic hose, elastic sleeve, or sequential compression device can be used instead

secures dress or covers confined area

provide comfort to a wider area , begen distally and wind proximally

used over joint easy flexion

bandage distal portions of extrem or stump, best pressure

hold dress in place or support tissues

chest, abd, or pelvic area

firm elastic fabirc w velcro fasteners across front

hold dress in place,l not support -- washed easy, air circulation, stretch to shape

hold perineal dressing or pack in place, single female, double male, elastic, muslin, or disposable

debride wound surface -- moist gauze absorbs drainage, dry adheres to surface, surface debris removed w dressing

uncomfortable, moistening negates purpose

kills all pathogens and spores

kills pathogens but not spores

iv pumps or electircal equip

steam pressure w heat ranging from 250-s70 degrees, sterilize

10 mins kills non-spore forming organisms but not spores

kills pathogens of sutures, some plastics, and biological mat

kill path on equipment and supplies that cannot be heated, cidex - sterilize rubber-based catherters for urological

kills pathogens on supplies and equip that are heat sensitive or must remain dry

soft latex rubber tubing material, one end is placed in bottom of wound and other opens to outside of bd trhu small surgical stab wound, sterile safety pin attachied to penrose drain to prevent sliding down into wound

placed during surgery, drainage tube w mult openings, attachec to vaccuum unit, hemovac, jp drain, used after breast, hep or perineal surg

folded gauze pads

absorb drainage, pack wounds

combinations -

nonadherent, synthetic material attached to one side,

thin sheet plastic, called by brand names, one side ahdesive, allows gases to move thru, provide moist surface encouraging epitherlialization of wound surface, small wounds and iv sites

duoderm, soft wafer, epithethelilization and healing, impermeable, used over stage 2 one week

used around tubes or drains to hold them awy from skin and prevent abrasion

tie across large/bulky dress, avoids skin irritation caused by repeated tape removal, eyelets, twill tape to secrue,

disposable, allows measurement, control odor,