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how do you describe the odor in wound drainage?
absent, faint, moderate, or strong
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how do you describe the color in wound drainage?
serous or clear, serodsnguineous, sanguineous, purulent, or seropurulent (composed of serum and pus)
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what to do if drain is present
measure the amount of fluid in a collection container
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how to describe the amount in a wound drainage
none, light, moderate or heavy
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used to cleanse wounds by flushing. (there is a risk of splattering when doing this, so you need to use gowns, mask and googles
irrigating wounds (lavage)
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a flexible, flat latex tube that is placed in the wound bed but usually not sutured into place. A clip or pin may be attached to the drain at the insertion site to keep it from slipping into the wound
Penrose drain
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Some drains are attached to a collection device
Hemovac and Jackson Pratt
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used to identify persons at risk for developing pressure ulcers.
the Braden scale
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assess risk based on the patient's physical condition, mental state, activity, mobility and incontinence
The Norton scale
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the removal of devitalized tissue or foreign material from a wound
Debridement
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the use of a sharp instrument, such as scalpel or scissors, to remove devitalized tissue. This method provides an immediate improvement of the wound bed and preservers granulation tissue.
Sharp debridement
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may be performed via lavage (discussed in a preceding section), the use of wet to dry dressing, or hydrotherapy (whirlpool)
mechanical debridement
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uses proteolytic agents to break down necrotic tissue without affecting viable tissue in the wound
enzymatic debridement
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the use of an occlusive, moisture retaining dressing and the body's own enzymes and defense mechanisms to break down necrotic tissue (this procedure involves applying the dressing and observing the fluid the collects under it). (changed every 72 hours)
autolysis
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the use of medical grade larvae of the greenbottle fly to dissolve dead and infected tissue from wounds. The larvae secrete enzymes that liquefy dead tissue and create an alkaline environment (changed 48-72 hours)
maggot debridement therapy
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the ones that are placed in the wound bed and actually touch the wound
dressing
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covers or holds a primary dressing in place
secondary dressing
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why are wounds irrigated?
to remove debris from a wound
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The death of cells or tissues from severe injury or disease, especially in a localized area of the body.
necrosis
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used to keep a wound closed when there is danger or dehiscence, or to immobilize a body part to aid in the healing process.
binding
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used to support the upper extremities
triangular arm binder or sling
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used to secure dressings or pads in the perineal area
T binder
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used to provide support to the abdomen
abdominal binder
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