2/18/24, 8:15 AM NU 136, Galen College of Nursing, Exam 2, Units 4-6, Chapters 22, 28, 39, 29, 30, 38 Flashcards | Quizlet
NU 136, Galen College of Nursing, Exam 2, Units 4-6, Chapters 22, 28, 39, 29, 30, 38 Study
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NU 136, Galen College of Nursing, Exam 2, Units 4-6,
Chapters 22, 28, 39, 29, 30, 38
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Terms in this set (557)
-between toes
-tips of toes
what are the locations for arterial ulcers
-over phalangeal heads
-around lateral malleolus
-severe pain
-minimal drainage
-decreased temperature
what are the characteristics of arterial ulcers -absent or diminished pulses
-cyanosis
-thickened toenails
-gangrene
-medial lower leg
-ankle
what are the locations for venous ulcers
-superior to medial melleolus
-seldom, if ever noted on the foot or above the knee
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,2/18/24, 8:15 AM NU 136, Galen College of Nursing, Exam 2, Units 4-6, Chapters 22, 28, 39, 29, 30, 38 Flashcards | Quizlet
-moderate to large amount of drainage
NU 136, Galen College of Nursing, Exam-pain
2, Units 4-6, Chapters 22, 28, 39, 29, 30, 38
levels vary
what are the characteristics of venous ulcers -ankle flare
-lipodermatosclerosis (hard fibrous of surrounding tissue)
-dialated superficial veins
-plantar aspect of foot
what are the location for neuropathic (Diabetic) ulcers -over metatarsal heads
-under heel
-low to moderate drainage
-foot deformities
-deminished or absent sensation in foot
what are the characteristics for neuropathic ulcers
-palpable pulses
-osteomyelitis
-usually painless
hemostatis
inflammation
what are the phases of wound healing
proliferation
maturation
what phase is the hemostasis phase 1 -the immediate response the body initiates to heal (blood clotting)
phase 2 - begins immediately and last 4-5 days, it is the protective response (heat, pain,
what phase is the inflammation
edema) wbc & macrophages migrate to the wound & begin the repair
what phase is the proliferation phase 3 - reconstructive phase - begins on 3rd or 4th day and lasts 2-3 weeks
phase 4 - final phase/remodeling phase - scar maturation, scar slowly thins and
what phase is the maturation phase
becomes paler - begins about 3 weeks after injury and can last up to 2 years
-age
-nutrition (protein/fluid needed for healing)
-medications (heparin, steroids, antineoplastics interfere
w/healing
-Infection (slows healing) chronic illness (COPD, DM, CV)
what factors affect wound healing
slows wound healing due to lack of oxygen & nutrients at
the cellular level
-lifestyle (regular exercise)
-decreased immune system
-decreased liver function
what is first intention (Primary) little tissue loss - edges of wound approximate and only a slight chance of infection
a wound with tissue loss - edges of wound do not approximate;wound left open & fills
what is second intention
with scar tissue
occurs when there is delayed suturing of a wound/wound sutured after granulation
what is third intention (Tertiary)
tissue begins to form. (Healing.)
-contusion (bruise w/out breaking skin)
what are the closed wounds and characteristics -hematoma (pooling of blood under unbroken skin)
-sprain (twisting of a joint)
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,2/18/24, 8:15 AM NU 136, Galen College of Nursing, Exam 2, Units 4-6, Chapters 22, 28, 39, 29, 30, 38 Flashcards | Quizlet
-incision (surgically made separation of tissues w/clean
NU 136, Galen College of Nursing, Exameven
2, Units
edges) 4-6, Chapters 22, 28, 39, 29, 30, 38
-laceration (traumatic separation of tissue)
-abrasion (traumatic scraping)
what are the open wounds and characteristics -penetrating (bullet/metal)
-avulsion (tearing away)
-ulceration (excavation of skin
-perforation (internal organ/cavity)
-crush (tissue disrupted or compressed
-hemorrhage (uncontrolled bleeding)
-dehiscence (spontaneous opening of an incision)
list complications of wound healing -evisceration (protrusion of an internal organ through an
incision)
-infection (redness, edema, pain, purulent drainage)
what is the purpose of wound drains to provide an exit for blood & pus that accumulate during the inflammation process
it is attached to a wound suction device to remove any accumulated exudate or other
how does an active drain work material
(ex. Hemovac & Jackson-Pratt)
it has no suction device, it works by the increased pressure inside the wound & depends
how does a passive drain work
on gravity & capillary action to pull out any fluid buildup (Penrose)
color
consistency
what do you assess with drainage
odor
amount
-increase healing rate by 40%
-increases blood flow to wound
what are the advantages of negative pressure wound
-less frequent dressing changes
therapy (wound vac)
-improved tissue growth
-draws out fluid
vacuum assisted closure involves applying a suction device to a special dressing to
what is negative pressure wound therapy institute negative pressure at the site, drawing the edges together, a mechanical stretch
of cells occur which increases cellular proliferation and tissue growth
a cold compress can be on no longer 20 minutes
than____________________________
what is the most common place for neuropathic ulcers metatarsals
what is charcot foot when the arch collapses and causes an ulcer
the skin around it for:
edema
what do you assess about a wound
erythema
temp
sutures
staples
what are types of wound closures
steri-strips (if wound is small)
dermabond (synthetic, non-invasive glue_
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, 2/18/24, 8:15 AM NU 136, Galen College of Nursing, Exam 2, Units 4-6, Chapters 22, 28, 39, 29, 30, 38 Flashcards | Quizlet
sharps - cut it out
NU 136, Galen College of Nursing, Examenzymatic
2, Units 4-6,substances
- topical Chapters that 22,
break28, 39,
down 29, 30, 38
& liquefy
the dead tissue
chemical - the use of Dakin solution or sterile maggots on a
what are the different types of debridement
wound with necrotic tissue that isn't responding
mechanical-physical removal of debris by irrigation or
hydrotherapy with a whirlpool bath or
ultrasound mist
-self adhesive dressing that keeps a wound moist
-water and air occlusive
what is a hydrocolloid
-facilitates autolytic debridement
-provides thermal insulation
-tie tapes
what are montgomery straps -allow for changing of the dressing without removing and
reapplying tape (which can cause skin irritation)
-non-adherent dressing
shiney non adherent surface on one side that is applied to the wound, exudate seeps
what is telfa
through this surface & collects in the absorbent material, causing less wound trauma
when removed
-arythema (redness;inflammation can mean infection)
-edema(if it goes away & comes back could mean infection)
-denuded (looks raw/epithelial sloughed off)
what do you assess on a wound
-fluxuants (movement like fluid under the skin
-drainage (color, consistency, amount and odor but only if
odor remains after wound has been cleaned)
why is cold not applied to an area that is already because it will slow circulation and prevent absorption of interstitial fluid
edematous
why is cold not applied to a patient when neuropathy is because they may be unable to determine whether the tissue becomes too cold
present
if a patient has cardiovascular problems why is it unwise it can cause massive vasodilation that may divert blood supply from major organs
to apply heat to a large part of the body
the assessment of the wound indicates healing is pink granulation tissue is visible
occurring when
a rise in temperature
a wbc count above 10,000/dL
signs of wound infection restlessness & discomfort
purulent drainage
tenderness around the wound
when caring for a pressure ulcer, you know that eschar must usually be removed before the wound will heal
hydrocolloid dressings are useful for open wound keep the wound moist while blocking entry of microorganisms
dressings because they
If you are assisting a surgical patient to the bathroom dehiscence
and he suddenly says, "it feels like something has given
way" you would suspect that_______________________has
occured
cold packs applied during the first 24 hours after injury causing vasoconstriction and decreasing bleeding from damaged blood vessels
decrease swelling by
when granulation tissue becomes rounded
what is hypergranulation
this needs to be removed
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