Moist Wound Healing
Reason moisture is necessary for proper wound healing
What is moisture facilitates the formation of granulation tissue?
The physiological process immediately after tissue injury
What is inflammation?
Tissue death due to an absent oxygenated blood supply
What is necrosis?
One of the primary goals of wound dressings is to protect the wound from bacteria and contaminants to prevent this
What is prevention of infection?
This action by the nurse should be avoided if you suspect a pressure wound
This stage of pressure ulcer is characterized by a deep ulceration, extending to muscle and bone
What is stage IV?
The normal, non-injured skin immediately surrounding the wound
What is periwound?
During the proliferation phase, this type of tissue is formed that is made of new cells and blood vessels
What is granulation tissue?
Type of open drain that allows gravity to assist with drainage
What is a Penrose Drain?
This technique is used to encourage debridement through frequent dressing changes
What is wet to dry dressings?
This type of wound is often caused by friction and fragile skin
What is a skin tear?
This stage of pressure ulcer is characterized by reddened skin accompanied by blistering or skin tear
What is stage II?
Method for keeping deep wounds and tunneling wounds moist.
What is sterile gauze moistened with normal saline or hydrogel-impregnated dressings?
These are typically used after staple removal or for small wound closure
What are steri-strips?
Removal of nonviable tissue (sometimes necrotic tissue or eschar) from the wound
What is debridement?
Normal saline delivered with a syringe or commercial cleaners during dressing change
What is irrigation?
Type of wound drainage that is clear/yellow watery plasma
What is serous?
This type of wound is caused by decreased circulation to the extremities
What is stasis ulcer?
Ways to manage proper moisture in a wound
What is use of dressings such as alginate or hydrofiber?
The separation of wound edges without the protrusion of organs
What is dehiscence?
Name 3 methods of debridement?
What is autolytic, enzymatic, mechanical, or sharp?
This stretchy bandage is typically used over gauze dressing for compression
What is ACE wrap?
Type of wound drainage that is bright red
Sanguineous
This stage of pressure ulcer is characterized by a shallow skin crater that extends to the SQ tissue
What is stage III?
The softening and wasting away of skin due to excess moisture
What is maceration?
The dead tissue on the wound surface that is moist and yellow/grey/green
What is slough?
Type of closed drain that requires manual suction by compressing the collection chamber
What is JP drain or Hemovac?
What is gaps and wrinkles?
Type of wound drainage that is a mixture of plasma and blood
What is serosanguineous?
To initiate suction on a closed drainage system, this action needs to take place
What is compression of collection container?
Why might alginate dressings be confused with purulent drainage?
What is they have a slightly greenish tint?
Type of wound drainage that is yellow, green, and has a foul odor
What is purulent drainage?
when prescribed topical agents, like collagenase ointment, are directly applied to wound bed daily or more frequently if dressing becomes soiled to cause debridement
What is enzymatic debridement?
The granules in this dressing become gelatinous to keep wound moist
What is hydrocolloids?
These are signs of infection
What are erythema, induration, pain, edema, purulent exudate and odor?
uses a vacuum system to withdraw fluids and collect them in a reservoir, drainage must be emptied and measured routinely
What is a wound vac?
Ways of preventing maceration of the periwound skin
What are skin barrier creams, skin protective wipes, skin protective wafers, apply moist dressings carefully to maintain wound bed moisture while protecting the peri wound skin?
The process by which these cells consume cellular debris
What is phagocytes?
Invasive procedure performed by a trained healthcare provider at bedside or in an operating room involving a scalpel or scissors to remove necrotic tissue and leave only viable tissue
What is sharp debridement?
can be used as a primary dressing or moistened to use for packing, inexpensive, must be changed daily, unless moistened may stick to wound
what is gauze or Kerlix?
passageways underneath the skin surface extending from a wound that can take twists and turns
What is tunneling?
Reason that sterile technique for sterile removal indicates removing every second staple at first
What is prevention of dehiscence in case wound is not healed enough to stay closed on its own?
In what types of wound is packing strips used?
What is tunneling wounds?
When the body produces an increased amount of white blood cells
What is leukocytosis?
A technique used for flushing debris out of wound
What is irrigation?
Can be used on wounds with little or no exudate to retain moisture, commonly used to secure other dressings such as foam
What are transparent films?
A condition that occurs when the tissue under the wound edges becomes eroded resulting in a pocket beneath the skin at the wound edge
What is undermining?
3 ways to prevent pressure ulcers
What is change positions frequently, lift during repositioning, avoid plastic covered pillows, lateral oblique, keep skin clean/dry, pressure-relieving devices, pad vulnerable areas, keep HOB elevated <30degrees, balanced diet, skin prep?