NR I224 IExam I2 IStudy IGuide
1. What Iassessment Idata IisIneeded IforIwound
I healing?IA ssess I the I patient I NUTRITION.
Nutrition Irole Iin Ihealing
• Calories: ICell Ienergy
• Protein: Iwound Iremolding
• VIt. IC, IA, IE
• Zinc I: ICollage
• Fluid:Icell Ifunction
a. Complications
Nutrition: Iweight: Iany Ichange Irecently
I (malnourished).ISkinI condition: I turgor I dehydration.
Lab: Ialbumen I(normal Iis I3.5-5.0)
AskIquestion: IhowImuchImeat IdoIyou
I eat/protein?IN ecrosis
DrainageI
Infection
PerfusionI(lackIof IO2)
IhypoxiaIHemorrhage
Hematoma
Dehiscence: Ipartial IseparationIof Iwound Il ayer.
Evisceration: Itotal Iseparation Iof Iwound Il ayered: Iorgans
IexposureILaceration: I cut. I Can I be Ibleeding I more I profusely
Puncture: IbleedIinIrelatedItoIsize.
b. HealthyItissue: Ibeefy Ired
• GranulationItissue:Ired,ImoistItissue Icomposed Iof Inew IbloodIvessels.
• No IInduration( IEdge IhardIis Inot IgoodIfor IwoundIheal)
• Edge: Iwell I approximated
• No Itunneling
• No Iundermining
c. Drainage Itypes IandItheir Icharacteristics
• SerosanguineousI:Ipale, Ipink,Iwatery, Imixture Iof IclearIandIred Ifluid. I*
• Serous: Iclear, Iwatery,Iplasma
• Snaguieous:IbrightIred,Iindicates, Iactive Ibleeding.
• Purulent: Ithick, Iyellow,Igreen,Itan, Ior IredIfluid.I(infection)-IbadInews
• Serosang uino us: I This I thin, I pink-colored I discharge
I isIusually I associated Iwith I normal Iw ound I recovery.
• Purulent:IOften IaIsign Iof Iinfection,Ipurulent Idischarge Iis
generally Ithick I and Ieither I green Ior I yellow Iin Icolor.
• Sero purulent: I Sometimes I linked I more I mild I infections,
I thisIi s I a Iyellow I and I especially Icloudy I form I of I drainage.
, • Sero us: I Though I expected I during I the I inflam mation
I stage, Iserous I drainage I can I later Ibe Iindicativ e Iof
severe Iinfection.
• Sang uino us: I This I type I of I drainage I is I most I associated
I with Ibroken Icapillaries, Iwhich Iexplains Iits I dark Ired Icolor.
• SuddenIdrainage IisIblackIsoIneedIto Inotify Ito Idoctor.
d. Wound Icare Isupplies IandIinfection
Type IofIdrainage
Perose-fat Iballoon Ithat IsticksIout Iand Idrains Ionto
I4*4IHemvac
VAC
Jackson I–PrattI(Self-suction) Idrainage I(less30mL), Ieach Ione Iput
Isparely.I( Mastectomy)
• 10cc Isaline Isyringe I - I wear I( IPPE)
• TakingIthe IdressingIoff Iis IcleanIproximal IandIdistal.I(AbdomenIwound)
• Clean Iand Ichange INewIChange Idressing IisIsterile.
2. Describe Ithe Iproliferation Iphase Iof IwoundIhealing
o Epithelization: Iresurfacing Iof Ithe IwoundIdepositionIwithIgranulationItissue.
o 3 I-24Idays
o Collage
o New Iblood Ivessels
o BleedIeasily
o Dark IgranulationItissue Iis IinfectionIand Iischemia.I(PoorIbloodIperfusion)
o NoIsign IinfectingIincludingIPara IwoundIarea, Ino Iyellow/thickIpurulentIdrainage.
• Phases Iof Ithe IwoundIhealing:IHemostasis, IInflammatory,
Iproliferative,Iremodeling.( I full I –thickness I )
• HealingIprocess:
❖ PrimaryIintention: IwoundIclosed IbyIsurgical Ii ncision( Iexternal)
I ex;Isurgical I suture
❖ Secondary Iintention: Iwound Iedges Inot IapproximatedI(internal) Iex:
pressure Iulcer
Wound Iheals Iby Igranulation Itissue Iformation.
❖ Tertiary Ii ntention: IwoundIleft IopenIfor Iseveral Idays(
Icontaminated/Ii nfection Iwound)
3. Risks Ifor Ipressure Iulcers I(pressure Ipoints)
a. TypesIof IpatientsIis IriskIfor Ipressure Iulcer
• Secondary Ilifestyle IpatientI(smoking)
• People Iwho Icannot Ichange ItheirIown Iposition(quadra)
• Decrease IMental Istatus
• Unconscious
• Incontinent/diaperIhow Ioften Ido IyouIuse Itoilet
• No IsensoryIfelling
b. Alterations Ii nIhealth IriskIfor Ipressure
I ulcer:IDiabetes I neuropathy,
CHF I(no Igood Iblood Iflow)
1. What Iassessment Idata IisIneeded IforIwound
I healing?IA ssess I the I patient I NUTRITION.
Nutrition Irole Iin Ihealing
• Calories: ICell Ienergy
• Protein: Iwound Iremolding
• VIt. IC, IA, IE
• Zinc I: ICollage
• Fluid:Icell Ifunction
a. Complications
Nutrition: Iweight: Iany Ichange Irecently
I (malnourished).ISkinI condition: I turgor I dehydration.
Lab: Ialbumen I(normal Iis I3.5-5.0)
AskIquestion: IhowImuchImeat IdoIyou
I eat/protein?IN ecrosis
DrainageI
Infection
PerfusionI(lackIof IO2)
IhypoxiaIHemorrhage
Hematoma
Dehiscence: Ipartial IseparationIof Iwound Il ayer.
Evisceration: Itotal Iseparation Iof Iwound Il ayered: Iorgans
IexposureILaceration: I cut. I Can I be Ibleeding I more I profusely
Puncture: IbleedIinIrelatedItoIsize.
b. HealthyItissue: Ibeefy Ired
• GranulationItissue:Ired,ImoistItissue Icomposed Iof Inew IbloodIvessels.
• No IInduration( IEdge IhardIis Inot IgoodIfor IwoundIheal)
• Edge: Iwell I approximated
• No Itunneling
• No Iundermining
c. Drainage Itypes IandItheir Icharacteristics
• SerosanguineousI:Ipale, Ipink,Iwatery, Imixture Iof IclearIandIred Ifluid. I*
• Serous: Iclear, Iwatery,Iplasma
• Snaguieous:IbrightIred,Iindicates, Iactive Ibleeding.
• Purulent: Ithick, Iyellow,Igreen,Itan, Ior IredIfluid.I(infection)-IbadInews
• Serosang uino us: I This I thin, I pink-colored I discharge
I isIusually I associated Iwith I normal Iw ound I recovery.
• Purulent:IOften IaIsign Iof Iinfection,Ipurulent Idischarge Iis
generally Ithick I and Ieither I green Ior I yellow Iin Icolor.
• Sero purulent: I Sometimes I linked I more I mild I infections,
I thisIi s I a Iyellow I and I especially Icloudy I form I of I drainage.
, • Sero us: I Though I expected I during I the I inflam mation
I stage, Iserous I drainage I can I later Ibe Iindicativ e Iof
severe Iinfection.
• Sang uino us: I This I type I of I drainage I is I most I associated
I with Ibroken Icapillaries, Iwhich Iexplains Iits I dark Ired Icolor.
• SuddenIdrainage IisIblackIsoIneedIto Inotify Ito Idoctor.
d. Wound Icare Isupplies IandIinfection
Type IofIdrainage
Perose-fat Iballoon Ithat IsticksIout Iand Idrains Ionto
I4*4IHemvac
VAC
Jackson I–PrattI(Self-suction) Idrainage I(less30mL), Ieach Ione Iput
Isparely.I( Mastectomy)
• 10cc Isaline Isyringe I - I wear I( IPPE)
• TakingIthe IdressingIoff Iis IcleanIproximal IandIdistal.I(AbdomenIwound)
• Clean Iand Ichange INewIChange Idressing IisIsterile.
2. Describe Ithe Iproliferation Iphase Iof IwoundIhealing
o Epithelization: Iresurfacing Iof Ithe IwoundIdepositionIwithIgranulationItissue.
o 3 I-24Idays
o Collage
o New Iblood Ivessels
o BleedIeasily
o Dark IgranulationItissue Iis IinfectionIand Iischemia.I(PoorIbloodIperfusion)
o NoIsign IinfectingIincludingIPara IwoundIarea, Ino Iyellow/thickIpurulentIdrainage.
• Phases Iof Ithe IwoundIhealing:IHemostasis, IInflammatory,
Iproliferative,Iremodeling.( I full I –thickness I )
• HealingIprocess:
❖ PrimaryIintention: IwoundIclosed IbyIsurgical Ii ncision( Iexternal)
I ex;Isurgical I suture
❖ Secondary Iintention: Iwound Iedges Inot IapproximatedI(internal) Iex:
pressure Iulcer
Wound Iheals Iby Igranulation Itissue Iformation.
❖ Tertiary Ii ntention: IwoundIleft IopenIfor Iseveral Idays(
Icontaminated/Ii nfection Iwound)
3. Risks Ifor Ipressure Iulcers I(pressure Ipoints)
a. TypesIof IpatientsIis IriskIfor Ipressure Iulcer
• Secondary Ilifestyle IpatientI(smoking)
• People Iwho Icannot Ichange ItheirIown Iposition(quadra)
• Decrease IMental Istatus
• Unconscious
• Incontinent/diaperIhow Ioften Ido IyouIuse Itoilet
• No IsensoryIfelling
b. Alterations Ii nIhealth IriskIfor Ipressure
I ulcer:IDiabetes I neuropathy,
CHF I(no Igood Iblood Iflow)
