NR224 Fundamentals: Skills Exam 2 Study Guide

70 questions 1. What assessment data is needed for wound healing? Assess the patient NUTRITION. Nutrition role in healing  Calories: Cell energy  Protein: wound remolding  VIt. C, A, E  Zinc : Collage  Fluid: cell function a. Complications Nutrition: weight: any change recently (malnourished). Skin condition: turgor dehydration. Lab: albumen (normal is 3.5-5.0) Ask question: how much meat do you eat/protein? Necrosis Drainage Infection Perfusion (lack of O2) hypoxia Hemorrhage Hematoma Dehiscence: partial separation of wound layer. Evisceration: total separation of wound layered: organs exposure Laceration: cut. Can be bleeding more profusely Puncture: bleed in related to size. b. Healthy tissue: beefy red  Granulation tissue: red, moist tissue composed of new blood vessels.  No Induration( Edge hard is not good for wound heal)  Edge: well approximated  No tunneling  No undermining c. Drainage types and their characteristics  Serosanguineous : pale, pink, watery, mixture of clear and red fluid. *  Serous: clear, watery, plasma  Snaguieous: bright red, indicates, active bleeding.  Purulent: thick, yellow, green, tan, or red fluid. (infection)- bad news  Serosanguinous: This thin, pink-colored discharge is usually associated with normal wound recovery.  Purulent: Often a sign of infection, purulent discharge is generally thick and either green or yellow in color.  Seropurulent: Sometimes linked more mild infections, this is a yellow and especially cloudy form of drainage. This study source was downloaded by from CourseH on :46:27 GMT -06:00 NR224 Fundamentals: Skills Exam 2 Study Guide  Serous: Though expected during the inflammation stage, serous drainage can later be indicative of severe infection.  Sanguinous: This type of drainage is most associated with broken capillaries, which explains its dark red color.  Sudden drainage is black so need to notify to doctor. d. Wound care supplies and infection Type of drainage Perose-fat balloon that sticks out and drains onto 4*4 Hemvac VAC Jackson –Pratt (Self-suction) drainage (less30mL), each one put sparely. (Mastectomy)  10cc saline syringe - wear ( PPE)  Taking the dressing off is clean proximal and distal. (Abdomen wound)  Clean and change New Change dressing is sterile. 2. Describe the proliferation phase of wound healing o Epithelization: resurfacing of the wound deposition with granulation tissue. o 3 -24 days o Collage o New blood vessels o Bleed easily o Dark granulation tissue is infection and ischemia. (Poor blood perfusion) o No sign infecting including Para wound area, no yellow/thick purulent drainage.  Phases of the wound healing: Hemostasis, Inflammatory, proliferative, remodeling.( full –thickness )  Healing process:  Primary intent