Tissue Integrity Part 2

Question 1

what is convection

Answer 1

transfer of heat

Question 2

what is primary intention

Answer 2

wound margins are well approximated (opposing edges are together)
laceration and surgical incision
has most rapid healing

Question 3

what is secondary intention

Answer 3

infected wounds or wound margins are not well approximated
larger wound area requires formation of granulation tissue to fill gap
longer time to heal

Question 4

what is tertiary intention

Answer 4

associated w/ large infected and contaminated wounds

Question 5

how do you treat a primary intention wound

Answer 5

edges brought together by sutures
no granulation tissue seen w/ healing
short healing period w/ minimal tissue loss
clean wound

Question 6

how do you treat a secondary intention wound

Answer 6

packed w/ gauze
surgical wound left open to heal by scar formation
primary intention is not possible due to tissue damage/loss (trauma)
wound is allowed to granulate

Question 7

what is needed for a wound to heal

Answer 7

o2 and nutrients

Question 8

what is thrid intention used for

Answer 8

manages heavily infected or contaminated wounds
left open
granulation tissue

Question 9

what are the 3 phases of wound healing

Answer 9

inflammatory phase
granulation phase
maturation phase

Question 10

what happens in the inflammatory phase

Answer 10

lasts 3-5 days
homeostatis develops- macrophages remove debris

Question 11

what happens in the granulation phase

Answer 11

lasts 5-21 days
new bvs and tissue are formed

Question 12

what happens in the maturation phase

Answer 12

lasts for months
collagen fiber is remodeled- scar formation and contraction occur

Question 13

what populations are at higher risk for impaired tissue integrity

Answer 13

infants
children
older adults

Question 14

what does macerated mean

Answer 14

excess moisture- wrinkly skin after shower

Question 15

what is cleansing

Answer 15

removal of debris and exudate

Question 16

what do you use to irrigate

Answer 16

normal saline

Question 17

if you have drainage what dressing do you apply

Answer 17

absorbant dressing

Question 18

why do diabetic foot uclers occur

Answer 18

sensory neuropathy
peri vascular disease (poor circulation)
immunocompromised (hyperglycemia impairs ability for leukocytes to destroy bacteria)

Question 19

what is the developemnt of diabetic foot ulcers

Answer 19

soft tissue injury- skin breakdown btwn toes, areas of dry skin, or formation of callus
unable to feel pain- injuries from cutting nails, foreign objects, or ill-fitting shoes
cant feel temp
unaware of pressure

Question 20

what are the clinical signs of diabetic foot ulcer

Answer 20

drainage
swelling
redness of leg
gangrene

Question 21

what is the treatment for diabetic foot ulcers

Answer 21

keep pt off of feet
control bgl
antibiotics
debridement

Question 22

what are some risk factors for diabetic foot ulcers

Answer 22

diabetes for more than 5 years
age over 40
smoking
decreased peripheral pulses
decreased sensation
anatomic deformities or pressure areas
hx of foot ulcers or amputations

Question 23

how do you manage diabetic foot ulcers

Answer 23

feet examined at least once a yr
assess for neuropathy
pressure areas (calluses or thick toenails) treated by podiatrist
routine nail trimming by podiatrist
monitoring and managing bgl

Question 24

what are nursing management for diabetic foot ulcers

Answer 24

foot assessment at each encounter
educating on well fitting shoes, wearing same shoes for no more than 2 days in a row, never go barefoot, check feet daily, no lotion btwn toes, check bath water w/ hands