quiz 1 - wounds Flashcards
Briefly describe when a Jackson Pratt drain is indicated.
Your Jackson-Pratt drain has a soft plastic bulb with a stopper and a flexible tube attached. The drainage end of the tubing (flat white part) goes into your surgical site through the insertion site. The insertion site is the small opening near your incision.
It is indicated to be put in during surgery and usually used to prevent fluids from collecting underneath the incision site.
Removing Sutures: - outline the procedure for removing staples and contraindications.
Look at orders to ensure that that is what is supposed to be done for the patient and see if any analgesics are prescribed for the patient. Explain to the patient what will be done today, and what to expect. Perform hand hygiene. Make sure there is privacy, then get a sterile suture removal kit and get field prepared for the skill. Apply clean gloves, then remove the dressing careful from the patient. Inspect the wounds incision and suture line. Take dirty gloves off and perform hand hygiene again. Cleanse the sutures with antiseptic swabs, changing in between each swipe. Use the staple extractor tool and put it under the first staple, then close the handled to extract the ends. Move staple away from the surface of the skin, then drop it in the garagbage bag, repeat until all staples are done.
Contraindications would include if the wound showed signs of dehiscence and or evisceration.
Describe what a VAC dressing is and when it is indicated.
VAC dressing is also known as a vacuum-assisted closure of a wound. It uses negative pressure to help heal the wound with less complications involved. It has been used to help fluid collection, helps stop infection, increase tissue perfusion, stimulates granulation of tissue and reduces Edema.
infection
occurs when all the chains of infection are linked, and occurs when virus, bacteria, etc. Enters a portal of entry and begin to multiply.
dehiscence
partial or total separation of wound edges due to an improper healing process
evisceration
the process of which a wound has organs perfusing out of it.
approcimation
how close the wound edges are to each other
undermining
when there is a ‘pocket’ that forms underneath the wound
tunneling
is like undermining but refers to the deeper penetration of skin within the pocket
maceration
this occurs when skin has been exposed to moisture for too long, it clinically presents as skin that looks soggier and feels soft to the touch
erythema
wound caused by unrelieved pressure. It usually occurs over bony prominences and can be compounded by friction, shearing and/or moisture. Clinical presentation is skin intact with localized warmth, soft tissue swelling and/or induration (firmness of the tissue)
granulation
also known as healing tissue. Clinical presentation is firm, moist, pebbly, pink or red tissue. It has small-moderate amounts of serous exudate. No odour and presences in wounds of any depth
slough
Is the white/yellow tissues that is shown around the wound. it can be presented dry slough or wet. Dry slough clinically presents as dry slough, with small amounts of exudate, odour after cleansing is likely. Peri-wound erythema can also be present. Wet slough is presented as a wound partially or fully covered with wet, stringy necrotic debris, which can be yellow, green, grey or brown, moderate to severe amounts of serous or Sero-purulent exudate. Odour is likely after cleansing and peri-wound erythema can also be present.
eschar
dead tissue that forms over dead tissues, clinical presentation is a thick leathery black or brown tissue, which may cover the entire wound bed. It can be dry or moist.
hemostatis phase
Blood vessels constrict and clotting factors are activated. Clot formation blocks the bleeding and acts as a barrier to prevent bacterial contamination. Platelets release growth factors, which alert various cells to start the repair process at the wound location.
