module 2 of NF2

what is the inflammatory phase of healing

1. this occurs incision day to post op day two

2. hemostasis happens and phagocytosis happens ( blood clots and white blood cells)

3. it appears mildy red and mild swelling

what is the proliferative phase (granulation)

1. occurs day 2-21

2. collagen strengthens wound, scar tissue produces \

3. granulation tissue is highly vascular

what is the maturation phase - early

1. occurs 2-3 weeks to 6 weeks

2. Collagen reorganized into more orderly structure

3. raised scar forms

what is the maturation phase- later

1. occurs 6 weeks to 1-2 years

2. scar tissue has 80% or less original tissue strength

3. flat thin scar

what does a nurse asses during wound care

1. they asses REEDA

2. Redness

3. Edema

4. Ecchymosis

5. Drainage

6. Approximate (size)

what does the nurse also asses during wound care

1. they asses TACO

2. Type (serous, purulent, sanguineous, serosanguinous)

3. Amount

4. Color/Consistency

5. Odour

what patient assessments should be done prior to completing a surgical dressing change

• Patient identity, pain level, allergies.

• Practitioner’s order & facility policy.

• Signs of infection or complications.

what are the first 5 steps for Surgical Wound Care

1. Verify practitioner orders and check policy and procedure

2. Complete hand hygiene, identify patient, provide privacy, explain procedure

3. Complete pre-assessments including pain assessment

4. Gather supplies

5. Complete assessment of incision and drainage

what are the last five steps for surgical wound care

1. Donn clean gloves, remove dressing away from patient vision

2. Remove gloves and discard along with used dressing in appropriate receptacle. Perform hand hygiene. Set up sterile field(s) as necessary

3. Donn clean gloves. Cleanse incision. Complete any remaining incision assessments

4. Remove sutures/staples. Apply adhesive strips and sterile dressing as ordered

5. Provide teachings and document