week4studyguide2025
Dressing types to promote healing,
Hydrocolloid - moist environment promoting healing and protecting new tissue
Calcium alginate primary dressing - wet to dry stage 3-4
Silicone absorban dressing
Wound stages description
Stage 1 - nonflammable skin, skin intact
Stage 2 - skin barriers are broken to epiderm or dem
Stage 3 - full thickness but no bone exposure ulcer goes till fat layer SUBCUTANEUS TISS
Stage 4 - full-thickness bone, muscle exposure. Undermining tunneling
unstageable
Healing stages
Inflammatory
Primary intention - closed surgical parallel
Secondary deep- heals down to up
Wound drainage types
Serous- Clear, watery plasma
purulent- pus THICK yellow green tan brown
Serisanginous - bloody liquid (sanguin and serous combo) pale red
Sanguineous- bleeding bright red
Causes of delays in wound healing
Immunocompromised, diabetic, edema
Immunosuppressant agents
Antineoplastic agents
Corticosteroid
NSAIDS
Anticoagulants
Pedal pulse less than 2
The phase of healing in a wound
Inside to outside
Lost muscle fat or dermis is not replaced
If it reopens, it has the same classification ex stage 4 always stage 4 even after healing doesnt become 3
Filled with granulation scar tissue
Risk factors for pressure ulcer and injury
Moisture
Aging skin
Chronic illnesses
Immobility Malnutrition
Fecal and urinary incontinence
Altered level of consciousness
Spinal cord and brain injuries
Neuromuscular disorders
External pressure compressing blood vessels
Friction or shearing forces tearing or injuring blood vessel
Ostomy care steps
Empty bag into biohazard waste bag?
Clean skin and stoma with soapy water (povidone-iodine)
Replace adhesive
⅛” larger than stoma
Empty when ⅓ - ½ full
Urinary incontinence types and nursing teaching on preventing irritation
Pee comes out can't hold pee
Stay on the toilet after peeing
Pelvic floor training kegels etc
Providing teaching about ileostomy care to a client
Permanent
Small frequent meals
Hydrate
Limit fiber for 6 weeks
gassy
Procedure for Wound Irrigation
Top to bottom
Sodium chloride 0.9%
Clean before culture
Eviscerated wound nursing priority
Keep organs moist
Put organs packed inside
What interventions should the nurse use to help maintain the integrity of the client's skin?
R: reposition every 1-2 hrs
I: inspect skin every shift
S: suspend heels off the bed
K: keep head of bed LESS than 30 degrees unless medically contradicted
Hygiene - no diapers
Linen = less is best
Keep dry and clean
Barrier cream!
Vitamins ABCDEK
Instructions should be included in teaching a client with constipation.
Increase fiber
Avoid eggs dairy
More water
Bed rest, reduced fluids/fiber, CNS disorders, narcotics
Raw vegetables (unless immune compromised)
Enema insertion and know types
Hold oil retention for 30 min
Hold up 12-15 in
Cramping, bring the bag down a little
Sims position