Asepsis

Question 1

how are wounds characterized?

Answer 1

cause, severity of tissue damage, cleanliness

Question 2

when assessing wounds, need to assess and document what?

Answer 2

*type of wound (acute/chronic, pressure ulcer/surgical wound, intentional/contaminated)
*location
*appearance (open/closed)
*tissue types and amounts (granulation, slough, eschar %)
*Periwound assessments (RITA)
*staples/sutures/glue?
*size (LxWxD)
*tunneling/undermining with clock positioning
*tissue damage (full, partial)
*drainage/exudate (COCA)
*drains/tubes?
*dressing removal
*wound cleaning? Or irrigation?
*new wound dressing/materials
*patients response (tolerance, pain scale during/after)
*education (pt was educated on the importance of repositioning and increasing protein intake)

Question 3

acute wounds heal in about _______

Answer 3

2-4 weeks, otherwise they’re considered chronic

Question 4

wound size is measured in what unit?

Answer 4

centimeters

Question 5

abdominal pad

Answer 5

AKA: ABD
*high absorbency
*used as a secondary dressing

Question 6

non-adherent dressing

Answer 6

mild-moderate drainage
Example: Telfa or Bandaid

Question 7

transparent dressing

Answer 7

Self-adhesive
Semipermable
Traps moisture
good for IV dressings
Ideal for small superficial wounds

Question 8

foam

Answer 8

moderate to heavy exudate
Provides thermal insulation and protection
Does not stick to wound
Example: Mepilex (Foam with adhesive border)

Question 9

alginate dressing

Answer 9

Heavy Exudate Absorbers
Forms soft gel while absorbing drainage
Not for dry wounds

Question 10

hydrocolloid

Answer 10

Occlusive hydrophilic (water loving)
changed every 3-5 days
maintains moist healing, can be used in clean and necrotic wounds.
For light to moderate drainage
Can mold to shape of body (heels, buttocks)
Ex. Tegasorb, duoderm

Question 11

hydrogel dressing

Answer 11

Gauze of sheet dressing impregnated with water or glycerin
High water content creating jelly like consistency that does not adhere to wound bed
Promote moist environment and rehydrate wound bed
For minimal drainage

Question 12

Jackson-Pratt

Answer 12

bulb, constant pressure, closed drainage device

Question 13

Hemovac

Answer 13

circular with spring, constant pressure, closed drainage device

Question 14

Wound Vacuum Assisted Closure

Answer 14

packed black foam, Suction and negative pressure facilitates healing
Dressing changed 3 times weekly, drainage canister changed weekly or as needed

Question 15

Culturing a wound; what drainage do you collect?

Answer 15

clean the wound first b/c you don’t want old drainage

Question 16

Stage 1 pressure injury

Answer 16

Nonblanchable Erythema of intact skin

Question 17

Stage 2 pressure injury

Answer 17

Partial Thickness Skin Loss
*Presents as a shallow open ulcer with a red-pink wound bed
*No slough.
*Can present as an intact or open serum-filled blister
*Shiny or dry

Question 18

Stage 3 Pressure Injury

Answer 18

Full Thickness Skin Loss
*subq and adipose exposed
*may be slough or eschar
*bone/tendon/muscle NOT exposed
*may have undermining/tunneling

Question 19

Stage 4 pressure injury

Answer 19

*full thickness loss
*Bone, tendon, or muscle exposed or directly palpable
*slough or eschar, maybe
*undermining and tunneling common
*often requires a year to fully heal

Question 20

urine: freshly voided (purpose?)

Answer 20

This method is used when identification of bacteria or infection is not required.

Question 21

urine: sterile specimen
*how to obtain sample?
*what’s it used for?

Answer 21

*clamping a drainage bag and withdrawing with a syringe OR using a straight cath
*urine culture

Question 22

what can be identified with a stool sample?

Answer 22

infection, parasites, and presence of blood

Question 23

what can be identified with a nasal swab?

Answer 23

MRSA, influenza and RSV

Question 24

what do you swab when obtaining a wound sample?

Answer 24

first clean wound, THEN swab area of red granulation in wound bed

Question 25

read TB test results how long after administering?

Answer 25

48-72 hours

Question 26

what does it mean to heal by primary intention?

Answer 26

the edges of the wound are well approximated (brought together well = touching). ex: paper cut or surgical incision

Question 27

healing by secondary intention

Answer 27

a wound is intentionally left open to heal through granulation. granulation/contraction/epithelialization. Heals from the inside out. Higher risk of infection but longer healing time. Ex. pressure injury

Question 28

healing by tertiary intention

Answer 28

the closure of the wound is intentionally delayed so we can irrigate/debride the wound and observe it for about a week THEN we will close it when risk of infection is lower

Question 29

ARF

Answer 29

acute renal failure

Question 30

anuria

Answer 30

lack of urine production

Question 31

dysuria

Answer 31

discomfort when urinating

Question 32

ESRD

Answer 32

end stage renal disease

Question 33

enuresis

Answer 33

bedwetting

Question 34

hematuria

Answer 34

blood in urine

Question 35

oliguria

Answer 35

low urine output

Question 36

nephropathy

Answer 36

deterioration of kidney function = the final stage of end-stage renal disease. Kidney failure

Question 37

nephrotoxic

Answer 37

rapid deterioration of kidney function due to toxic effects of medications and chemicals. Nephrotoxins are substances displaying nephrotoxicity

Question 38

nocturia

Answer 38

frequent urination at night

Question 39

micturition

Answer 39

the action of urinating

Question 40

pessary

Answer 40

a silicone device that is inserted into the vagina to support the uterus/vagina/bladder or rectum. It’s most often used to treat prolapse of the uterus but can also help to relieve urinary incontinence

Question 41

proteinuria

Answer 41

protein in urine

Question 42

pyuria

Answer 42

the presence of WBC’s in the urine