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NRSG 201 > Lab 10 simple dressing part 2 > Flashcards

Lab 10 simple dressing part 2 Flashcards

1
Q

What is within a students scope of practice when it comes to wound care

A

-they may assess and treat surgical wounds
-Cleanse wounds
-pack wounds

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2
Q

what is outside a students scope when it comes to wound care

A

-sharps debridement
-ankle brachial indexes
-compression therapy

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3
Q

which drainage systems are closed drainage

A

Jackson-Pratt drain
Hemovac drain

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4
Q

what drainage systems are open drain

A

penrose drain

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5
Q

what type of wound would a drainage bag be used for

A

mostly used for chronic wounds with copious amounts of drainage

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6
Q

what is the total volume that a hemovac drain can collect per 24 hours

A

400 ml/24h (this also means it’s full)

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7
Q

when should you empty a hemovac drain

A

when it is around 200 ml full

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8
Q

what type of drain is this

A

Hemovac

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9
Q

what type of drain is this

A

jackson pratt drain

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10
Q

what is the max volume of a jackson pratt drain

A

100 ml/24 hours

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11
Q

what type of drain is this

A

Penrose drain

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12
Q

how is a penrose drain removed

A

usually removed in stages using sterile technique and sterile safety pin

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13
Q

what kind of drain is this

A

percutaneous drain

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14
Q

what is a percutaneous drain usually used for

A

often used to drain an abscess

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15
Q

what type of drain may have to be sutured in place

A

percutaneous drain

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16
Q

if a client has a penrose drain when can they shower

A

they should not shower until the drain is removed

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17
Q

should a drain ever get wet

A

NO

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18
Q

would it be appropriate to withhold a shower if the pt has a hemovac/JP drain that is expected to be removed in 3-4 days

A

yes since its better to not get it wet

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19
Q

when should a braden scale be preformed

A

within 8 hours of admission or upon return from ER
-if at risk every shift
-if not at risk at least daily

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20
Q

what braden scale score means the client it at risk

A

any score less than 18 means the client is at risk

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20
Q

if someone is at risk for pressure injuries what angle should the head to the bed be kept at

A

should be kept at less than 30 degrees since it distributes pressure better

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21
Q

would you use a dressing on a stage 2 pressure ulcer

A

no since it can create more friction and sheer

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21
Q

what type of wound is air fluidized therapy and non contact low frequency ultrasound therapy used for

A

Used for deep tissue injuries

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22
Q

what are products used for an unstageable pressure injury with necrotic tissue

A

anything with iodine in it

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23
Q

where do venous ulcers usually develop

A

usually distal medial 1/3 of lower leg and ankle

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24
Q

would you use an absorbent or moisturizing dressing with a venous ulcer

A

most of the time an absorbent dressing since there is lots of drainage with a venous ulcer

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25
Q

what percentage of leg ulcers are venous ulcers

A

81% of leg ulcers are venous ulcers

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26
Q

how often do you need to replace compression stockings if worn daily

A

need to replace every six months if worn daily

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27
Q

where are arterial ulcers usually located

A

-toes
-metatarsal heads (bottom of foot)
-outside ankle
-heels

28
Q

how much drainage is there with an arterial ulcer

A

little to no drainage

29
Q

where would you put the legs in relation to the heart for a venous ulcer

A

raise the legs above the heart to minimize edema and pain

29
Q

what type of ulcer will have diminished or absent pedal pulses venous or arterial?

A

Arterial ulcer will have diminished or absent pedal pulses

30
Q

would you ever debride a non healable wound and why ?

A

NO because they are already at such a risk for compramised healing that it will only make it worse by disturbing it more

31
Q

where would you put the legs in relation to the heart for an arterial ulcer

A

lower the legs below the heart

31
Q

where are diabetic ulcers located

A

usually located on the bottom of the foot

32
Q

what is one way that you could tell a arterial ulcer and diabetic ulcer apart

A

diabetic ulcer the peripheral pulses will still be palpable whereas arterial ulcers they will not be

33
Q

should a person with a chronic wound shower

A

yes there is no reason not to and it may also assist in removing old dressings

34
Q

what are the 7 principles of wound care

A
  1. assess and treat the underlying cause
  2. Debride necrotic tissue
  3. maintain moisture
  4. Assess and protect periwound skin
  5. promote and support granulation tissue
  6. fill dead space
    7.stop infection and trauma
35
Q

what are the 5 types of debridement

A

autolytic
Enzymatic
mechanical
surgical/sharp
natural

36
Q

what are 4 ways to promote and support granulation tissue

A

-encourage good nutrition
-avoid frequent dressing changes
-cleanse with each wound change
-use non adherent dressing if dressing is sticking to wound

37
Q

when should a nurse obtain a C&S swab of a wound

A

when there are two or more signs and symptoms of local or systemic wound infection

38
Q

what is the diagnosis of a wound infection usually based off

A

usually based off an assessment not solely the C&S test

39
Q

what is a culture test

A

a test to find bacteria or a fungus that can cause infection

40
Q

what is a sensitivity test

A

a test to see what kind of drug/antibiotic will work best to treat the illness or infection

41
Q

what are 4 contraindications for doing a C&S swab

A

-wounds that have been cultured within the last 24-72 hours
-inability to transport the culture within 12hrs of taking the swab
-the absence of signs of infection or delayed healing (unless screening for ARO)
-wound covered with necrotic eschar or slough

42
Q

when taking a C&S what tissue do you swab

A

only granulation tissue (ie not hard eschar exudate etc)

43
Q

how big of an area do you swab and for how long while taking a C&S

A

rotate swab over 1 cm square area of wound for a full 5 sec

44
Q

does cooling promote wound healing

A

no anything that cools the wound down slows healing (ie frequent dressing changes, saline solution)

45
Q

what is the goal of healing with red wounds

A

protect and keep moist

46
Q

what is the goal of healing with yellow wounds

A

debride slough reduce bacterial colonization

47
Q

what is the goal of healing with black wounds

A

remove eschar and keep dry

48
Q

usually how often is a dressing changed for a chronic wound

A

usually changed every 3-5 days

49
Q

how much fluid should someone drink per day to promote wound healing

A

2500 ml + per day

50
Q

what nutritional elements are important to wound healing

A

protein
Vit B C D
iron
zinc
calories

51
Q

can potable tap water be used to rinse wounds

A

YES

52
Q

if a pt has both a incision and a drain which do you clean first

A

clean the incision first and then the drain site

53
Q

where is one place you need to document only with drains

A

in/out record (all other types of wounds except open wounds just document in the 24 hour and narrative notes if necessary)

54
Q

where do you document open wounds

A

in the wound assessment and treatment flow sheet and narrative notes if concerned

55
Q

how often should a full assessment be done on a wound

A

every 7 days or there is a significant change

56
Q

how often should a partial assessment be done on a wound

A

when a dressing change is being preformed between the weekly assessments

57
Q

do you note the odor of the wound before or after cleaning

A

after cleaning

58
Q

what is a demarcated wound edge

A

when you can clearly see the edges of the wound

59
Q

what is a diffuse wound edge

A

when you can not see the wound edges

60
Q

when do you take a pain scale for a wound

A

while the dressing is being changed

61
Q

how deep does a wound have to be to start packing

A

any wound with a depth of greater than 1cm start packing

62
Q

What type of skin lesion is this

A

Macules/papules

63
Q

What type of skin lesion is this

A

Wheal

64
Q

what type of skin leasion is this

A

Papules/plaque

65
Q

REVIEW the week 10 class assignment about the different types of skin lesions

A
66
Q
A

NRSG 201 (12 decks)

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