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Medical-Surgical NRSNG Canada > Wound Care > Flashcards

Wound Care Flashcards

1
Q

A type of wound results from planned treatment (ex. Self-harm)

A

Intentional

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2
Q

A type of wound results from unexpected trauma.. accident/ burns / shooting.

A

Unintentional

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3
Q

A type of wound: skin broken, portal of entry

A

Open

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4
Q

A type of wound: trauma from force, skin intact, soft tissue damage, internal injury, possible bleeding

A

Closed

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5
Q

A type of wound: that goes through normal/ timely healing process < 3 mos.

A

Acute

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6
Q

A type of wound: fails to go through normal stages of healing; no timely progress in healing >3 mos.

A

Chronic

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7
Q

Four inflammatory responses:

A
  1. Vascular
  2. Cellular
  3. Formation of e exudate
  4. Healing (regeneration and repair)
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8
Q

Inflammatory response: 4 cardinal signs and symptoms :

A
  1. Pain
  2. Redness
  3. Heat
  4. Edema
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9
Q

Managing inflammation using:

A 
RICE!
▫️Rest
▫️Ice
▫️Compress
▫️Elevation

Heat therapy
▫️24-48hrs post ➡️ heat vasodilation ➡️ promotes healing

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10
Q

What not to do with ice therapy:

A

◽️ice place directly on skin
▫️ice wrapped tightly to knee with tensor
▫️ice left for 1hr

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11
Q

Phase 1 wound healing: systemic inflammatory response

A

▫️fever
▫️elevated WBC
▫️Malaise

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12
Q

Phase 2 Wound Healing:

A

▫️granulation phase (body activates collagen)

▫️thin layer of epithelial cells forms

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13
Q

Phase 3 wound healing

A

▫️maturation phase (begins as early as 7days after injury)
▫️collagen remodel and reorganizes
▫️scar forms
▫️keloid

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14
Q

Delayed wound healing

A

▫️local factors
▫️systemic factors
▫️site of injury

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15
Q

A skin 10 cms. Beyond the wound edge

A

periwound

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16
Q

___is a skin barrier used to place before dressing, to prevent peeling off 1st layer of skin

A

Cabalone

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17
Q

Maceration can occur if excessive moisture is present. Common problem in ____, _____ and ___

A

Venous leg ulcers, diabetic ulcers and high draining / exudating wounds

18
Q

Assessing Drainage:

A

▫️sanguineous
▫️serosanguineous
▫️serous
▫️purulent

19
Q

Controlling odour w wound care

A

Deodorizers

Ventilation

20
Q

Wound odour is largely due to tissue degradation/tissue death

A

Klebsiella, pseudonomas

21
Q

Signs of infection

A 
▫️inflammation 
▫️pus
▫️⬆️/change in exudate
▫️fever
▫️pain
▫️delirium in elderly
22
Q

When doing dressing changes DO NOT:

A

▫️wrap tape completely around an extremity
▫️pull dressing off a wound
- can cause further tissue damage
- soak to remove

23
Q

Frequency of wound dressing?

A

3-7 days

24
Q

________ healing stimulates cell proliferation and encourages epithelial cells growth

A

Moist

25
Q

How does wound heal?

A

from the bottom up

26
Q

is the medical removal of dead, damaged, or infected tissue to improve healing potential of the remaining healthy tissue.

A

Debridement

27
Q

Methods of wound debridement:

A

▫️Surgical
▫️mechanical
▫️autolytic
▫️enzymatic

28
Q

Types of dressing

A 
▫️films
▫️hydrogels
▫️hydrocolloids
▫️alginates
▫️foams
29
Q

Type of dressing: retains moisture, protect from infection. Minimally absorbent, allow O2,
Tegaderm, opsite

A

Films

30
Q

Type of dressing: creates moist environment, not for excessive drainage. Gently eliminate necrotic tissue by autolytic debridement
DouDerm

A

▫️Hydrogels

31
Q

A type of dressing: moist environment, promotes autolytic debridement. Occlusive (does not allow atmospheric O2 to enter). Supports debridement.
Tegasorb

A

Hydrocolloid

32
Q

A type of dressing: use for moderate drainage.

Mepilex

A

Foams

33
Q

A type of dressing: moderate to heavy drainage. Form gel-like substance that facilitate autolytic debridement
Gel fills wound space (e.g. aquacel)

A

Calcium alginate

34
Q

Specialty dressings: antimicrobial

A

▫️silver
▫️cadexomer iodine
▫️broad spectrum Abx

35
Q

Complications of wound healing:

A

▫️infection
▫️adhesions
▫️dehiscence
▫️evisceration

36
Q

Stage of pressure ulcer: intact skin with no Blanchable redness. Often present over bony prominence

A

Stage 1

37
Q

Stage of pressure ulcer: partial-thickness skin loss with exposed dermis. Wound bed is PINK/RED. Fat tissue is not visible

A

Stage 2

38
Q

Stage of pressure ulcer: full thickness skin loss. Fat tissue involved. Granulation tissue present. No fascia, muscle or tendon exposure

A

Stage 3

39
Q

Stage of pressure ulcer: full thickness skin and tissue loss. Exposed fascia, muscle, tendon, ligament, cartilage or bone. Slough and Eschar often visible.

A

Stage 4

40
Q

Braden scale key assessment indicators

A 
▫️sensory perception 
▫️moisture
▫️activity 
▫️mobility
▫️Nutrition 
▫️friction and sheer

Medical-Surgical NRSNG Canada (6 decks)

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