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AE 3 > Exam 2 - Wound Care > Flashcards

Exam 2 - Wound Care Flashcards

(50 cards)

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1
Q

Max amount of time for sitting in a chair for individuals with pressure injuries

A

3x/day in periods of 60 min or less

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2
Q

What devices should not be used for sitting/elevating heels?

A
  • donut shaped/ring devices
  • synthetic sheepskin pads
  • intravenous fluid bags
  • water filled gloves
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3
Q

Pressure Ulcer Nutrition

  • calorie intake
  • protein intake
A

30 - 35 kcal/kg

1.25-1.5 g protein/kg

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4
Q

What surfaces can you consider for Stage 1 and stage 2 ulcers? (2)

A
  • High specification reactive foam mattress

- Non-powdered pressure redistribution surface

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5
Q

What surfaces can you consider for stage 3, 4, and unstageable ulcers?

A
  • Low air loss mattress
  • Air fluidized mattress
    (enhanced pressure redistribution, shear reduction, and microclimate control)
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6
Q

How do you reduce pressure injury pain?

A
  • Keep the wound bed covered and moist

- Use a non-adherent dressing

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7
Q

What are adequate pain control measures for pressure ulcer pain management?

A
  • Regular pain medication

- Additional dosing prior to wound care procedures

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8
Q

What do you do at the time of each dressing change?

A

Cleanse the pressure injury

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9
Q

Consideration for ulcers with debris, confirmed or suspected infection, or suspected high levels of bacterial colonization?

A

Cleansing solutions with surfactants and or antimicrobials

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10
Q

How should you perform debridement if there is no urgent clinical need for drainage or removal of devitalized tissue?

A
  • mechanical
  • autolytic
  • enzymatic
  • biological methods
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11
Q

What type of debridement is recommended in the presence of extensive necrosis, advancing cellulitis, and or sepsis?

A

Surgical/sharp debridement

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12
Q

How do you debride a stable, hard, dry eschar in ischemic limbs?

A

Do NOT debride

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13
Q

For non-infected, shallow stage 3 pressure injuries

A

Hydrocolloid dressing

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14
Q

For autolytic debridement when the individual is NOT immunocompromised

A

Transparent film dressing

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15
Q
  • Minimal drainage
  • Granulating
  • Painful
  • Not clinically infected
A

Hydrogel dressing

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16
Q

For moderately and heavily exuding pressure injuries

A

Alginate dressing

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17
Q

Highly exuding stage 2 and shallow stage 3

A

Foam dressing

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18
Q

Clinically infected or heavily colonized

A

Silver Impregnated dressings

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19
Q

Stage 2 and 3

A

Honey-Impregnated

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20
Q

Which dressing should be avoided in impaired kidney failure, history of thyroid disorders or known iodine sensitivity?

A

Cadexomer Iodine

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21
Q

For prevention of periwound injury when periwound is fragile

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A

Silicone dressing

22
Q

For non-healing stage 3 and 4 pressure injuries

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A

Collagen Matrix

23
Q

Negative Pressure Wound Therapy is for

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A

Early adjuvant treatment of deep stage 3 and stage 4

- intended for ulcers free of necrotic tissue

24
Q

Can patients with systemic clinical infection or those on anticoagulant therapy get negative pressure wound therapy?

25
Where do you avoid gauze dressing?
Open pressure injuries that have been cleansed and debrided
26
- Intact - Area usually over bony prominence - Does not blanch with external pressure
Stage 1
27
- Skin NOT intact - Partial thickness skin loss of epidermis or dermis - Superficial ulcer
Stage 2
28
- Full thickness skin loss - Subcutaneous tissue and underlying fascia may be damaged/necrotic - possible undermining and tunneling
Stage 3
29
- Full thickness skin loss - Bone or tendon or muscle exposure - Slough, eschar
Stage 4
30
Do patients get their own measuring tool?
Yes
31
Granulation description
- Red - Cobblestone appearance - Filling in appearance
32
Undermining
Separation of tissue from the surface under the edge of the wound
33
How do you describe undermining?
Describe by lock face (head being 12)
34
Exudate
Fluids from wound
35
Do you assess odor before or after cleaning?
After cleaning
36
Factors that contribute to wound healing
- infection - nutrition - hydration - circulation (pressure relief, oxygenation) - edema - glucose control
37
What does incontinence lead to
Maceration (looks like stage 1) | - don't keep patients in diapers
38
Documenting turning
- Document if the patient refuses to turn
39
When should you assess a wound?
At least every shift - change dressing if not improving
40
Firm, dry stable eschar - debride or not?
DON'T
41
Eschar with purulent material, redness or edema around - debride or not?
Yes
42
Can wounds heal in the presence of necrotic tissue? What does it increase?
No, rather increases bioburden
43
Types of Debridement
- Autolytic - Enzymatic - Sharp/surgical - Biological - Hydrotherapy
44
5 basic categories of dressings
- Films - Hydrogel - Hydrocolloids - Alginates - Foams
45
Films
- keeps wound dry - impermeable to larger molecules - transparent film is good for autolytic debridement when the individual is not immunocompromised
46
Hydrogel
Good for dry wounds with minimal drainage
47
Hydrocolloids
Gel or foam (ex: tegaderm) | - good for non-infected shallow stage 3
48
Alginates
High calcium content to impede epithelialization - not soluble in water - requires secondary dressing - can be too drying --> good for heavily exuding pressure ulcers
49
Foams
Film dressing + absorbancy - Creates a lot of moisture underneath the dressing - Can be used preventatively - or for highly exuding stage 2 and shallow stage 3
50
Specialty treatments for huge open and gaping wounds
- Vacuum-assisted wound treatments (monitor the drainage in the canister!) - Hyperbaric oxygen treatment

AE 3 (8 decks)

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