Inflammation, Wounds, and Pressure Ulcers part 7 Flashcards Preview

Test 3 > Inflammation, Wounds, and Pressure Ulcers part 7 > Flashcards

Flashcards in Inflammation, Wounds, and Pressure Ulcers part 7 Deck (25)
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1

What is the assessment for pressure injuries?

-past med history
-meds
-surgery/treatments
-functional health patterns
-assessment findings: integumentary and diagnostic findings

2

Acute care pressure injuries care

-relieve pressure
-do not turn patient onto unblanchable skin
-do not massage
-lift versus sliding when repositioning

3

What area of the body do you not debride?

heels

4

Explain nursing care of pressure injuries

keep wound bed moist
-do not disrupt new granulation tissue
-avoid cytotoxic cleaning
-nutrition support
-

5

What labs would make a pt nutritionally at risk?

-albumin <3.2
-prealbumin <15
lymphocyte <1,000
Hgb-A1c > 6.5%
glucose >126

6

How do you document a wound?

location - specifically
-stage
-size: length (head to toe), width (hip to hip), depth (deepest point)
-measure in cm
-tunneling: measure using a clock
-edges: approximation (edges meet), rolled, jagged, undermining
-wound base: granulation, epithelialization, necrotic tissue (slough, eschar, adherence)
-tunneling
-undermining
-drainage: serous, sanguineous, sero-sangineous, purulent, odor, amount
-surrounding tissue
-pain
-wound progress

7

Who performs the first dressing change 24-48 hours after surgery?

the surgeon

8

What are the types of debridement?

-autolytic: dressing (clear) and bodys own mechanisms
-enzymatic: commercially prepared enzymes
-mechanical: physical force (dry and wet dressing to remove
-surgical/sharp: using an instrument

9

What are the 3 basic tyes of dressings?

maintain mositure
absorb mositure
add mositure
-keep wound tissue moist and surrounding skin dry

10

Dressings:
remain for 4-7 days
-use for stage 1 pressure injuries
-minimal drainage
-facilitate autolytic debridement

transparent

11

Dressings:
-use for stage 2 and 3
-use for high riskfriction areas
-wounds with necrosis or slough
-not for infected wounds

hydrocolloid EX duoderm

12

Dressings:
-use for 3-5 days
-use for stage 2-4
-absorb light to heavy
-surgical wounds

Foams EX: Mepilex

13

↓bacteria
Removes excess fluid
Promotes moist wound environment
Used for:
Stage 3 of 4 PI
Arterial, venous, and diabetic ulcers
Dehisced surgical wounds
Infected wounds, skin graft sites
Full thickness burns

negative pressure wound vac

14

What vitamins are good for nutrition therapy for wound healing?

C and B

15

increases amount of oxygen dissolved in plasma

HBOT

16

Promotes cell proliferation and healing,
Increases wound metabolism,
Promotes an increased response to growth factors, stimulates development of blood vessels,
antibacterial and antioxidant effects, improve immune function

HBOT

17

What are some nursing interventions for the immobile older adult?

exercise
increase protein, calcium, and D
pace activities
assistive devices
reduce risk of falls

18

What does immobility do to the cardiovascular system?

-increases workload of the heart
-increases risk of orthostatic hypotension
-increases risk for venous thrombosis

19

What does immobility do to the respiratory system?

-decreases depth of resp
-decreases rate of resp
-pooling of secretions
-impaired gas exchange

20

What does immobility do to the GI system?

-disturbance in appetite
-altered protein metabolism
-altered digestion and utilization of nutrients
-decreased peristalsis

21

What does immobility do to the urinary system?

-increased urinary stasis
-increases risk of renal calculi (stones)
-decreases bladder muscle tone

22

What does immobility do to the musculoskeletal system?

-decreases muscle size, tone, strength
-decreases joint mobility and flexability
-bone demineralization
-decreased endurance and stability
-increased risk for contracture formation

23

What does immobility do to the metabolic system?

-increased risk for electrolyte imbalance
-altered exchange of nutrients and gases

24

What does immobility do to the integumentary system?

increases risk for skin breakdown and formation of pressure injuries

25

What does immobility do to psychological well-being?

-increased sense of powerlessness, depression
-decreased self concept, social interaction, sensory stimulation
-altered sleep-wake pattern
-risk for learned helplessness