Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Funds II Lab > Would Care, Sterile Technique, Ostomy Care, & Foley Catheters > Flashcards

Would Care, Sterile Technique, Ostomy Care, & Foley Catheters Flashcards

1
Q

Incision

A

made from a sharp instrument

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Contusion

A

blow from an object; BRUISE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Abrasion

A

surface scrape

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Puncture

A

penetration of skin and underlying tissues by a sharp object

can’t see bacteria inside

PIN/NAIL/ ETC

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Laceration

A

tissues torn apart

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Penetrating

A

penetration of skin and underlying tissues (bullet or metal fragments)

can’t see extensive injuries from outside

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Pressure Ulcers

A

redness, sores or ulcers over a bony prominence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Wound Assessment: Appearance

A

signs of healing or infection
foreign bodies

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Wound Assessment: Drainage

A

location, color, consistency, odor, amt
serous (thin, clear)
serosanguineous (thin, watery, pale red or pink)
purulent (thin/thick, opaque tan, yellow, or green)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Wound Assessment: Other

A

size (measure w/ disposable ruler)
depth and tunneling
edema
peri area
pain
drains and tubes in place and functioning

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Dressings should be inspected regularly to ensure they are:

A

clean, dry, intact

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Dressing Changes

A

sterile vs. clean technique
prevent growth of microorganisms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Post Op Considerations for Dressing Changes

A

surgeon may want to change first dressing

if excess drainage, contact HCP

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Type of dressing is determined by:

A

location, size, and type of wound

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Closed wounds

A

post op or laceration

dry dressing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Open wounds

A

no dry packing (bc will stick to healed tissue)

moist dressing (wet to dry)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Telfa Dressing

A

slick/shiny surface that is absorbent
non-adherent
have to put outside dressing to cover it

pulls drainage away from wound

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Island Dressing

A

telfa with an adhesive border, eliminates need for an outer dressing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Surgipads or Abdominal (ABD) Pads

A

very absorbent; often used over additional dressings (outside)
blue stripe faces outward

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Transparent Film (Tegaderm)

A

semipermeable, nonabsorbent
used to cover IV sites
can see site

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Impregnated Nonadherent (Vaseline Gauze)

A

material is impregnated with petroleum jelly (vaseline gauze) or other agents
covers partial and full-thickness wounds without drainage
requires an outer dressing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Hydrocolloids (DuoDerm)

A

waterproof adhesive wafer
gelatinous/rubbery
absorbs drainage and forms an occlusive seal
can stay on up to 7 days
used for pressure ulcers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Alginate (Algiderm, Curasorb)

A

nonadherent dressing available in many forms
very absorbent (up to 20x their wt)
made from seaweed
all previous alginate must be removed prior to adding new
need something on top of it

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

VAC means

A

vacuum assisted closure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Wound VAC Purpose

A

applies a negative pressure to a variety of wounds using suction equipment
pulls fluid from the wound and helps wound edges pull together
provides a moist protected environment for wound healing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Wound VAC Use

A

sterile pieces of foam and vacuum tubing are inserted into wound and covered with transparent, occlusive dressing to create an artificial seal

very important the seal is maintained (maintains the negative pressure)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Drains Use

A

permit drainage of excessive serosanguineous fluid/purulent material
promote healing of underlying tissue

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Open Drain

A

open end that drains onto a dressing

penrose drain (flimsy tube)

29
Q

Closed Wound Drainage System

A

drain connected to either an electric suction or a portable drainage suction

Hemovac (holds more drainage/accordion-looking)
Jackson-Pratt (make sure it’s squeezed to ensure suctioning) (bomb)

30
Q

Closed Wound Drainage System Benefits

A

reduces entry of microorganisms into the wound through the drain
drainage tubes are sutured in place
connected to a reservoir
provide an accurate measurement of drainage
inserted in surgery; discontinued 3-5 days (minimal drainage)

31
Q

Who is responsible for maintaining wound suction?

A

nurses

32
Q

Stryker

A

postoperative reinfusion in clients with knee or hip arthroplasty

33
Q

Argyle

A

autotransfusion-ready chest drainage unit

34
Q

Changing a Dressing

A

pt centered (pre-med if necessary)
wash hands
apply clean gloves
remove old dressing
remove gloves and hand hygiene
set up sterile field
clean wound, as ordered
apply new dressing

35
Q

Principles of Sterile Technique

A

outer wrap/covering is non-sterile
sterile items that are out of sight are unsterile
no coughing/sneezing over sterile field
hands/objects must stay above waist/table height
do not reach over sterile field (go around)
when using forceps (tweezer), tips stay pointed down

36
Q

What part of the sterile field is unsterile?

A

outer 1 inch at least

37
Q

Surgical Hand Scrub

A

used in surgery and other specialties (OB)
hands must stay higher than elbows
pre-wash with antimicrobial solution and then use a scrub brush with antimicrobial solution
scrub for the appropriate amt of time (agency policy)

38
Q

Establishing a Sterile Field

A

don’t need sterile gloves to set up

opening towel/drape (away, sides, towards)
drop items into sterile field

39
Q

Wound/Incision Care Prep

A

remove and discard soiled dressings (use biohazard bag if saturated in blood)
complete wound assessment
set up sterile field
apply sterile gloves

40
Q

Clean Wound/Incision ***

A

top to bottom, in to out
outward from the incision
circular (around a drain)
use a clean sterile swab for each stroke
dry surrounding skin-pat or air dry
apply dressings to drain site/incision
document

41
Q

Cleansing Agent: Normal Saline

A

does not disinfect; moves bacteria
top to bottom
inward to outward

42
Q

Cleansing Agent: Chlorhexidine

A

antiseptic agent
friction scrub back and forth
at least 30 sec

43
Q

Cleansing Agent: Betadine

A

top to bottom, OUT to IN

44
Q

Irrigating a Wound

A

used to flush excessive drainage, foreign bodies, etc… out of an area
premedicate
solution temperature
syringe w/ catheter (18 or 19 gauge) attached or irrigating tip
if using catheter to reach crevices, insert only until resistance is met
irrigate until clear
dry before applying dressing

45
Q

Packing a Wound Purpose

A

facilitates formation of granulation tissue, removal of drainage, and necrotic (eschar) tissue
heals from the inside to outside

46
Q

Packing a Wound Procedure

A

premedicate
use sterile technique
remove old packing and clean as ordered
prepare new packing material (correct length/damp)
pack the wound using sterile forceps or sterile swab
don’t pack too tight, pack in one continuous strip
apply the outer dressing

47
Q

Retention Sutures

A

BIG (for bigger/obese people)

48
Q

Removal of Sutures/Staples

A

requires physician’s order
usually done 7-10 days after (retention sutures are usually longer, 14-21 days)
may be removed by RN if allowed by agency
use sterile technique
suture scissors/staple remover

49
Q

Removing Sutures

A

using suture scissors, clip suture close to skin (under the knot)

CONTINUOUS: take out every other (not the ends), reassess and make sure wound is well approximated, then take out the rest

50
Q

Removing Staples

A

place lower tip of sterile staple remover under staple
squeeze handles until completely closed
gently remove staple

51
Q

Clean suture/staple line with:

A

antimicrobial solution (betadine or chlorhexidine)

chlorhexidine: friction scrub

52
Q

Stoma Appearance

A

pink or red; moist; pt does not feel (getting bl flow)

53
Q

Ileostomy, Ascending ostomy, Transverse ostomy

A

need appliance to catch feces

54
Q

Ileostomy stool

A

liquid consistency, mild odor

55
Q

Ascending Ostomy Stool

A

liquid, more odor

56
Q

Transverse Ostomy Stool

A

mushy and stinky

57
Q

Descending Ostomy and Sigmoid Ostomy

A

may not need appliance

58
Q

Descending Ostomy stool

A

more formed/solid

59
Q

Sigmoid Ostomy stool

A

formed stool

60
Q

What makes peristomal skin at risk for breakdown

A

fecal matter and digestive enzymes

61
Q

How often are ostomy appliances changed?

A

at least weekly; more often if manufacturer recommends or if peristomal skin needs treatment

don’t let bag get more than half full

62
Q

Changing Ostomy Appliance

A

determine need to change appliance
select appropriate time
position pt (sitting up)
empty the pouch and remove skin barrier
clean and dry peristomal skin
assess stoma and peristomal skin (no breakdown or redness)
measure stoma (1/8” clearance around stoma)
cut skin barrier to appropriate size and apply
if two pieces, attach pouch to skin barrier

63
Q

Colostomy Irrigation

A

only done for pts with sigmoid or descending ostomies
purpose is to distend the bowel enough to stimulate evacuation
use warm tap water

64
Q

Reasons a catheter may be inserted

A

acute urinary retention
open sacral or perineal wound
comatose
critically ill pts

65
Q

CAUTI; Prevention

A

catheter-associated UTI

cath care, aseptic technique, bag below level of bladder

66
Q

S&S of CAUTI

A

redness around insertion site
discharge
dark and concentrated and cloudy foul smelling urine
change in LOC

67
Q

Foley Insertion Steps

A

perineal cleaning
open bag, put on bed
open wrapping
sterile gloves
drapes (shiny side down)
lube
saline syringe attach
open betadine and pour over lollipops
hand spreads labia
clean with betadine (side, side, middle)
move tray to between legs
lube catheter
insert until see urine, then 2 more inches
inflate balloon
attach catheter to leg
hang bag on bed

68
Q

Foley Removal Steps

A

deflate balloon (passively)
pt take deep breath
remove by wrapping around fingers
check tip for intactness
discard appropriately

Funds II Lab (5 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions