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NURSING EXAM 3 > WOUND CARE > Flashcards

WOUND CARE Flashcards

(73 cards)

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1
Q

medical clean asepsis/ clean technique

A

Reduce or prevent the spread of microorganisms

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2
Q

surgical asepsis/ sterile technique

A

Eliminate microorganisms

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3
Q

clean

A

Removal of all soil from an object or surface

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4
Q

disinfect and antiseptic

A

Elimination of many germs from inanimate objects (disinfect) or living surfaces (antiseptic)

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5
Q

sterilization

A

Elimination of germs from inanimate objects

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6
Q

leukocytosis

A

high white blood cells. have infection or inflammation

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7
Q

neutropenia

A

decrease white blood cells. risk of infection/ disease

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8
Q

WBC range

A

4500-11000

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9
Q

identify wound

A

Surgical, Traumatic, Pressure, Burn, Other (dermatitis, vascular, arterial, etc.)

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10
Q

determine size of wound

A

Measure length (head to toe), width (left to right), depth (use cotton tip) cm
Note any tunneling, undermining

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11
Q

wound cleaning

A

If ordered, follow orders
If not ordered, you may use a commercially available wound cleanser, an isotonic solution such as 0.9% Sodium Chloride (Normal Saline) to clean the wound
Generally clean from areas of least contamination to areas of greater contamination
- Use a new swab or cloth for each stroke
remember to dry peri-wound skin

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12
Q

incision cleaning

A

clean down the incision line then moving away from the incision

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13
Q

open wound cleaning

A

clean from the center of the wound outward in circles

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14
Q

purpose of irrigation

A

To clean the area and promote healing
To instill antiseptic solution or medication
To remove excess drainage or other materials

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15
Q

isotonic solutions

A

No antibacterial action **
Removes exudates
Moisturizes wound surfaces
Commonly used to cleanse wounds
- ex. Sterile normal saline or Lactated ringers

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16
Q

chlorhexidine gluconate

A

Skin antiseptic
Kills bacteria, spores, viruses, fungi
- Toxic to granulation tissue. **
Used preoperatively, before invasive procedures and sometimes daily
Can be used as a weaker concentration to irrigate wounds
Other names: CHG, hibiclens, chloraprep

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17
Q

hydrogen peroxide

A

Used for mechanical debridement of open wounds
Causes too much trauma with effervescent action for deep tunneling wounds
Removes blood clots → but we do want the blood to clot so it can heal
No sustained antiseptic action
Not used in full strength
Half strength is half specimen cup of sterile water and the other half hydrogen peroxide

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18
Q

is wound irrigation clean or sterile procedure

A

Sterile procedure

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19
Q

simple dressing

A

dry sterile dressing DSD

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20
Q

complex/ deep dressing

A

Packing
Wet to dry
Damp to dry
Dry
Negative pressure/ vacuum

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21
Q

simple dressing do what

A

Wound with little to no drainage
Protects wound from injury
Prevents introduction of bacteria
Reduces discomfort
Speeds healing
Used on abrasions, non-draining post-op incisions
Moisten with SNS to reduce trauma when removing dressing if it is adhered to the wound

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22
Q

wounds that are dry are typically packed…

A

with wet or moist gauze

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23
Q

wounds that are draining will usually be packed…

A

packed with dry gauze

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24
Q

wounds with slough will be…

A

mechanically debrided with gauze that is placed in the wound wet, and left in place until it is dry. As it is removed, some non-viable tissue will come out with the gauze

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25
negative pressure or vacuum dressings
Requires an order and special equipment (often rented) Assists in wound closure by applying negative pressure to draw the edge of the wound together - Accelerates healing - Reduces edema - Improves circulation - Reduces bacterial counts in the wound
26
wound vacuum
Clear tape will go over the wound and a tube will go inside the tape/wound and will provide negative pressure and it will pull and collapse the foam into the wound. Helpful for pt. With complex wounds
27
pressure dressing
Used for temporary control of the excessive bleeding following Trauma Surgery Puncture may stop bleeding may be combined with sandbag use
28
intentional dressing
sandbags on the groin after cardiac catheterization to ensure a hematoma does not form
29
purpose of dressings
Protecting a wound from microorganism contamination Aiding hemostasis Promoting healing by absorbing drainage and debriding a wound Supporting or splinting the wound site Promoting thermal insulation of the wound surface Providing a moist environment
30
gauze pads
2 x 2’s, 4 x 4’s, gauze squares Can be used sterile or clean Gauze is a primary dressing - Used on top of the wound Special types: Iodoform, Vaseline, Xeroform, Nuguaze
31
fluffed or rolled gauze
May be referred to as: Kerlex, Fluff, Bulkee Large or long pieces of loosely woven gauze Can be layered or folded to absorb drainage Used for packing wounds or wrapping extremities
32
ABD pads
Sometimes referred to as Combine Pads or Combination Pads Large, absorbent pads Generally used as a secondary dressing (over another dressing)
33
hydrocolloid dressings
Brand name: Duoderm Soft wafer that can be cut to fit Absorbs small amounts of drainage Provides protection for autolytic debridement of small wounds - Keeps wound, warm moist and allows to heal on own Can be used to protect the skin from tape Can be used to prevent or treat Stage I & II pressure injuries Maintains an adequate moist environment for healing clean, shallow wounds Can remain in place for 5 -7 days if kept clean and dry
34
non-adherent dressings
The brand name is Telfa (and Band-aide!) Used directly on the wound bed or incision to prevent injury to granulation tissue when dressings are removed May be impregnated with petroleum or antimicrobial ointment
35
transparent dressings
Brand names: OpSite, Tegaderm Used to manage superficial wounds or provide skin protection Allows visualization of wound or IV insertion site It is moisture and vapor permeable - Allows gas to pass through dressing Leave top, supportive paper on the dressing until after the adhesive side is applied to the skin
36
skin protectants/ barriers protect skin from...
Drainage Urine Stool Tape
37
tape
Various widths Variety of materials - Paper - Silk - Plastic - Adhesive Steri-strips: Used to approximate incisions of lacerations not requiring stitches
38
drains
Promotes wound healing Enhance the flow of drainage out of the wound
39
hemovac
Spring activated self suction → pulls fluid out of body Empty every 4-8 hours
40
Jackson-pratt JP drain
Bulb activated self suction
41
penrose
Passive drainage only, no collection device Like a tourniquet so the driangae can passively have blood drip into the gauze. Bobby pins keep it from going back inside the body.
42
stage 1 sanguineous
bloody , thick drainage, not transparent Interventions: Relieve pressure, protective dressing, hygiene, moisturizing the skin, nutrition of pt.
43
stage 2: sero-sanguineous
Blood and serum, red-pink, thinner than sanguineous, thicker than serous Interventions: Apply silicone dressing to help create the auto lytic debridement. , offloading devices (wedges, heel pads), nutrition, educate Notify the provider because it has become a never event.
44
stage 3: serous
Serum from the body, pale yellow, watery, fluid blister-like Interventions: - Need expert opinion on how to handle wound. Speciality surface (therapeutic bed to reduce pressure all over bed) nutrition physician, educate pt. Will need packing and dressing changes several times throughout the day.
45
stage 4: purulent
Pus, pale yellow to green, white blood cells, infection Interventions: Graph to heal, huge nutritional demand to regrow tissue. Extensive dressing changes and the most available intensive pressure relieving services.
46
burns: first degree
Least severe Reddened area (sunburn)
47
burns: stage 2
Blisters form/ painful Moderate to deep partial thickness Involves epidermis and portions of the dermis
48
buns: stage 3
No pain Skin is charred or non-existent Severe fluid loss, nerve destruction Full thickness - Destruction of epidermis and demis - Requires debridement and grafting
49
burns: 4th degree
Deep brun necrosis Extensive damage involving fascia, muscles or bone
50
nutrition for healing
Vitamins A & C, Minerals Protein Calories Adequate hydration
51
purpose of wraps
Creating pressure over a body part Immobilizing a body part Supporting a wound Reducing or preventing edema Securing a splint Securing a dressing - Usually rolled gauze (Kerlix, Kling) or Ace wrap
52
assessment before applying the wrap
Inspect the skin - Abrasions, edema, discoloration, or exposed wound edges Cover exposed wounds or open abrasions with a sterile dressing - Assess the condition of underlying dressings and changing if soiled Assessing the 5 “P’s” - Neurovascular assessment - Circulation, Movement, Sensation (CMS) assessment
53
the 5 P's
Assess the extremity distal to the bandage for: 1. Pallor: paleness 2. Paresthesia: numbness or tingling 3. Pain: nerve function 4. Pulselessness: circulatory function 5. Paralysis: motor and nerve function Assess before and after applying bandage
54
implementation of wraps
Wraps need not be sterile Wrap tight enough to hold without constricting blood flow Apply wrap distal to proximal - Facilitates venous return → towards heart** Avoid bandaging over wrinkled dressing to prevent pressure Avoid bandaging over soiled dressings Prolonged heat & moisture on skin may cause epithelial cells to deteriorate - Avoid unnecessarily thick bandages
55
slings and braces
Fasten slings off-center, behind the neck to avoid rubbing on the cervical vertebra - Distal extremity should be elevated to prevent edema Place & support the body part to be bandaged in normal functioning position - Prevents deformities and discomfort and enhances circulation Place pins or knots well away from wound, tender areas, or pressure points Frequently assess skin where there is contact with the brace for irritation or damage from friction
56
binders
Used to support, immobilize, or splint Used around the chest, abdomen, or pelvis Used to hold a dressing in place Generally made of cloth or elastic material
57
application of cold
Causes vasoconstriction Used in early wound management - Reduces hemorrhage - Reduces edema - Reduces muscle spasm - Reduces pain Alternate ½ hr cold, then ½ hr warm to reduce swelling, pain, increase perfusion. Apply for 30 mins, let the blood rebound and apply an hour or so later.
57
indications for cold application
Trauma - Puncture wounds - Sprains - Sports injuries - Fractures - Lacerations - Muscle strains Arthritis: apply after activity to reduce hematoma or edema from occurring
58
application of heat
Causes vasodilation/dilates peripheral blood vessels to dissipate heat. - Promotes healing by increasing oxygen, nutrients & leukocytes to tissue - Eliminates toxic waste products that accumulate in swollen areas - Can reduce swelling by increasing circulation Relieves pain from muscle spasms or injured joints. Reduces muscle tension/promotes muscle relaxation Increases tissue metabolism
59
indications for heat
Arthritis: apply before activity to get circulation following Muscle spasms Cramps Low back pain Surgical wounds Hemorrhoids Episiotomies Phlebitis IV Infiltration
60
safe use of cold or heat
Age of the patient/Sensory deficits Level of consciousness Circulatory impairment Skin integrity Patient diagnosis Degree of heat and cold applied Amount of body surface covered by the application
61
clean or sterile irrigation?
if in doubt, sterile is always acceptable
62
ear irrigation purpose
To remove objects (cerumen) or foreign bodies; or to instill medication. Do not irrigate if there is a suspected perforated membrane
63
is ear irrigation clean or sterile
clean because we are touching the outside and the ear drum protects
64
how do you position the pt. with ear irrigation
sitting or laying down
65
cold or warm solution for ear irrigation
Warm the solution to body temperature
66
straighten the ear canal
Adult: pull pinna up and back Child: pull pinna down and back
67
STOP irrigation if...
the patient reports severe pain or dizziness
68
eye irrigation purpose
To remove foreign bodies (sand, fiberglass, dirt), injurious fluids, or secretions (conjunctivitis)
69
is eye irrigation sterile or clean?
sterile procedure
70
how do you position pt. during eye irrigation
Supine or With head turned with the eye to be irrigated down
71
where do you introduce the sterile irrigation fluid in the eye?
Introduce sterile irrigation fluid into lower conjunctival sac at inner canthus Solution and syringe tip remain sterile
72
evaluation
Prevention of skin damage Evidence of healing (epithelialization) Absence of infection Minimization of edema, pain, bleeding No compromise to circulation or nerve function Reduction of pain, Removal of debris, Return of function

NURSING EXAM 3 (6 decks)

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