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Nursing Techniques 2 > Wound Care > Flashcards

Wound Care Flashcards

1
Q

What should you check on the package to check for sterility?

A

expiration date, if it was previously opened, and if it is wet

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2
Q

What are wounds that need “complex dressing?”

A

-wounds with drains or tubes
-deep open wounds
-venous, arterial, and mixed etiology wounds
-wounds that require packing

All of these require sterile technique!

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3
Q

List the type of wound drains

A
  1. Hemovac (3 spring drain)– closed, suction, single suture
  2. Jackson-Pratt (JP)– closed, suction, single suture
  3. Penrose– open, passive, sterile safety pin
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4
Q

What is the purpose of a wound drain?

A

to collect/measure excessive drainage from wound to prevent formation of abscess, protect the skin, and remove secretions from the surgical site

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5
Q

What is a stent?

A

a tube placed in the body to create a passage between 2 spaces

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6
Q

What causes an ulcer?

A

circulatory impairment– interruption of the circulation to the tissue resulting in localized ischemia, the ischemia deprives cells of oxygen and nutrients and the waste products of metabolism accumulate. The tissue dies because of the anoxia.

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7
Q

What are the types of ulcers?

A

-venous stasis ulcers
-pressure ulcers
-arterial ulcers
-diabetic ulcers

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8
Q

What is a skin tear?

A

a wound associated with friction and shearing

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9
Q

What impacts an ulcer?

A

-moisture
-nutrition
-perfusion
-comorbidities

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10
Q

What are the key predisposing risk factors for developing a pressure injury?

A

-previous history of pressure ulcers
-malnutrition
-immobility
-impaired circulation
-age (premature infants and those over 70)
-body build
-decreased sensory perception/altered mental status
-skin moisture (perspiration, exudate, incontinence, etc.)
-co-existing health conditions
-and extrinsic factors such as treatment protocols, restraints, medications, etc.

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11
Q

What causes venous ulcers

A

-caused by chronic venous disease/insufficiency
-most common leg ulcer
-a history of deep vein thrombosis, stroke, obesity, or multiple pregnancies can increase risk
-can be treated using compression therapy and wound care management

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12
Q

What does a venous ulcer look like?

A

-medial/lateral malleolar area, posterior calf
-irregular border, shallow
-pink/red base may be covered with yellow fibrous tissue
-exudate often large amounts “weeping”
-pain is mild but may be severe

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13
Q

What does primary intention refer to?

A

when the wound edges are neatly approximated (ex. surgical incision or paper cut)– neat edges and minimal tissue loss

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14
Q

What does secondary intention refer to?

A

wounds with wise or irregular wound margins which are not/cannot be “well approximated” (ex. pressure injury or traumatic injury)– greater inflammatory response and the site heals from bottom up and from the sides in, creating a bigger scars

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15
Q

What does tertiary intention refer to?

A

delayed wound closure– the wound is intentionally left open to heal as it would not heal, or healing would be impaired by contamination, infection, edema or poor circulation– a good ex. is compartment syndrome

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16
Q

What is exudate?

A

discharge that signals infection

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17
Q

What are the ways of classifying a wound?

A

-depth of tissue effected (superficial, partial, full thickness)
-acute vs chronic
-open vs closed
-superficial vs penetrating

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18
Q

What are the 3 ways of classifying the depth of tissue affected?

A

1) superficial wound– only epidermis is affected, ex. lightly skinning the surface
2) partial thickness– a wound that extends into the dermis, ex. road rash from falling off bike
3) full thickness– extends further than the dermis into the subcutaneous tissue and deeper

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19
Q

What is the difference between superficial and penetrating?

A

superficial means only involving the epidermal layer (ex. skin tear)

penetrating means a break in the epidermis, dermal, and deeper tissues and organs (ex. stab wound)

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20
Q

What is dehiscence?

A

the partial or total rupturing of a surgical wound, it usually involves abdominal wounds where the layers below the skin also separate– factors that increase risk of dehiscence are obesity, smoking, poor nutrition, multiple traumas, failure of suturing, sneeze, excessive coughing, vomiting, and dehydration

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21
Q

What is evisceration?

A

the protrusion of the internal viscera through an incision– the patient needs to immediately be supported with large sterile dressings, soaked in normal saline, and placed in bed with their knees bent

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22
Q

What are adhesions?

A

internal scar tissue (collagen) around or between organs due to disturbance of the tissue or organs– can result in more surgeries

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23
Q

What are contractures?

A

wound contracture is normal (final stage of healing by primary intention)– when in excess it can cause deformity, commonly seen in burn patient’s when the burn is over a joint

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24
Q

What are hypertrophic scars?

A

also called Keloids, they are when excessive collagen makes the scar lumpy and large

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25
Q

What is the acronym NERDS used for and what does it stand for?

A

NERDS is used to identify and classify infection
N– nonhealing wound
E– exudate
R–red and friable tissue (red and bleeds easily)
D– debris
S– smell after cleaning

having 3 or more of the criteria indicates the need for antimicrobial dressing

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26
Q

What is the acronym STONES used for and what does it stand for?

A

STONES is used to identify and classify deep or spreading infection (think “stones sink” to signal deeper infection)
S– size increasing
T– temperature
O– “os” probes to the bone
N– new areas of breakdown
E– erythema, edema, exudate
S– smell after cleaning

27
Q

What are the goals of treatment?

A

-promote healing (palliative might me maintenance)
-prevent complications
-prevent deterioration
-minimize harmful effects

Treat the cause– if you do not eliminate pressure, friction, etc. then you are fighting an endless battle

28
Q

What is debridement?

A

the medical removal of dead, damaged, or infected tissue to promote healing

29
Q

Describe disinfection

A

-eliminate all pathogens except bacterial spores using heat, chemicals, or UV light
-disinfectants used on inanimate objects and antiseptics are used on living tissue
-boiling doesn’t kill all organisms or spores

30
Q

Describe sterilization

A

-destroy all microorganisms including spores
-most commonly done with steam under pressure, ethylene oxide gas, hydrogen peroxide plasma, and chemicals
-many items that were once sterilized and reused are now disposable

31
Q

Describe clean technique (medical asepsis)

A

procedures used to reduce and prevent the spread of microorganisms (ex. hand hygiene)

32
Q

Describe sterile technique (surgical asepsis)

A

procedures used to eliminate all microorganisms including spores from an object or area– an object or area is considered contaminated if touched by an object that is not sterile

33
Q

What steps must be taken prior to providing wound care?

A

-client education and support
-pain assessment
-client position
-role of PCRA in safety
-gather all equipment

34
Q

What are the differences between sutures and staples?

A

staples– made of stainless steel, cause less trauma and provide more support (require adequate distance between the skin and underlying structures)

sutures– threads of wire or other material such as silk, cotton, or nylon. They come in different sizes and are absorbent or nonabsorbent, and come with or without the needle attached.

Both are generally removed in 7-10 days if healing is adequate but retention sutures usually stay in place 14-21 days

35
Q

How do you determine the type of wound closure device necessary?

A

-site of wound
-type of wound
-tissue involved
-purpose of the closure
-client’s history of wound healing

36
Q

What is the acronym MEASURE used for?

A

It is used for assessing wounds
M– measure (L x W x D)
E– exudate quality and quantity
A– appearance of wound bed
S– suffering (pain level)
U– undermining
R– reevaluate regularly
E– edge (condition of wound edge and surrounding skin)

37
Q

What does CWCMS stand for?

A

colour, warmth, circulation, movement, sensation

38
Q

What are the 5 P’s?

A

pain, pulse, pallor, paresthesia (pins and needles), paralysis

39
Q

What are the differences between bandages, binders, and splints?

A

bandage– a material to wrap a body part
binders– a type of bandage used to wrap a specific body part
splints– a rigid appliance for fixation of a body part

40
Q

Describe how to properly apply a tensor bandage

A

-support the limb to be bandages
-place limb in slight flexion
-wrap distal to proximal
-use appropriate wrap method
-hold bandage in dominant hand
-overlap 1/2 to 2/3
-firm but not tight
-assess CWCMS/5 P’s

41
Q

What are the possible complications from improper bandaging procedure?

A

-circulatory impairment/ edema
-skin breakdown
-infection
-damage to joint/contractures
-compromised surgical site

42
Q

When should you apply cold and when should you apply heat?

A

cold– first 24-48 hours, to decrease pain, decrease swelling and inflammation, and vasoconstriction

heat– used only >48 hours post injury, vasodilates, reduces joint stiffness and muscle spasms

43
Q

What are the effects of cold application to an injury site?

A

-vasoconstriction
-decreased cellular metabolism (less O2 needed at site)
-decreased capillary permeability
-slows bacterial growth
-increases blood viscosity
-decreases muscle tension
-local anesthetic

44
Q

What are the effects of heat application to an injury site?

A

-vasodilation (increased blood flow)
-increases capillary permeability
-decreases blood viscosity
-decreases muscle tension
-increases cellular metabolism
-increases inflammation
-has sedative effect

45
Q

What is the rebound phenomenon?

A

-occurs when the maximum therapeutic effect of the hot/cold application is achieved, and the opposite effect begins (occurs in about 30 min)

46
Q

What are the contraindications to the use of heat and cold?

A

neurosensory impairment, impaired mental status, impaired circulation and open wound– ex. diabetes

47
Q

When should you not apply heat?

A

<24hrs after traumatic injury, active hemorrhage, noninflammatory edema, and skin disorder

48
Q

When should you not apply cold?

A

open wound, impaired circulation, allergy/hypersensitivity to the cold

49
Q

When doing a complex dressing change which site is considered cleanest: surgical site or drain site?

A

surgical site is considered the cleanest and thus should be cleaned first, followed by the drain site and then the outside of the wound

50
Q

Describe a hemovac wound drain

A

3 spring drain
closed, suction (the compressed springs create the vacuum for suction), single suture

often seen with mastectomies, cranial, and orthopedic surgery

51
Q

Describe a Jackson-Pratt (JP) wound drain

A

closed, suction, single suture

seen in abdominal surgeries and mastectomies, has a bulb shaped reservoir that creates suction when compressed and collects the drainage

needs to be emptied every 8-12 hours (empty when half full)

patients can be sent home with these drains as they are easy to care for

52
Q

Describe a Penrose wound drain

A

open, passive, sterile safety pin

soft rubber tubing that is placed during surgery– does not have a collection device attached

53
Q

What is the purpose of a wound drain?

A

-to collect/measure excessive drainage from wound to prevent formation of an abscess
-protect the skin
-remove secretions from the surgical site

54
Q

What is a stent?

A

a tube placed in the body to create a passage between 2 spaces, such as a pigtail in the bile duct

55
Q

What are arterial ulcers?

A

pressure injuries caused by inadequate blood flow commonly secondary to PAD (peripheral artery disease)

also called ischemic ulcers

56
Q

What are some characteristics of arterial ulcers?

A

-found on the pressure points of the toe joints, anterior shin and base of heel
-punched out, irregular border
-base dry often pale or necrotic eschar
-severe pain

57
Q

What are some predispositions for arterial ulcers?

A

-smoking
-diabetes
-dyslipidemia
-intermittent claudication

58
Q

What are diabetic ulcers?

A

ulcers frequently caused by neuropathy in individual’s with diabetes

59
Q

What are some characteristics of diabetic ulcers?

A

-plantar surface of foot, over metatarsal heads, heel, and pressure points
-punched out, calloused border or under callouses
-usually superficial but sometimes deep (appearance depends on etiology)
-red base but can be covered with eschar
-usually no pain due to neuropathy

60
Q

What are the risk factors for skin tears?

A

Intrinsic:
-aging skin
-dehydration
-poor nutrition
-cognitive impairment
-altered mobility
-decreased sensation
-impaired sensory perception
-prolonged corticosteroid use (thins skin)

Extrinsic:
-those that need assistance for bathing, toileting, etc.
-those that are dependent on others for total care

61
Q

What should a nurse assess during a wound assessment?

A

-size
-infection
-exudate
-undermining
-tunneling
-conditions of wound margins and surrounding skin

62
Q

What should be assessed when evaluating wound exudate?

A

quantity (scant, moderate, copious)

characteristics (serous, serosanguinous, sanguineous, and purulent)

odour (present, absent, foul)

63
Q

What are the clinical manifestations present that indicate that the nurse needs to culture?

A

-non-healing/non-progressing
-deteriorating
-heavy exudate
-cellulitis

64
Q

What should you include in the documentation of a wound site?

A

-appearance of wound
-drainage type, colour, amount, odour
-appearance of wound drain site
-type of dressing(s) (amount, size, and if packed with Nugauze state the length)
-client tolerance

Nursing Techniques 2 (6 decks)

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