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201B Exam #3 > Wound Care > Flashcards

Wound Care Flashcards

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1
Q

do nurses stage wounds?

A

no, b/c of financial implications for the hospital

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2
Q

what causes wounds (6)?

A
  1. pressure
  2. truma
  3. surgery
  4. burns
  5. infections (skin contaminated)
  6. arterial/venous insufficiency
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3
Q

wounds need to be protected from what three things?

A
  1. mechanical injury
  2. pressure
  3. microbial contamination
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4
Q

are wounds cared for using “sterile” or “clean” techniques?

A

it depends, we mostly see clean

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4
Q

what are the 6 objectives wound care is meant to do?

A
  1. protect
  2. enhance healing
  3. absorb drainage
  4. splint/immobilize
  5. prevent premature closure of infected wounds
  6. debride wound site
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5
Q

after surgery who changes the dressing on surgical incisions for the first time?

A

physicians, unless otherwise ordered

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6
Q

what is an example of a wound that requires clean technique?

A

decubitous (pressure injury)

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7
Q

what is an example of a wound that would use sterile technique?

A

a wound in the abdomen or chest

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8
Q

what is tunneling?

A

when a wound extends deeper than its surface creating tunnel or channel

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9
Q

what is undermining?

A

a wound complication where the edges of a wound separate from the healthy tissue around it, creating a pocket of dead space under the skin.

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10
Q

what are the 10 aspects of a wound that might need to be documented?

A
  1. location
  2. size/shape
  3. appearance/color
  4. approximation
  5. drainage
  6. odor
  7. undermining/tunneling
  8. suture/ staples
  9. dressing type
  10. drains
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11
Q

what is dehiscence?

A

separation of wound edges

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12
Q

what is evisceration?

A

abdominal contents protrude through wound opening

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13
Q

what are some wound complications that require immediate intervention?

A

dehiscence and evisceration

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14
Q

what are the three types of wound healing?

A

primary, secondary
and tertiary

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15
Q

what is secondary wound healing?

A

will not be closed by sutures, heals from the inside out
-wound gaping and irregular
-granulation occurs over time
-epithelium fills in scar (bigger)

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15
Q

what is primary wound healing?

A

-clean wound (most wounds)
-sutured early
-results in a hairline (small) scar

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16
Q

what is tertiary wound healing?

A

will be closed by sutures
-wound not sutured but needs to be
-granulating tissue sutured together

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17
Q

what is the Braden scale for?

A

-used to help predict skin breakdown
-scoring charted each shift
-used to guide care and prevent skin breakdown

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18
Q

what are three causes of pressure wounds?

A

-pressure (bony prominences)
-compromised blood flow
-shearing forces

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18
Q

what are shearing forces?

A

friction from moving pt. around

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19
Q

the Braden score assesses which 6 areas?

A
  1. sensory perception
  2. moisture
    3.activity
  3. mobility (pt. demo)
  4. nutrition
  5. friction and shear
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20
Q

what are some bony prominences to look out for in regards to pressure wounds?

A

back or side of head
scapulae
elbows
sacrum
heels
knee
ear
malleous (ankle)
hip
shoulder
vertebrae
pelvis
toes
breasts
cheek

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21
Q

with the Braden scale a lower score equals _______ risk

A

higher
range 6-23

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22
<18 score on the braden scale means what?
at risk for skin breakdown and begin skin preventative interventions
23
hat are preventative intervention for someone who is at risk for skin breakdown?
turn/ reposition protect bony prominences increase activity nutrition/ HYDRATION MANAGE MOISTURE use pressure redistribution surfaces
24
Pressure injuries staging 1-4
1 red skin 2 broken skin 3 deep, through sub-q tissue 4 to bone
25
what is eschar?
eschar is dead tissue that forms a scab-like covering over wounds and eventually falls off unstageable
26
describe a stage 1 pressure injury
reddened area localized nonblanchable usually over bony prominence painful hard/soft warmer/cooler dark skin may be diff.color
27
describe a stage 2 pressure wound
-partial thickness loss of dermis -open but shallow -pink wound bed
28
describe a stage 3 pressure wound
-deep crater -full thickness skin loss -may extend into adipose layer
29
what are 5 other types of wounds besides pressure?
1. skin tears 2. arterial ulcers 3. venous ulcers 4. diabetic foot ulcers 5. incontinence associated dermatitis
29
what are medical devices that can cause skin breakdown?
nasal cannula o2 face mask o2 sat probes tracheostomy parts feeding tubes vascular lines/hubs urinary and fecal tubing chest tubes cervical collars braces/splints/casts SCDs bedpans
30
describe a stage 4 pressure wound
full thickness skin loss -very deep - may extend into muscle or bone - slough/eschar may be present (dead tissue)
30
who stages pressure wounds and how do they do it?
a wound care expert photos taken w/ facility camera, measured (tunnels too)
31
what is undermining/tunneling?
a wider are of wounding that lies beneath the wound opening
31
who directs wound care?
MD order supersedes PT/RN wound specialist
32
what are some types of wound dressings that are commonly used?
transparent adhesive wound barriers (tegaderm) impregnated npn-adherent dressings (adaptic or vaseline gauze, xeroform)
33
what are some different types of gauze?
2x2 4x4 fluffs kerlix ABD pads split drain sponge
34
what are some example s of hydrocolloids? why is it not used often?
mepilex duoderm must be specifically ordered. not used often due to possible damage upon removal used for bedsores (mildly exuding wounds) maintain moisture and protect from bacteria
35
what is hydrogel and how does it help wounds?
it is a 90% water in a gel base. creates a moist healing environment and fills in dead space
36
what does hydrogel promote?
-granulation -epithelialization -autolytic debridement (enzymes break down necrotic tissues)
37
can hydrogel be used with infection present?
yes
38
should hydrogel be applied directly to wounds or to dressings?
can do both
38
what are some wound irrigation solutions?
normal saline hydrogen peroxide (full/partial strength) dakins solution
38
what are the 8 steps in wound care planning?
1. review order 2. determine clean vs. sterile 3. pre-medicate 4. source doc. 5. explain procedure/consent 6. necessary supplies to rm. 7. extra help? 8. lucky gloves
39
it is important to move from ________ to __________ areas in wound care
Clean to contaminated
40
pressure injuries are considered __________, so we use ____________ with them
colonized clean technique
41
a wound itself is considered what?
sterile
42
what is the purpose of wet-to-dry dressings?
to gently debride the area
43
wet to dry dressings are actually supposed to be what?
moist to dry avoid placing wet dressing on healthy skin, it will macerate (break down)
44
what is the procedure for changing a wound dressing? 14 steps
1. hand hygiene 2. prepare sterile field 3. add necessary sterile supplies 4. pour cleansing solution 5. remove outer dressing with clean gloves 6. remove inner dressing with sterile tweezers 7. discard tweezers/ non-sterile gloves 8. apply sterile gloves/use new suture kit 9. insert guaze w/ sterile tweezers/sterile q tips and gloves 10. DO NOT TOUCH OUTSIDE OF WOUND 11. fill entire wound with gauze 12. cover wound with absorbent pad/gauze 13.cover with protective dressing 14. secure dressings
45
what are three ways to secure dressings?
tapes wraps montgomery straps
46
what are three kinds of tape?
paper plastic cloth
47
what are three kinds of wraps?
gauze stretch netting ace bandage
48
what is sanguineous drainage?
bloody
49
what is serous wound drainage?
watery
50
what is serosanguineous drainage?
watery/bloody
51
what are abdominal binders commonly used for?
to help pt. feel better and supported after surgery
52
how to wrap ace bandage?
diagonally back and forth, secure with hooks
53
what are the two suture types?
plain interrupted plain continuous
54
when removing plain interrupted sutures what part do the tweezers hold onto?
the knot side
55
what are three ways to close a wound?
sutures staple cyanoacrylate glue (derma bond)hat is
56
a penrose drain?
drain that allows for open drainage through capillary action to skin surface through tube, drainage absorbed in dressing (not for lg. amts. of drainage)w
57
What is a JP suction drain? and what does it do?
(jackson pratt) provides gentle suction must be compressed 150 mL max (sm amt.) keep track of amt.
58
what is a hemovac? and what does it do?
used for lg. volumes placed in vascular cavity must be compressed stronger and larger than JP
59
what is cold therapy good for? what does it do?
-controls bleeding -decreases edema -pain control -anti-inflammatory effect
60
what is heat therapy good for? what does it do?
-facilitates soft tissue -repair -relaxes skeletal muscles -increases blood flow to area
61
what are the safety factors with heat therapy?
order required intact sensory function assess response
62
what are the safety factors for cold therapy?
order required not applied directly to skin discontinue when numbness is achieved assess response 15 min on/ 15 min off
63
what is generally applied first to a wound? hot or cold therapy?
cold therapy for about 2 days then move on to hot therapy

201B Exam #3 (3 decks)

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