Wounds Flashcards

Question

Stage IV involves

Answer 1

full-thickness tissue loss with exposed bone, tendon, or muscles

Answer 2

the term for a hollow area between the outer wound and the wound bed. It resembles a cave.

Answer 3

leathery covering that is dead tissue and is usually removed by debridement.

Answer 4

a cavity or channel formed from a wound.

Answer 5

is the opening of a previously closed surgical wound.

Answer 6

``` Albumin of less than 3.2 mg/dL . Hemoglobin A1C levels greater than 8% due to prolonged high glucose levels. Glucose levels greater than 120 mg/dL Body weight decrease 5%-10% TLC <1,800/mm3 ```

Answer 7

Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention.

Answer 8

Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, require more tissue replacement often contaminated, take longer to heal form more scar tissue. If a wound that is healing by primary intention becomes infected, it will heal by secondary intention.

Answer 9

``` are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed ```

Answer 10

The nurse would place an OpSite over a central venous access device insertion site. An OpSite helps to secure the device and is appropriate for a site with little drainage. The nurse would use appropriate aseptic techniques when changing a dressing.

Answer 11

The nurse would place a Sof-Wick around a drain insertion site. The Sof-Wick absorbs drainage and protects the wound from contamination or injury.

Answer 12

purpose of a Telfa is to not adhere to the wound, and allows drainage to pass through to a secondary dressing.

Answer 13

a piece of foam is cut to the shape of the wound and placed in the wound bed. Irrigation requires sterile, not clean, technique and the pressure setting of the V.A.C. Therapy Unit is specified by the physician rather than increased until drainage is visible. Suction is always provided by the V.A.C. Therapy Unit, not by attaching the tubing to wall suction.

Answer 14

Biosurgical debridementuses fly larvae to clear the wound of necrotic tissue. This is accomplished through an enzyme the larvae releases. Autolytic debridement involves using the client?s own body to break down the necrotic tissue. Enzymatic debridement involves the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed. Mechanical debridement involves physically removing the necrotic tissue, such as surgical debridement.

Answer 15

Provides sinus tract Ex. After incision and drainage of abscess, in abdominal surgery

Answer 16

For bike drainage | Ex. After gallbladder surgery

Answer 17

Decreases dead space by collecting drainage | Ex. After breast removal abdominal surgery

Answer 18

Jackson-Pratt | Decreases dead space by collecting drainage

Answer 19

Decreases dead space by collecting drainage | Ex. After abdominal surgery orthopedic surgery

Answer 20

Allow healing from base of wound | Ex. Infected wounds after removal of hemorrhoid

Answer 21

3.5-5 mg/dL | <3.2 risk

Answer 22

1000-4000/mm3 | <1800@risk

Answer 23

<6% | Greater then 8 % @risk

Answer 24

70-120 mg/dL | Greater then 120 @risk

Answer 25

Location of any lesion or ulcer Identification of the stage Size of the ulcer: length, width, depth; presence of undermining, a hollow between the skin surface and the wound bed, resulting from death of the underlying tissue Color and type of wound tissue Presence of any abnormal pathways in the wound, such as a sinus tract (a cavity or channel underneath the wound that has the potential for infection) or tunneling (a passageway or opening that may be visible at skin level, but with most of the tunnel under the surface of the skin). Visible necrotic tissue; necrotic tissue that is in the process of separating from viable portions of the body is referred to as slough. Presence of an exudate or drainage (amount and type) Presence of odor Presence or absence of granulation tissue Visible evidence of epithelialization Periwound skin condition

Answer 26

Assess the skin of patients at risk on a daily basis. Pay particular attention to bony prominences. Cleanse the skin routinely and whenever any soiling occurs. Use a mild cleansing agent, minimal friction, and avoid hot water. Maintain higher humidity in the environment and use skin moisturizers for dry skin. Avoid massage over bony prominences. Protect the skin from moisture associated with episodes of incontinence or exposure to wound drainage. Minimize skin injury from friction and shearing forces by using proper positioning, turning, and transferring techniques. Use lubricants, protective films, dressings, and padding to diminish the effects of friction on the skin. Use appropriate support surfaces (tissue load management surfaces). Investigate reasons for inadequate dietary intake of protein and calories. Administer nutritional supplements or more aggressive nutritional intervention as needed. Continue efforts to improve mobility and activity. If this is unrealistic, attempt to maintain current level of activity, mobility, and range of motion. Document measures used to prevent pressure ulcers and the results of these interventions

Answer 27

``` Provide physical, psychological, and aesthetic comfort Prevent, eliminate, or control infection Absorb drainage Maintain a moist wound environment Protect the wound from further injury Protect the skin surrounding the wound Remove necrotic tissue, if appropriate ```

Answer 28

Allow exchange of oxygen between wound and environment Are self-adhesive Protect against contamination; waterproof Prevent loss of wound fluid Maintain a moist wound environment Facilitate autolytic débridement No absorption of drainage Allow visualization of wound May remain in place for 24 to 72 hours, resulting in less interference with healing

Answer 29

Wounds with minimal drainage Wounds that are small; partial-thickness Stage I pressure ulcers Cover dressings for gels, foams, and gauze Secure intravenous catheters, nasal cannulas, chest tube dressing, central venous access devices

Answer 30

Are occlusive or semi-occlusive, limiting exchange of oxygen between wound and environment Minimal to moderate absorption of drainage Maintain a moist wound environment Are self-adhesive Provide cushioning Facilitate autolytic débridement Protect against contamination May be left in place for 3 to 7 days, resulting in less interference with healing

Answer 31

Partial- and full-thickness wounds Wounds with light to moderate drainage Wounds with necrosis or slough Not for use with wounds that are infected

Answer 32

Blanching of skin over an area under pressure results from ischemia. When pressure is relieved, reactive hyperemia follows and the skin is red and feels warm. Reactive hyperemia is not a stage I pressure ulcer.

Answer 33

Cognitive behavior therapy (CBT) requires a therapist to work through any maladaptive sleep beliefs. CBT can be very successful is used with other complementary therapies. CBT can include progressive muscle relaxation measures, stimulus control, and sleep restriction therapy. Sedatives and hypnotics would not be used in conjunction with CBT. Pharmacological approaches do not have to be attempted prior to CBT initiation. A client undergoing CBT is not asked to stay in bed during normal sleep hours if the client is not able to sleep.

Answer 34

Proliferation stage Gentle cleansing and change of dressing Need protection

Answer 35

Hydrocolloids

Answer 36

Transfer films

Wounds Flashcards

(63 cards)