201 sterile glove technique

Question 1

what cream is used for mild to moderate Incontinence associated dermatitis?

Answer 1

-basic protectant silicone 24%
-remedy hydraguard cream

Question 2

what is the cream used for moderate to severe IAD?

Answer 2

-advanced protect zinc 30%
-secura extra protective

Question 3

what cream is the txt for dry, cracked skin?

Answer 3

-advanced moisturizer urea 10% aha 4%
-attrac-tain cream

Question 4

what is used prevention and txt of interigo (red, itchy, burning skin fold)

Answer 4

-skin fold textile silver
-interdry ag sheet

Question 5

what is the goal of surgical drains for simple wounds?

Answer 5

to decompress or drain either fluid or air from the area of surgery

Question 6

what are the types and subcategories of surgical drains?

Answer 6

-closed drainage system : jackson-pratt, hemovac drain
-open drainage: penrose
-other: wound drainage bag (ostomy bag with a drain) which may be used for chronic wound with lots of drainage , and percutanous drain secured with a stat-lock

Question 7

what is a hemovac and what does it do?

Answer 7

-also called a 400 ml drain (total volume is 400ml/24 hours): usually emptied when half full or per facility policy
-it is a portable self-contained unit
-it is placed into a vascular space where blood drainage is expected after surgery (such as with abdominal and orthopaedic surgery)
-suction is maintained by compressing a spring like device

Question 8

what is a jackson pratt drain and what does it do?

Answer 8

-also called a 100ml drain (100ml/24 hours): usually emptied when 25-50 ml or per policy
-it is a portable self contained unit
-shaped like a bulb
-consists of a perforated round or flat tube connected to a negative collection device

Question 9

what is a penrose drain?

Answer 9

-an open drainage system
-is made out of soft rubber tube
-no sunction
-held in place with a safety pin
-usually pulled out in stages (using sterile technique and sterile safety pin)

Question 10

what are wound drainage bags used for?

Answer 10

used for wounds that have lots of drainage

Question 11

what is a percutaneous drain and what is it used for?

Answer 11

-it is a small plastic drain through the skin that is attached to a drainage bag
-used to drain an abscess
-may use a securement device
-often covered with a clear transparent dressing
-requires weekly dressing changes and prn

Question 12

how do you empty a drain?

Answer 12

-clean gloves
-release vacuum by opening the drain port
-empty drainage into appropriate container
-to re-establish suction: place the container on a flat surface, and have the palm of one hand hold down the top and bottom together, and the other hand clean the port (make sure to close the port before releasing the hold)

Question 13

what are some things you should know about a pts’ drain?

Answer 13

-what it’s used for and how long it should be in
-if the surgeon wants the drain to be wet or not

Question 14

what situations should a client not get the drain wet?

Answer 14

-if the drain is in-situ short term
-pts with penrose drain should not shower until the drain is out
-a client with hemovac or JP that is expected to be removed in 3-4 days once the drainage has slowed down may not need to shower

Question 15

what situations can the client get their drain wet?

Answer 15

-long term g tubes (feeding tubes)
-if client showers, the dressing should be kept dry

Question 16

what can cause pressure ulcers?

Answer 16

-localized ischemia (deficiency of blood supply to the tissue)
-lower limb injury (increased risk of developing a pressure injury to the heal)
-incorrect use of therapeutic support surfaces
-declining condition: when there’s a change in client’s condition make sure to repeat braden scale assessment to decrease risk, then implementing pressure injury strategies based on changes in the braden scale assessment can prevent pressure injuries

Question 17

location, how deep, drainage with pressure ulcers?

Answer 17

-over bony prominences
-can be shallow or deep, and go through to bone
-wound base may be covered with slough or eschar
-no drainage to large amounts of serous or purulent depending on the stage

Question 18

what is the braden scale flow important for?

Answer 18

prevention of wound injuries

Question 19

when would you complete the braden risk and skin assessment?

Answer 19

-within 8 hours of admission
-upon return from the OR
-if pt is at risk: every shift
-it pt is not at risk: at least daily

Question 20

if a wound gets better, do you down stage it?

Answer 20

No, because tissue that was lost in the original wound was not replaced - granulation tissue fills the defect

Question 21

what is stage 1 pressure injury?

Answer 21

-intact skin with non-blanchable redness of a localized area, usually over a bony prominence
-darkly pigmented skin may not have visible blanching
-color may be different from the surrounding area

Question 22

what is stage 2 pressure ulcer?

Answer 22

-partial thickness loss of dermis
-presents as a shallow open ulcer with a red pink wound bed, without slough
-can also present as an intact of open/ruptured serum filled or serosanguineous filled blister

Question 23

what is stage 3 pressure ulcer?

Answer 23

-full thickness skin loss which subcutaneous tissue is visible
-granulation tissue is often present
-may extend down, but not through fascia

Question 24

what is a stage 4 pressure ulcer?

Answer 24

-full thickness skin loss with extensive damage or tissue necrosis to muscle, bone or supporting structures (tendon, joint capsule)
-slough, eschar or both may be visble
-rolled edges, underminng, tunnelling or a combination often occur

Question 25

what is unstageable pressure ulcer?

Answer 25

-full thickness skin and tissue loss -unable to determine extend of damage/depth of the wound due to presence of slough or eschar

Question 26

what is deep tissue injury?

Answer 26

-non-blanchable intact/ non-intact skin -deep red, purple or maroon discolouration (may appear differently in darkly pigmented skin) -may reveal a dark wound or blood filled blister -painful, firm or mushy -may get worse and expose severity of the injury or it may improve and heal w/o causing futhur damage

Question 27

what are tips for assessing darkly pigmented skin?

Answer 27

-be more highly suspicious of pressure injuries (early visible signs are delayed by the pigment by sometimes up to 48 h) -good lightening -compare the colour of the wound skin and periwound -use a chart to describe variations -moisten the skin (darker skin is usually thicker and drier) -palpate the skin that has been exposed to pressure and shear -be aware of different presentations of DTPI -consider using technology to assess perfusion and subepidermal moisture (infrared thermography) -superficial wounds are easily more identified and open blisters usually still have the epidermis -healing wounds can lead to changes in pigmentation: inflammatory = skin may turn tan, brown, purple, healing = hypopigmentation

Question 28

how can you prevent pressure injuries?

Answer 28

-promote activity/mobility -encourage good nutrition and appropriate hydration -prevent/manage moisture assosciated skin damage -skin integrity assessment including bony prominences (atleast once a day) -complete risk assesment tool as required ( less than 18 means at risk) -keep HOB less than 30 degrees when possible -provide skin care -treat any skin wounds or tears promptly -frequent turning and positioning -off loading heal pressure -providing pressure reducing support surfce -use foam wedges for side lying

Question 29

what is a treatment for stage 1 pressure ulcer?

Answer 29

-relieve pressure -protect (barrier pressure) -prevent from becoming worse

Question 30

what is the txt for stage 2?

Answer 30

-relieve pressure -usually there's no dressing (but there's barrier cream), but sometimes a dressing is on the wound to absorb drainage -debride slough if present -protect

Question 31

what is the txt of stage 3 or 4?

Answer 31

-relieve pressure -debride slough/eschar if present -pack deep wounds and sinus tracts/undermining if present -dressing to absorb drainage -decrease bacterial colonization -protect

Question 32

what is the txt of unstageable pressure ulcer?

Answer 32

-surgical debridement to remove eschar -if non-surgical, keep dry, protect, and prevent infection (maintenance wound) -products used: iodine swab or liquid with cotton swab, iodasorb ointment (good for diabetic ulcers), inadine (antimicrobial providone impregnanted gauze)

Question 33

what is the txt of deep tissue injury?

Answer 33

-depends on presentation and when/if the wound becomes open -may become stage 3 or 4 -some txt: air-fluidized therapy (causes finely divied particles to acquire the characteristics of fluid), and non-contact low frequency ultrasound therapy (low energy ultrasound generated mist used to promote wound healing)

Question 34

what is a venous ulcer?

Answer 34

-shallow, superficial, irregular shape ulcer -usually appear distal medial 1/3 of the lower leg and ankle -peri wound is often edematous with weeping dermatitis (swollen,red skin), occasional cellulitis -skin color may be cyanotic, reddish-brown, or red due to dermatitis -moderate to large serous draining -peripheral pulses are palpable (may be difficult to find due to edema), cap refill normal -aching pain when legs dependent (when legs are hanging down or same level as the heart): relieved on elevation -81% of ulcers are venous

Question 35

what are venous ulcers caused by?

Answer 35

chronic venous insufficiency and the associated ambulatory venous hypertension

Question 36

what is the txt for venous ulcers?

Answer 36

-cleanse, irrigate prn -use autolytic debridment if indicated -absorbent dressing to maintain moisture balance but keep peri wound skin dry -elevate legs above heart to minimize edema, improve circulation, decrease pain -compression stockings if not contraindicated analgesic prn

Question 37

when is compression therapy used?

Answer 37

-in conjunction with wound txt for venous ulcers from venous insuffiency -client education -if stockings are worn every day, they need to be replaced every 6 months

Question 38

what is arterial ulcer caused by?

Answer 38

severe tissue ischemia

Question 39

what is an arterial ulcer?

Answer 39

-"punched out" appearance and round -shallow or deep, pale pink or yellow base, necrotic and eschar common -commonly on the toes, metatarsal heads, lateral malleolus, heels -little or no drainage -peri wound skin thin, dry, shiny with hair loss on lower extremities, thickened toenails and callouses -often severe pain: relieved by lowering the leg below heart level (eg. dangling leg over the edge of the bed) -peripheral pulses dimished or absent, cap refill delayed -ABI = Ankle brachial index (measures blood flow in the legs compared to the arms) less than 0.91 (normal 1.0-1.4) -skin temp cool/cold -color pale on elevation and rubour when dependent (arm or leg is hanging lower than the heart -pain often sever: worse with activity or elevation

Question 40

what is the txt for healable, arterial ulcers

Answer 40

-for dry ulcers: keep dry, maintain eschar dry, use antiseptic and dry dressing as needed -for wet ulcers: support moist wound healing, use autolytic debridement if indicated

Question 41

what is the txt for non-healable, arterial ulcers?

Answer 41

-for dry ulcers, keep dry, maintain dry eschar, use antiseptic and dry dressing prn -for wet ulcers, dry and protect the wound with antiseptic and dry dressing -do not debride wet or dry wounds if non-healable

Question 42

what are others ways of txt for arterial ulcers?

Answer 42

-pain management, analgesic prn -positioning for comfort -good foot care

Question 43

what are diabetic ulcers?

Answer 43

-shallow or deep, may probe to bone (meaning the infection has reached the bone) -may be necrotic, pink or pale -usually at presssure points on the plantar suface -small to moderate drainage: dry or wet gangrene may be present -callouses are common to peri-wound skin -usually painless -peripheral pulses are palpable -change in sensation

Question 44

what is the txt for diabetic ulcers?

Answer 44

-cleanse, irrigate -use autolytic debridement if indicated -maintain moisture balance -keep peri wound skin dry -protect wound -analgesics prn -monitor and control blood sugars -regular feet inspection; appropriate foot and nail care

Question 45

what are factors that affect wound healing?

Answer 45

-wound temperature (saline cools the wound, but first the wound has to reach body temp to start healing) -frequency of dressing changes (cooling effect) -moisture (too wet/dry) -yellow slough or necrotic tissue inhibiting granulation tissue (debride) -packed too tight (damages tissues) -dead space not filled (the open may close prematurely) -infection (wound will not heal until resolved) -pressure on wound (can damage tissue/prevent healing)

Question 46

what are the principle of wound care?

Answer 46

1. assess and treat the underlying cause 2. debride necrotic tissue 3. maintain a moist environment 4.assess and protect peri-wound skin 5.promote and support granulation tissue 6. fill dead space 7. stop infection and trauam

Question 47

what are factors to consider about a person's underlying cause?

Answer 47

-nutritional status -chronic helath conditons -equipment: wheelchair, mattress (pressure) -underlying infection

Question 48

what are types of debridement?

Answer 48

-autolytic (eg. gels) -enzymatic (use of an enzyme) -mechanical (physical force loosens/removes dead tissue) : irrigation, shower, whirlpool, dressing removal -surgical/sharp ( only ET nurses or physicians) -natural (eg. maggots, leeches)

Question 49

what is natural debridement?

Answer 49

-maggots eating necrotic tissue -maggots secrete calcium carbonate and ammonia which disinfect wounds -provide warmth with may stimulate tissue growth -increase fibroblast which promotes granulation tissue

Question 50

when do you remove maggot gauze on the skin?

Answer 50

in 2-3 days

Question 51

what is another natural therapy besides maggots?

Answer 51

-leeches: have unique saliva that increases blood flow, and contains anticoagulant properties that prevent clotting -once the maggots are full of blood, they detach from the body

Question 52

when would you use leech therapy?

Answer 52

-to reduce severe and dangerous venous engoregement (swelling) post surgery in fingers, toes, ears and scalp reattachments -limp transplants -skin flap surgery -breast reconstruction

Question 53

why would you maintain a moist environment?

Answer 53

-to promote angiogenesis (blood vessel development), tissue growth, and cell migration

Question 54

if a wound is too dry or too wet what do you do?

Answer 54

-dry: apply a produc to add moisture -wet: apply a product to absorb moisture -if the dressing becomes saturated, change the dressing

Question 55

what are you assessing for, on the peri wound?

Answer 55

-assess for maceration , if there is, you might need a more absorbent dressing or increase the frequency of dressing change -assess for redness, irritation, or skin breakdown: may be the surrounding skin needs a barrier

Question 56

how can you promote and support granulation tissue?

Answer 56

-encourage good nutrition -avoid frequent dressing changes -cleanse with each wound change -be gentle when cleansing fragile tissue -use non adherent dressing if dressing is sticking

Question 57

why would you want to fill up the dead space?

Answer 57

-to allow the wounds to heal from the bottom up -use loose "fluffy" packing material to fill in the open wounds (fluff don't stuff) -damp packing not wet -fill areas of undermining and sinus -use one piece of gauze/packing if possible (or ensure all pieces can be removed easily and not accidentally left in the wound)

Question 58

do wounds normally contain bacteria?

Answer 58

yes

Question 59

what is bacteria colonization?

Answer 59

-bacterial attached to the wound bed starts replicating, but may not be infected -treat with iodine

Question 60

whats an infection?

Answer 60

-when the wound becomes infected and the bacteria starts to invade the surrounding tissues causing an inflammatory response which can lead to a local infection and maybe a systemic infection -treat with iodine and antibiotics

Question 61

how can you help with the diagnose and treatment of an infection?

Answer 61

-culture and sensitivity -systemic antibiotics -wick draining to prevent abscess formation if warranted -change dressing more frequently to remove contaminated drainage -observe closely for deterioration (locally and systemically)

Question 62

what will nurse do if they suspect a wound infection?

Answer 62

-if there are 2+ s/s of local or systemic wound infection, the nurse will obtain a C & S swab -the assessment is what diagnoses the infection, not the culture results -may start oral or IV antibiotics (may be ordered before or after culture results come back) -will need to use a anti-microbial wound care products to decrease bacteria in the wound

Question 63

how do you obtain a C & S swab?

Answer 63

-cleanse wound with 60-100 ml of saline -swab only granulation tissue (not eschar, slough, pus or exudate) -rotate swab over 1 cm square area of wound for 5 seconds (may need to press into the wound to obtain fluid) -label specimen with client ID, swab source site, current antibiotic therapy and any pertinent info (eg. diagnosis, suspected causative agent) -refrigerate swab and transport lab within 12 hours in biohazard bag

Question 64

how can you protect a wound?

Answer 64

-protective dressing -removing dressing and tape appropriately -off loading -use non adherent dressing when necessary

Question 65

what are wound care txts?

Answer 65

-pack sinus tracts and cavities -provide moisture -prevent sticking of dressing -absorb excess exudate -promote autolysis of necrotic tissue -pad and insult to prevent trauma -prevent bacterial invasion/decrease bacterial colonization -debride (clean, remove packing and hydrofiber)

Question 66

when should a wound dressing be changed?

Answer 66

-too wet/leaking drainage -too dry -ordered (eg. VAC changed 3x/week or per policy) -when product has reached time limit (eg 7 days) -when loose or falling off -for chronic wounds, if wound dressing appropriate and no issues then q 3-5 days the dressing is changed

Question 67

when cleaning a surgical incision, what direction do you go to?

Answer 67

from clean to dirty using a clean swab every time

Question 68

when cleaning an open surgical incision what direction do you clean?

Answer 68

-clean to dirty -if a surgical drain site, clean to dirty (meaning from drain site outwards), using a clean swab each time

Question 69

if there is an incision and a drain site, which one do you clean first?

Answer 69

cleanse the incision (clean) and then the drain site (dirty)

Question 70

can a pt with a chronic would shower?

Answer 70

yes, showering may assist a dressing to loosen from the wound bed with less mechanical trauma than removing a dressing that is dry

Question 71

what patient teaching be done regarding wound care?

Answer 71

-s/s of infection and when to call the doctor or go into a clinic -healing time -importance of good nutrition (protein, vit c & b & d, iron, zinc, calories) -importance of fluids (2500 + ml/day) -hygiene (preventing infection/sepsis): hand hygiene before and after dressing changes, clean area for storage of dressings) -positioning and off loading -proper disposal of dressing -how the client may bathe/shower with the wound -portable tap water may be used to clean the wounds

Question 72

where would you document for closed incisons & minor superficial wounds, drains, suture/staple removal, open wounds?

Answer 72

-closed incisions & minor superficial wounds: 24 h record, narrative notes prn -drains: 24 h record, narrative notes, in/out -suture/staple removal: 24 h record, narrative notes -open wounds: wound assessment and treatment flow sheet (put a checkmark ont eh 24 h record), and narrative notes if concerns

Question 73

when is a wound assessment and treatment flowsheet (WATFS) initated

Answer 73

when there is wound present

Question 74

when is a WAFTS filled out?

Answer 74

each time a dressing change is scheduled to be changed

Question 75

when is a full assessment using WAFTS done?

Answer 75

every week (7 days) and whenever a significant change occurs (eg. odour develops, wound deteriorates)

Question 76

when is a partial wound assessment done?

Answer 76

for dressing changes that occur between weekly assessments (this includes all assessment parameters except measuring the wound)

Question 77

when the wound is closed and no longer requires care, what do you write on the WAFTS?

Answer 77

"closed" on the assessment form and the entry initialled

Question 78

what are the 3 types of goals of care on the WATFS?

Answer 78

-to heal -to maintain (preventing it from getting worse) -to monitor/manage (cancer wound

Question 79

when would you need to fill out a PSLS for wound care?

Answer 79

if it's a skin tear, pressure injury, incontinence

Question 80

when would you measure the size of the wound?

Answer 80

every week or if there's a change in the wound

Question 81

what is the measurement of wound?

Answer 81

cms

Question 82

what are sinus tracts and how do you measure them?

Answer 82

-visible tunnels that can extend deep into the tissues -measure each sinus -location is recorded in "o clock", using a 12 hour clock (towards the head is 12 and towards the feet is 6) -use a sterile 1 tip and paper measuring tape, or a measuring too,

Question 83

what is undermining and how do you measure?

Answer 83

-hidden missing pieces of skin that are under overhanging skin -location uses o clock -use sterile Q tip, paper measuring tape or measurement tool

Question 84

how do you describe exudate?

Answer 84

-by the % of each color of exudate present -all percentages must add up to 100

Question 85

what are the exudate categories?

Answer 85

-none -scant/small -moderate: half of dressing is saturated with drainage -large/copious: entire dressing saturated

Question 86

when do you assess for odour?

Answer 86

after cleansing the wound

Question 87

what is demarcated and diffused wound edges?

Answer 87

-demarcated: edges are clearly seen -diffuse: edges not clearly see

Question 88

what is indurated, excoriated, callused peri sound skin?

Answer 88

-indurated: abnormal firmness around the wound -excoriated: superficial loss of tissue -callused: thicked layer of the epidermis

Question 89

what kind of pressure ulcer requires packing?

Answer 89

-stage 4 -pack any wound greater than 1 cm