chap 38 part 5 ques 37 Flashcards
What are some of the ways that a dressing can be secured?
tape
stretch roller gauze
elastic bandage
montgomery straps
mesh netting
What are the purpose of Montgomery straps, and how would they be applied?
allow changing the dressing without removing and reapplying tape
adhered to either side of the wound and ties pull the tapes toward each other, relieving the tension around the wound
What are the advantages of a secured dressing?
Secures dressing in place
What is the proper technique for applying tape to a dressing?
ensure tape adheres to the skin for several inches on either side of the dressing
length of tape across middle of a large dressing
do not apply tape over irritated or broken skin
tape across a joint or crease
Sutures or staples might be kept in longer, for what type of patient?
older adults; prolonged healing time
injury from debris or chemical
Eye irrigation
wax or debris blocks ear canal and prevents sound from reaching tympanic membrane
Ear irrigation
infection or surgical preparation
Vaginal irrigation
What types of dressing would most likely be used on Stage II
hydrocolloid,
foam, or
hydrogel dressing,
which will protect against bacterial contamination.
What types of dressing would most likely be used on Stage III
use a dressing that will absorb exudate and maintain a moist environment.
For infected ulcers, always use a non-occlusive dressing
For infected ulcers, always use what type of dressing
a non-occlusive dressing
What is important for the nurse to do after each dressing change?
Date, initials and document
What is the purpose of negative pressure treatment with ulcers?
Increases development of granulation tissue, speeds healing rate, and reduces hospitalizations while minimizing the need for dressing changes.
observe dressing area when assessing vital signs
check setting on NPWT unit and assess working correctly
ensure tubing is not pressing on skin
assess for proper collapse of dressing
dressing changes
wound assessment
documentation
is the nurse’s responsibility for the wound vac?
What is the nurse’s responsibility for the wound vac?
observe dressing area when assessing vital signs
check setting on NPWT unit and assess working correctly
ensure tubing is not pressing on skin
assess for proper collapse of dressing
dressing changes
wound assessment
documentation