CHAP 38 PT 4 QUES 24 Flashcards
performed bedside or in OR; sterile scissors, forceps, scalpel blade; when signs of sepsis or cellulitis
sharp debridement
topical substances break down and liquefy dead tissue;
placed in wound and another dressings is place to absorb exudate;
useful for uninfected wounds
Enzymatic debridement
Dakin solution or sterile maggots is used for necrotic tissue that is not responding to other treatments
chemical debridement
longer process that uses body’s enzymes to break down nonviable tissue;
best for SMALL, UNINFECTED WOUNDS
because:
dressing creates A MOIST environment that encourages bacterial growth
autolytic
physical removal of wound debris by irrigation, whirlpool bath, hydrotherapy, ultrasound mist, wet-to-dry dressings
Mechanical
treatment for mechanical debridement is how long
three times a week
Who decides the type of dressing and the changing frequency?
physician
What abnormal findings should the nurse report to the physician?
fever, purulent drainage, lab values of elevated WBC, emergent conditions in state of wound
have a non adherent surface on one side that is applied to the wound
this dressing causes less wound trauma when it is removed
telfa and non adherent dressing
are used to cover small gauze dressing
hold dressings in place and absorb excess drainage
surgi-pad or abdominal pad(ABDs)
what is the purpose of dressing
to fully cover the wound and supply sufficient absorbent material to contain any exudate produced
superficial wound heals faster when
it is kept moist than dry
these dressing keep the wound moist while insulating and protecting
occlusive and semi-occlusive dressings (films, hydrocolloids, foams)
example of occlusive and semi-occlusive dressings are
(films, hydrocolloids, foams)
what are the two commonly dressing used
transparent fims and hydrocolloid dressing
other type of dressing are
hydrogels, calcium alginate, composites, collagens, enzymatic debriders
What are the two sides on the telfa dressing,
and which side is placed against the wound?
shiny, non-adhesive side (goes against the wound)
absorbent material
What type of dressing should be placed on a stage 1 wound/ulcer?
transparent film may be used for stage 1 (or 2) pressure wound
how long can a transparent film stay not the skin
3 to 7 day
or when the film can no longer stick to the skin
do not use transparent film on what
over an infected wound
What is the purpose of a Hydrocolloid dressing,
keep wound moist and reduce wound size
how long can Hydrocolloid dressing, be left in place?
3-5 days
not advised for heavily draining wounds
Why is a wound not allowed to dry?
moist wounds heal better
What is the advantage of warm vs cold solutions for wounds?
cold solution lowers wound temperature and results in slowed wound healing
Please list the steps for a sterile dry dressing change:
Loosens tape or binder, dons clean gloves, and removes old dressing.
Inspects dressing and places it in discard bag.
Removes and discards gloves; performs hand hygiene.
Prepares dressing supplies, maintaining asepsis.
Performs hand hygiene.
Dons sterile gloves.
Cleans around the wound with sterile technique.
Applies medication if ordered.
Applies sterile dressing with sterile technique.
Removes gloves and secures dressing; performs hand hygiene.
Document, including wound appearance, tolerance of procedure, pt education.
How should the tape be removed on the old dressing?
hold skin taut and peel tape in towards center of wound to avoid pulling on wound
What is the purpose of debridement?
removal of dead and necrotic tissue to enhance wound healing
Debridement would not be used on which area of the body?
heels
