CHAP 38 PT 4 QUES 24

Question 1

performed bedside or in OR; sterile scissors, forceps, scalpel blade; when signs of sepsis or cellulitis

Answer 1

sharp debridement

Question 2

topical substances break down and liquefy dead tissue;

placed in wound and another dressings is place to absorb exudate;

useful for uninfected wounds

Answer 2

Enzymatic debridement

Question 3

Dakin solution or sterile maggots is used for necrotic tissue that is not responding to other treatments

Answer 3

chemical debridement

Question 4

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

Answer 4

autolytic

Question 5

physical removal of wound debris by irrigation, whirlpool bath, hydrotherapy, ultrasound mist, wet-to-dry dressings

Answer 5

Mechanical

Question 6

treatment for mechanical debridement is how long

Answer 6

three times a week

Question 7

Who decides the type of dressing and the changing frequency?

Answer 7

physician

Question 8

What abnormal findings should the nurse report to the physician?

Answer 8

fever, purulent drainage, lab values of elevated WBC, emergent conditions in state of wound

Question 9

have a non adherent surface on one side that is applied to the wound

this dressing causes less wound trauma when it is removed

Answer 9

telfa and non adherent dressing

Question 10

are used to cover small gauze dressing

hold dressings in place and absorb excess drainage

Answer 10

surgi-pad or abdominal pad(ABDs)

Question 11

what is the purpose of dressing

Answer 11

to fully cover the wound and supply sufficient absorbent material to contain any exudate produced

Question 12

superficial wound heals faster when

Answer 12

it is kept moist than dry

Question 13

these dressing keep the wound moist while insulating and protecting

Answer 13

occlusive and semi-occlusive dressings (films, hydrocolloids, foams)

Question 14

example of occlusive and semi-occlusive dressings are

Answer 14

(films, hydrocolloids, foams)

Question 15

what are the two commonly dressing used

Answer 15

transparent fims and hydrocolloid dressing

Question 16

other type of dressing are

Answer 16

hydrogels, calcium alginate, composites, collagens, enzymatic debriders

Question 17

What are the two sides on the telfa dressing,

and which side is placed against the wound?

Answer 17

shiny, non-adhesive side (goes against the wound)

absorbent material

Question 18

What type of dressing should be placed on a stage 1 wound/ulcer?

Answer 18

transparent film may be used for stage 1 (or 2) pressure wound

Question 19

how long can a transparent film stay not the skin

Answer 19

3 to 7 day

or when the film can no longer stick to the skin

Question 20

do not use transparent film on what

Answer 20

over an infected wound

Question 21

What is the purpose of a Hydrocolloid dressing,

Answer 21

keep wound moist and reduce wound size

Question 22

how long can Hydrocolloid dressing, be left in place?

Answer 22

3-5 days

not advised for heavily draining wounds

Question 23

Why is a wound not allowed to dry?

Answer 23

moist wounds heal better

Question 24

What is the advantage of warm vs cold solutions for wounds?

Answer 24

cold solution lowers wound temperature and results in slowed wound healing

Question 25

Please list the steps for a sterile dry dressing change:

Answer 25

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.

Question 26

How should the tape be removed on the old dressing?

Answer 26

hold skin taut and peel tape in towards center of wound to avoid pulling on wound

Question 27

What is the purpose of debridement?

Answer 27

removal of dead and necrotic tissue to enhance wound healing

Question 28

Debridement would not be used on which area of the body?

Answer 28

heels