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AE 3 > Exam 2 - Wound Care > Flashcards

Exam 2 - Wound Care Flashcards

1
Q

Max amount of time for sitting in a chair for individuals with pressure injuries

A

3x/day in periods of 60 min or less

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2
Q

What devices should not be used for sitting/elevating heels?

A
  • donut shaped/ring devices
  • synthetic sheepskin pads
  • intravenous fluid bags
  • water filled gloves
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3
Q

Pressure Ulcer Nutrition

  • calorie intake
  • protein intake
A

30 - 35 kcal/kg

1.25-1.5 g protein/kg

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4
Q

What surfaces can you consider for Stage 1 and stage 2 ulcers? (2)

A
  • High specification reactive foam mattress

- Non-powdered pressure redistribution surface

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5
Q

What surfaces can you consider for stage 3, 4, and unstageable ulcers?

A
  • Low air loss mattress
  • Air fluidized mattress
    (enhanced pressure redistribution, shear reduction, and microclimate control)
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6
Q

How do you reduce pressure injury pain?

A
  • Keep the wound bed covered and moist

- Use a non-adherent dressing

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7
Q

What are adequate pain control measures for pressure ulcer pain management?

A
  • Regular pain medication

- Additional dosing prior to wound care procedures

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8
Q

What do you do at the time of each dressing change?

A

Cleanse the pressure injury

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9
Q

Consideration for ulcers with debris, confirmed or suspected infection, or suspected high levels of bacterial colonization?

A

Cleansing solutions with surfactants and or antimicrobials

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10
Q

How should you perform debridement if there is no urgent clinical need for drainage or removal of devitalized tissue?

A
  • mechanical
  • autolytic
  • enzymatic
  • biological methods
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11
Q

What type of debridement is recommended in the presence of extensive necrosis, advancing cellulitis, and or sepsis?

A

Surgical/sharp debridement

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12
Q

How do you debride a stable, hard, dry eschar in ischemic limbs?

A

Do NOT debride

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13
Q

For non-infected, shallow stage 3 pressure injuries

A

Hydrocolloid dressing

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14
Q

For autolytic debridement when the individual is NOT immunocompromised

A

Transparent film dressing

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15
Q
  • Minimal drainage
  • Granulating
  • Painful
  • Not clinically infected
A

Hydrogel dressing

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16
Q

For moderately and heavily exuding pressure injuries

A

Alginate dressing

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17
Q

Highly exuding stage 2 and shallow stage 3

A

Foam dressing

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18
Q

Clinically infected or heavily colonized

A

Silver Impregnated dressings

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19
Q

Stage 2 and 3

A

Honey-Impregnated

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20
Q

Which dressing should be avoided in impaired kidney failure, history of thyroid disorders or known iodine sensitivity?

A

Cadexomer Iodine

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21
Q

For prevention of periwound injury when periwound is fragile

A

Silicone dressing

22
Q

For non-healing stage 3 and 4 pressure injuries

A

Collagen Matrix

23
Q

Negative Pressure Wound Therapy is for

A

Early adjuvant treatment of deep stage 3 and stage 4

- intended for ulcers free of necrotic tissue

24
Q

Can patients with systemic clinical infection or those on anticoagulant therapy get negative pressure wound therapy?

A

No

25
Q

Where do you avoid gauze dressing?

A

Open pressure injuries that have been cleansed and debrided

26
Q
  • Intact
  • Area usually over bony prominence
  • Does not blanch with external pressure
A

Stage 1

27
Q
  • Skin NOT intact
  • Partial thickness skin loss of epidermis or dermis
  • Superficial ulcer
A

Stage 2

28
Q
  • Full thickness skin loss
  • Subcutaneous tissue and underlying fascia may be damaged/necrotic
  • possible undermining and tunneling
A

Stage 3

29
Q
  • Full thickness skin loss
  • Bone or tendon or muscle exposure
  • Slough, eschar
A

Stage 4

30
Q

Do patients get their own measuring tool?

A

Yes

31
Q

Granulation description

A
  • Red
  • Cobblestone appearance
  • Filling in appearance
32
Q

Undermining

A

Separation of tissue from the surface under the edge of the wound

33
Q

How do you describe undermining?

A

Describe by lock face (head being 12)

34
Q

Exudate

A

Fluids from wound

35
Q

Do you assess odor before or after cleaning?

A

After cleaning

36
Q

Factors that contribute to wound healing

A
  • infection
  • nutrition
  • hydration
  • circulation (pressure relief, oxygenation)
  • edema
  • glucose control
37
Q

What does incontinence lead to

A

Maceration (looks like stage 1)

- don’t keep patients in diapers

38
Q

Documenting turning

A
  • Document if the patient refuses to turn
39
Q

When should you assess a wound?

A

At least every shift - change dressing if not improving

40
Q

Firm, dry stable eschar - debride or not?

A

DON’T

41
Q

Eschar with purulent material, redness or edema around - debride or not?

A

Yes

42
Q

Can wounds heal in the presence of necrotic tissue? What does it increase?

A

No, rather increases bioburden

43
Q

Types of Debridement

A
  • Autolytic
  • Enzymatic
  • Sharp/surgical
  • Biological
  • Hydrotherapy
44
Q

5 basic categories of dressings

A
  • Films
  • Hydrogel
  • Hydrocolloids
  • Alginates
  • Foams
45
Q

Films

A
  • keeps wound dry
  • impermeable to larger molecules
  • transparent film is good for autolytic debridement when the individual is not immunocompromised
46
Q

Hydrogel

A

Good for dry wounds with minimal drainage

47
Q

Hydrocolloids

A

Gel or foam (ex: tegaderm)

- good for non-infected shallow stage 3

48
Q

Alginates

A

High calcium content to impede epithelialization

  • not soluble in water
  • requires secondary dressing
  • can be too drying –> good for heavily exuding pressure ulcers
49
Q

Foams

A

Film dressing + absorbancy

  • Creates a lot of moisture underneath the dressing
  • Can be used preventatively
  • or for highly exuding stage 2 and shallow stage 3
50
Q

Specialty treatments for huge open and gaping wounds

A
  • Vacuum-assisted wound treatments (monitor the drainage in the canister!)
  • Hyperbaric oxygen treatment

AE 3 (8 decks)

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