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3323 Advanced Assessment > EXAM 3 > Flashcards

EXAM 3 Flashcards

1
Q

Primary Intention

A

tissue surfaces have been well approximated; approximated with stitches, staples, skin glue, or tapes; used with very little tissue loss

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2
Q

examples of primary intention healing or primary union

A

surgical incisions, IV therapy, lumbar puncture

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3
Q

secondary intention healing

A

edges of wound not well approximated; wounds are extensive and involve considerable tissue loss

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4
Q

examples of secondary intention healing

A

large open wounds such as burns, pressure ulcers, venous stasis ulcers

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5
Q

secondary intention healing vs. primary intention healing

A

repair time is longer, scarring is greater, higher chance of infection d/t open and exposed wound

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6
Q

when stating a wound is well approximated…

A

means that the edges of the wounds fit nicely together and line up

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7
Q

tertiary intention healing

A

delayed or secondary closure; used when there is a reason to delay suturing or closing a wound to allow for drainage and/or edema/infection to resolve; used for heavy contamination in wound; usually held open for 48 hours after cleaned and then is surgically closed

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8
Q

examples of tertiary intention healing

A

abdominal wound that is initially left open to allow for drainage but later closed like dog bites

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8
Q

tunneling

A

wound is tunneling into the deeper tissue; usually in one direction

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9
Q

undermining

A

tissue loss occurring underneath the skin

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10
Q

use of cotton tipped appllicators

A

used to poke around the skin and determine how deep a wound is if the eyes cannot see; depth of applicator is then measured as part of the wound assessment

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11
Q

necrotic eschar

A

black tissue representing death of tissue; needs to be removes usually by surgical interventions

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12
Q

granulation

A

indicative of a healing wound; red an rich blood supply to area causing the bright coloring; slough on top needs to be removed

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13
Q

bright red colored wound means…

A

the wound is healing

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14
Q

types of wound exudate or drainage

A

serous- clear and watery with slight yellow tint; serosanguinous- combination of serous mixed with blood; sanguinous- mostly red blood composed from new bleeding; purulent- thicker green/yellow drainage that is sign of infection (pudding-like pus)

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15
Q

biofilm

A

wound biofilms are result of wound bacteria in clumps, embedded i n thick self-made protective slimy barrier of sugars and proteins; they impair wound healing; proper wound care requires removal of biofilm

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16
Q

dessication

A

process of drying up, cells dehydrate and die in dry environment forming crust over wound site delaying the healing

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17
Q

keeping wounds moist and hydrated (not wet)…

A

support epithilialization

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18
Q

maceration

A

softening and breakdown of the skin due to prolonged exposure to moisture

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19
Q

purpose of wound drains

A

used when anticipating collection of fluid

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20
Q

placement of wound drains

A

decided by the surgery that took place and the type of the wound

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21
Q

how often to assess wound drain

A

frequently throughout sift making note of the drainage, the site, thee pain associated, and the patient tolerance

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22
Q

common types of drains

A

open- gauze, iodoform gauze, nugauze, penrose; closed- chest tube, hemovac, jackson pratt (JP), T-tube

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23
Q

gauze, iodoform gauze, NuGauze open drain

A

gauze dressings packed loosely so wound is allowed to drainallow healing from base of wound up

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24
Penrose open drain
consists of rubber tube that provides a sinus tract; drains blood and fluid
25
example of open drain- gauze, iodoform gauze, NuGauze
infected wounds, after removal of hemorrhoids
26
examples of penrose open drain
after incision and drainage of an abscess, used in abdominal surgery
27
chest tube closed drain
mediastinal placement (different from chest tube in pleural space) used to drain blood
28
chest tube example
after cardiac surgery
29
hemovac closed drain
portable negative pressure suction device used to drain blood and fluid
30
jackson pratt closed drain
bulb suction device used to drain blood and fluid; bulb is squeezed prior to closing to create negative pressure; is sutured in place
31
jackson pratt example
used after breast surgery or mastectomy, used after abdominal surgery, (used for underarm)
32
examples of hemovac
used after abdominal surgery, used after orthopedic surgery, (breast surgery, underarm)
33
T-tube closed drainage
placed in the common bile duct to collect bile
34
example of t-tube
used following gallbladder surgery
35
NuGauze
used for wound packing via cotton tip applicator; allows for wound to heal from bottom up
36
montgomery strap
corsette looking dressing holding abdominal pad to wound; used for large wounds
37
hemovac vs JP
hemovac works the same way as JP by creating negative pressure but can hold more volume
38
flagging tubing
connect drain to clothing via safety pin to avoid disconnecting and pulling out of body
39
when to use negative pressure wound therapy or wound V.A.C.
used for large deep wounds that are not able to heal on own; used for individuals that have poor wound healing
40
purpose of NG tube
decompress or drain stomach of fluid, gastric secretions, or to instill solutions into stomach such as medications or feedings; used when conditions of peristalsis is absent; could be used for paralytic ileus or used to bypass areas of the stomach/intestines to allow for healing
41
salem sump pump
only NG tube used when continuously suctioning because it is a double lumen that stops a vacuum effect; contains a suction port, a passive air port for equalizing pressure (may have a pig tail over vent/passive air movement piecce)
42
where should the vent portion of sump pump be located?
higher then the stomach to avoid secretions backing up
43
is pt NPO with salem sump?
most likely because pump would immediately suck food/liquid out
44
levine tube
NG tube used for feeding only (AKA feeding tube); can be used for intermittent suctioning but not continuous; size correlates to size of pt
45
when measuring for placement of NG tube...
begin at tip of nose, to the tragus/ear lobe, then down to the xiphoid process; mark at xiphoid process and that is how far to insert the tube to reach pt stomach
46
providing enteral feeding via NG tube
used for short-term (~4 weeks); used for pt that have difficulty swallowing, failure to thrive/anorexia, and to give meds; need to flush tube prior to using
47
After inserting the NG tube...
need to confirm with x-ray for placement to avoid aspiration; if correctly placed then can begin using immediately; used to be able to aspirate stomach content and test pH for correct placement
48
when using the NG tube after placement confirmed prior...
need to recheck the length of the tube to ensure it has not moved and then can aspirate stomach contents to check pH
49
if NG tube placed in pt lungs
likely start coughing immediately
50
delivering enteral feeds in 3 ways
pump, gravity, bolus
51
pump enteral feeding
rate depends on pt; is required for continuous feedings; need to prime tubing prior to using
52
gravity enteral feeding
need to calculate drip rate
53
bolus enteral feeding
at an increased risk of distention; increased risk of aspiration
54
when delivering enteral feedings...
want pt sitting upright during and 1 hour after to decrease risk of aspiration
55
what to watch for when enteral feeding?
vomiting- how much was here, what was it consisting of, was there to much enteral feed being given to fast; aspiration- coughing and difficulty breathing
56
caring for NG tube
ensure tube is secured, ensure tube is taped to nose (specifically for salem sump d/t rigid tube), pin to gown to avoid removal of tube, assess skin irritation under/around tape, ensure mucous membranes are hydrated, if NPO then provide oral care
57
to promote safety when administering tube feeding...
ensure adequacy of tube by aspirating contents and checking pH, flush prior to giving food/meds and flush after, check placement before administering meds fluids or feedings
58
if meet resistance when flushing...
flush with coke to break down the clogging; can also use cranberry juice; removing tube is last resort
59
how long to leave tube in place
as long as possible unless there is policy at hospital or a defect with tube
60
how long is food bag good for?
usually good for 24 hours

3323 Advanced Assessment (4 decks)

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