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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
Q

Penrose open drain

A

consists of rubber tube that provides a sinus tract; drains blood and fluid

25
Q

example of open drain- gauze, iodoform gauze, NuGauze

A

infected wounds, after removal of hemorrhoids

26
Q

examples of penrose open drain

A

after incision and drainage of an abscess, used in abdominal surgery

27
Q

chest tube closed drain

A

mediastinal placement (different from chest tube in pleural space) used to drain blood

28
Q

chest tube example

A

after cardiac surgery

29
Q

hemovac closed drain

A

portable negative pressure suction device used to drain blood and fluid

30
Q

jackson pratt closed drain

A

bulb suction device used to drain blood and fluid; bulb is squeezed prior to closing to create negative pressure; is sutured in place

31
Q

jackson pratt example

A

used after breast surgery or mastectomy, used after abdominal surgery, (used for underarm)

32
Q

examples of hemovac

A

used after abdominal surgery, used after orthopedic surgery, (breast surgery, underarm)

33
Q

T-tube closed drainage

A

placed in the common bile duct to collect bile

34
Q

example of t-tube

A

used following gallbladder surgery

35
Q

NuGauze

A

used for wound packing via cotton tip applicator; allows for wound to heal from bottom up

36
Q

montgomery strap

A

corsette looking dressing holding abdominal pad to wound; used for large wounds

37
Q

hemovac vs JP

A

hemovac works the same way as JP by creating negative pressure but can hold more volume

38
Q

flagging tubing

A

connect drain to clothing via safety pin to avoid disconnecting and pulling out of body

39
Q

when to use negative pressure wound therapy or wound V.A.C.

A

used for large deep wounds that are not able to heal on own; used for individuals that have poor wound healing

40
Q

purpose of NG tube

A

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
Q

salem sump pump

A

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
Q

where should the vent portion of sump pump be located?

A

higher then the stomach to avoid secretions backing up

43
Q

is pt NPO with salem sump?

A

most likely because pump would immediately suck food/liquid out

44
Q

levine tube

A

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
Q

when measuring for placement of NG tube…

A

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
Q

providing enteral feeding via NG tube

A

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
Q

After inserting the NG tube…

A

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
Q

when using the NG tube after placement confirmed prior…

A

need to recheck the length of the tube to ensure it has not moved and then can aspirate stomach contents to check pH

49
Q

if NG tube placed in pt lungs

A

likely start coughing immediately

50
Q

delivering enteral feeds in 3 ways

A

pump, gravity, bolus

51
Q

pump enteral feeding

A

rate depends on pt; is required for continuous feedings; need to prime tubing prior to using

52
Q

gravity enteral feeding

A

need to calculate drip rate

53
Q

bolus enteral feeding

A

at an increased risk of distention; increased risk of aspiration

54
Q

when delivering enteral feedings…

A

want pt sitting upright during and 1 hour after to decrease risk of aspiration

55
Q

what to watch for when enteral feeding?

A

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
Q

caring for NG tube

A

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
Q

to promote safety when administering tube feeding…

A

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
Q

if meet resistance when flushing…

A

flush with coke to break down the clogging; can also use cranberry juice; removing tube is last resort

59
Q

how long to leave tube in place

A

as long as possible unless there is policy at hospital or a defect with tube

60
Q

how long is food bag good for?

A

usually good for 24 hours

3323 Advanced Assessment (4 decks)

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