Exam 3 Wound Care Flashcards
What are the burn categories and healing times by category?
⭐️Superficial Burns (1st degree) - usually heals 7 days
⭐️Superficial Partial Thickness (2nd degree) - usually heals 5-21 days
⭐️Deep Partial Thickness (2nd degree) - usually heals 3-5 weeks
⭐️Full Thickness (3rd degree) - 4-6 weeks (depends on depth)
Electrical Burns (4th degree) -
What are the outcomes for the stages of wounds?
Stage 1 - Superficial Thickness (redness,sunburn like, heals in 7 days)
Stage 2 - Superficial Partial Thickness (dermal mild to moderate,most painfull, blistered, will heal independent in about about 3 weeks)
Stage 3 - Deep Partial Thickness (molted red or waxy white, wet, soft but elastic, epiderimis and most of epidermis destroyed, destruction of some hair follicle/sweat glands, closes in 3-6 weeks)
Stage 4 - Full Thickness (white/tan, waxy feel, thrombosed veins, dry/leathery texture, rigid, all dermis/epidermis is destroyed, may involve the fat layer, painless)
What are the Iatrogenic factors in wound care?
⭐️Poor use of infection control practices
⭐️Excessive bandage changes
⭐️Not changing bandages often
⭐️Use of adherent dressings
⭐️Packing wounds too tight
⭐️Failure to relieve pressure
⭐️Failure to control incontinence
⭐️Failure to address intrinsic factors such as: diabetes, nutrition, circulatory problems
⭐️Excessive use of topical antimicrobials, cleaners and whirlpool additives
⭐️Excessive use of mechanical debridement and failure to consider use of autolytic debridement
Which wounds are the most painful?
Arterial Ulcers and any Superficial Partial Thickness Injury (use thin duoderm on burns)
What are the categories of wounds by sight (arterial, venous, pressure ulcers).
Toes, feet, and lower 1/3 of the legs - Arterial Ulcer (trophic nails, circular) (use hydrogel, foam, hydrocolloid) (nothing that dries it out)
Lower 1/2 (gator) of the leg - Venous Stasis Ulcer (calcium aginate
Bony prominences - Pressure Ulcer
Sole of foot - Neuropathic ulcer (Calus ring around it. Use foam)
What are the management of wounds by category?
Pressure Ulcers - pressure relief
Arterial Ulcers - add moisture dressing (hydrocolloid), avoid leg raising,
Venous Ulcers - add absorbent (foam) dressing compression stocking. Leg elavation. Jobst pump.
What are the wound solutions?
⭐️Dakin’s solutions - used to dissolve necrotic tissue and dry the wound🚨Not good for burns (bleach)
⭐️Acetic Acid .25 to .5 - bactericidal used for wet or wet-dry dressing in wounds with pseudonomas. (changes ph level, smells like vinegar, causes stinging)
⭐️Hydrogen Peroxide - used as a cleaning agent and to disolve dried up exudate or blood. (DO NOT use on closed wounds, the solution can cause gas build up and cause an embolism)
⭐️Betadine (Providone-Iodine) solution - Antimicrobial used on infected superficial wounds, dermatitis, eczema, safe for wounds with large cavities. ⭐️used before surgery (relatively few side effects)
What are the differences between selective and non-selective debridement techniques?
Selective debridement (wet to dry dressings, topical anabiotics, surgical debridement,sharp debridement,forceful irrigations, and whirlpool) the removal of necrotic tissue only while non-selective debridement (enzymatic debridement, use of moist and/or occlusive dressing for autolytic debridement, and saline soaks or gentle saline rinse) is the removal of both healthy & necrotic tissue (viable tissue sacraficed for rapid results)
What are the rules of Sterility?
- From waist up is steril
- 1 inch boarder steril field
- No talking over steril field
- Steril touches
What mechanisms result in pressure ulcers?
- Nutrition
- Pressure
- Friction/wrinkled sheets
What is the best way to pump venous blood back to the heart?
Calf muscle pump
What is a the effect of Hemosideran?
It permanently discolors the skin
What is the recommended time for hand washing?
30 seconds
What is the pressure applied to a healed burn to prevent hypertrophic scarring?
25mmhg. Will respond if less than 6 months old. 23 hours 12-18 months (Through splinting or Jobts stockings -pressure garments)
When should you was your hands?
Before and after every pt contact
When the hospital requires strict isolation, what does it mean?
Strict isolation is used for diseases spread through the air and in some cases by contact. Patients must be placed in isolation to prevent the spread of infectious diseases. Patients are often kept in a special room at the facility designed for that purpose.
Gloves, gown , mask
What does it mean when a hospital requires respiratory isolation?
Respiratory isolation is used for diseases that are spread through particles that are exhaled. Those having contact with or exposure to such a patient are required to wear a mask.
What should you do when applying clothing for isolation?
Begin with handwashing and end with gloving.
What is the difference between a first and second intention wound.
First is a surgical wound. All tissue is intact
Second has a piece of tissue missing. Pothole.
What are the names of the enzymes used to treat wound?
Panafil
Santyl
What is the basic premise of Standard Precautions?
Basic protection of everything. Treat everyone as infected
Which dressing absorbs or supplies moisture?
Hydrocolloid
Hydrogel Dressing
Calcium Algenate (wet or dry like foam)
What is the rule of nine?
The rule of nines assesses the percentage of burn and is used to help guide treatment decisions including fluid resuscitation and becomes part of the guidelines to determine transfer to a burn unit. You can estimate the body surface area on an adult that has been burned by using multiples of 9.
How long should patient with grafted body part be immobilized?
7-10 days
