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Surgical 1 > Exam 4: Wound Care Test > Flashcards

Exam 4: Wound Care Test Flashcards

1
Q

What are the three types of wound healing?

A

Primary Intention
Secondary intention
Teritiary intention

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2
Q

What is Primary intention

A

wound edges are approximated with staples or sutures, usually results in minimal scarring.

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3
Q

What is secondary intention?

A

wound is typically left open, heals by granulation, scarring is usually extensive with prolonged healing

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4
Q

What is tertiary intention

A

an infected wound is left open until there is no evidence of infection, the wound is then surgically closed

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5
Q

What are the three stages of wound healing

A

inflammatory phase
proliferative phase
remodeling phase

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6
Q

Types of wound drainage?

A

serous
sanguinous
sero-sanguinous
purulent

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7
Q

What is serous drainage

A

contains only the clear portion of the blood (often pale yellow)

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8
Q

what is sanguineous

A

thick, reddish appearance

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9
Q

What is sero-sanguineous

A

clear mixed with some blood (pink)

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10
Q

what is purulent drainage?

A

strong indicator of an infection, appears as a slightly thick, milk like texture. May be grayish yellow to green or brown

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11
Q

Other names for pressure ulcer

A

bed sores or decubitus ulcers

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12
Q

Where do pressure ulcers appear?

A

bony prominences and anywhere there is pressure, friction or shearing

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13
Q

True or False: pressure causes more damage when it’s applied to a small area than a larger surface?

A

True

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14
Q

Risk factors for pressure ulcer development

A

Advanced age
Incontinence
chronic illness
immobility

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15
Q

Different stages of pressure ulcers

A 
pressure injury
stage 1
stage 2 
stage 3
stage 4
unstageable 
deep tissue
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16
Q

stage 1 pressure ulcers?

A

reddened area, non blanchable, skin intact

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17
Q

stage 2 pressure ulcers?

A

partial thickness skin loss, dermis is exposed, moist , red or pink, no adipose tissue, some breakdown, can still heal

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18
Q

stage 3 pressure ulcer

A

full thickness skin loss, adipose skin tissue, granulation tissue, undermining and tunneling may be present.

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19
Q

stage 4 pressure ulcer

A

full thickness loss, exposed muscle and tendons, cartilage or bone, eschar, undermining and tunneling are often present.

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20
Q

unstageable pressure injury

A

obscured full thickness and tissue loss. obscured by sloughing tissue and eschar, worst pressure injury

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21
Q

Deep tissue pressure injury

A

there isn’t an open wound but tissues beneath the surface appear to be damaged. Skin may look purple or dark red.

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22
Q

What is the Braden scale

A

helpful in predicting a patients risk for pressure ulcers, lower the score, higher the risk ratings are in six subscales from 1-4

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23
Q

How to measure wounds

A

measure the length, width, and depth, measure in mm or cm

24
Q

What is wound tunneling

A

tunnels of a wound that extend from the wound through the subcutaneous tissue or muscle.

25
Q

What is a JP drain

A

jackson pratt drain. Used during surgery to prevent the collection of fluid underneath the skin. It’s a closed, air tight drainage system that operates by self suction.

26
Q

Calculation of IV drip rate

A

mL/min x gtts/mL

27
Q

what is a hemovac?

A

drain used to remove fluids that build up in the area of your body after surgery. It is a circular device that is connected to a tube. One end is placed inside the body during surgery and comes out through a cut in the skin called a drain site. The drain is compressed to allow for a vacuum effect to pull out the fluids.

28
Q

What is a penrose drain?

A

a soft, flexible rubber tube used as a surgical drain to prevent the buildup of fluid in a surgical site.

29
Q

What does evisceration mean?

A

When the edges of the wound separate and internal organs are protruding from the wound.

30
Q

What does dehiscence mean?

A

Separation of the edges of a surgical wound

31
Q

What type of incisions do dehiscence and evisceration often occur with

A

abdominal incisions

32
Q

Surgical wound drainage is usually what type of drainage?

A

Sanguineous (red)

33
Q

What is an abscess?

A

a swollen area within a body tissue which contains an accumulation of pus

34
Q

What is the formula for mL/hr?

A

total infusion volume (mL)/ total infusion time (h)

35
Q

Nurse Wendell will infuse 1 ½ L of NS in over 7 hours; Drop factor: 15 gtt/mL. What flow rate (mL/hr) will nurse Wendell set on the IV infusion pump?

A

214.3 mL/hr

36
Q

Nurse Sandra will infuse 1,200 mL of 0.45% Normal Saline at 125 mL/hr. Drop Factor: 12 gtt/mL. How many gtt/min will nurse Sandra regulate the IV?

A

25 gtts/min

37
Q

Nurse Nick will infuse 1/4 L of D5W for over 2 hours and 45 mins. The drop factor is 60 drops per mL. Nurse Nick should regulate the IV for how many drops per minute?

A

91 gtts/min

38
Q

Nurse Sarah will infuse 250 mL of platelets IV over 2 hr 30 min with a drop factor of 10 drops per mL. What flow rate (mL/hr) will nurse Sarah set on the IV infusion pump

A

100 mL/hr

39
Q

Granulation tissue

A

new vascular tissue in granular form on an ulcer or the healing surface of a wound.

40
Q

Abrasion

A

type of open wound that is caused by the skin rubbing against a rough surface. It may also be called a scrape or a graze.

41
Q

Avulsion

A

tearing away of a body part accidentally or surgically avulsion of a fingernail.

42
Q

Necrosis

A

the death of body tissue. It occurs when too little blood flows to the tissue. This can be from injury, radiation or chemicals.

43
Q

Nodule

A

growth of abnormal tissue, they can also develop in deeper skin tissues or internal organs.

44
Q

Laceration

A

a wound that is produced by the tearing of the soft body tissue. This type of wound is often irregular and jagged. A laceration wound is often contaminated with bacteria and debris from whatever object caused the cut.

45
Q

Lysis

A

another term for destruction. hemolysis is the destruction of red blood cells with the release of hemoglobin. Lysis can also refer to the subsidence of one or more symptoms of an acute disease.

46
Q

Keloid

A

an area of irregular fibrous tissue formed at the site of a scar or injury.

47
Q

Hemostasis

A

the stopping of a flow of blood.

48
Q

Exudate

A

fluid that leaks out of the blood vessels into nearby tissues, may ooze from cuts or from areas of infection or inflammation.

49
Q

Erythema

A

redness of the skin caused by congestion of the capillaries in the lower layers of the skin. It occurs with a skin injury, infection or inflammation.

50
Q

Cellulitis

A

means ‘inflammation of the cells’, a bacterial infection just below the skins surface.

51
Q

Adipose

A

tissue made up of mainly fat cells such as the yellow layer of fat beneath the skin

52
Q

Adhesions

A

abnormal union of membranous surfaces due to inflammation or injury.

53
Q

Abscess

A

a swollen area within body tissue, containing an accumulation of pus

54
Q

Papule

A

solid or cystic raised spot on the skin that is less than 1 centimeter wide. It is a type of skin lesion.

55
Q

What is the inflammatory phase of healing

A

Defensive phase lasts 4-6 days an associated with swelling of tissues, reddening of skin, heat and pain, focuses on removing debris and destroying bacteria.

56
Q

What is the proliferative phase of healing?

A

The proliferative phase begins the process of filling and covering the wound with new skin. This phase lasts 4-24 days It has three stages which are :
filling the wound
contracting the wound margin
growing new skin over the wound

57
Q

What is the remodeling phase of healing?

A

the process where the wound bed slowly strengthens and gains more flexibility. Collagen fibers reorganize, remodel, mature and regain strength. Can last anywhere from 21 days to 2 years

Surgical 1 (5 decks)

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