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Test 3 > Inflammation, Wounds, and Pressure Ulcers part 7 > Flashcards

Inflammation, Wounds, and Pressure Ulcers part 7 Flashcards

1
Q

What is the assessment for pressure injuries?

A
  • past med history
  • meds
  • surgery/treatments
  • functional health patterns
  • assessment findings: integumentary and diagnostic findings
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2
Q

Acute care pressure injuries care

A
  • relieve pressure
  • do not turn patient onto unblanchable skin
  • do not massage
  • lift versus sliding when repositioning
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3
Q

What area of the body do you not debride?

A

heels

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4
Q

Explain nursing care of pressure injuries

A 
keep wound bed moist 
-do not disrupt new granulation tissue
-avoid cytotoxic cleaning 
-nutrition support 
-
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5
Q

What labs would make a pt nutritionally at risk?

A

-albumin <3.2
-prealbumin <15
lymphocyte <1,000
Hgb-A1c > 6.5%
glucose >126

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6
Q

How do you document a wound?

A

location - specifically

  • stage
  • size: length (head to toe), width (hip to hip), depth (deepest point)
  • measure in cm
  • tunneling: measure using a clock
  • edges: approximation (edges meet), rolled, jagged, undermining
  • wound base: granulation, epithelialization, necrotic tissue (slough, eschar, adherence)
  • tunneling
  • undermining
  • drainage: serous, sanguineous, sero-sangineous, purulent, odor, amount
  • surrounding tissue
  • pain
  • wound progress
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7
Q

Who performs the first dressing change 24-48 hours after surgery?

A

the surgeon

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8
Q

What are the types of debridement?

A
  • autolytic: dressing (clear) and bodys own mechanisms
  • enzymatic: commercially prepared enzymes
  • mechanical: physical force (dry and wet dressing to remove
  • surgical/sharp: using an instrument
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9
Q

What are the 3 basic tyes of dressings?

A

maintain mositure
absorb mositure
add mositure
-keep wound tissue moist and surrounding skin dry

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10
Q 
Dressings: 
remain for 4-7 days
-use for stage 1 pressure injuries 
-minimal drainage 
-facilitate autolytic debridement
A

transparent

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11
Q

Dressings:

  • use for stage 2 and 3
  • use for high riskfriction areas
  • wounds with necrosis or slough
  • not for infected wounds
A

hydrocolloid EX duoderm

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12
Q

Dressings:

  • use for 3-5 days
  • use for stage 2-4
  • absorb light to heavy
  • surgical wounds
A

Foams EX: Mepilex

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13
Q 
↓bacteria
Removes excess fluid
Promotes moist wound environment
Used for:  
Stage 3 of 4 PI
Arterial, venous, and diabetic ulcers
Dehisced surgical wounds
Infected wounds, skin graft sites
Full thickness burns
A

negative pressure wound vac

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14
Q

What vitamins are good for nutrition therapy for wound healing?

A

C and B

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15
Q

increases amount of oxygen dissolved in plasma

A

HBOT

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16
Q

Promotes cell proliferation and healing,
Increases wound metabolism,
Promotes an increased response to growth factors, stimulates development of blood vessels,
antibacterial and antioxidant effects, improve immune function

A

HBOT

17
Q

What are some nursing interventions for the immobile older adult?

A 
exercise
increase protein, calcium, and D 
pace activities
assistive devices 
reduce risk of falls
18
Q

What does immobility do to the cardiovascular system?

A
  • increases workload of the heart
  • increases risk of orthostatic hypotension
  • increases risk for venous thrombosis
19
Q

What does immobility do to the respiratory system?

A
  • decreases depth of resp
  • decreases rate of resp
  • pooling of secretions
  • impaired gas exchange
20
Q

What does immobility do to the GI system?

A
  • disturbance in appetite
  • altered protein metabolism
  • altered digestion and utilization of nutrients
  • decreased peristalsis
21
Q

What does immobility do to the urinary system?

A
  • increased urinary stasis
  • increases risk of renal calculi (stones)
  • decreases bladder muscle tone
22
Q

What does immobility do to the musculoskeletal system?

A
  • decreases muscle size, tone, strength
  • decreases joint mobility and flexability
  • bone demineralization
  • decreased endurance and stability
  • increased risk for contracture formation
23
Q

What does immobility do to the metabolic system?

A
  • increased risk for electrolyte imbalance

- altered exchange of nutrients and gases

24
Q

What does immobility do to the integumentary system?

A

increases risk for skin breakdown and formation of pressure injuries

25
Q

What does immobility do to psychological well-being?

A
  • increased sense of powerlessness, depression
  • decreased self concept, social interaction, sensory stimulation
  • altered sleep-wake pattern
  • risk for learned helplessness

Test 3 (28 decks)

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