Lab 10 simple dressing part 2

Question 1

What is within a students scope of practice when it comes to wound care

Answer 1

-they may assess and treat surgical wounds
-Cleanse wounds
-pack wounds

Question 2

what is outside a students scope when it comes to wound care

Answer 2

-sharps debridement
-ankle brachial indexes
-compression therapy

Question 3

which drainage systems are closed drainage

Answer 3

Jackson-Pratt drain
Hemovac drain

Question 4

what drainage systems are open drain

Answer 4

penrose drain

Question 5

what type of wound would a drainage bag be used for

Answer 5

mostly used for chronic wounds with copious amounts of drainage

Question 6

what is the total volume that a hemovac drain can collect per 24 hours

Answer 6

400 ml/24h (this also means it’s full)

Question 7

when should you empty a hemovac drain

Answer 7

when it is around 200 ml full

Question 8

what type of drain is this

Answer 8

Hemovac

Question 9

what type of drain is this

Answer 9

jackson pratt drain

Question 10

what is the max volume of a jackson pratt drain

Answer 10

100 ml/24 hours

Question 11

what type of drain is this

Answer 11

Penrose drain

Question 12

how is a penrose drain removed

Answer 12

usually removed in stages using sterile technique and sterile safety pin

Question 13

what kind of drain is this

Answer 13

percutaneous drain

Question 14

what is a percutaneous drain usually used for

Answer 14

often used to drain an abscess

Question 15

what type of drain may have to be sutured in place

Answer 15

percutaneous drain

Question 16

if a client has a penrose drain when can they shower

Answer 16

they should not shower until the drain is removed

Question 17

should a drain ever get wet

Answer 17

NO

Question 18

would it be appropriate to withhold a shower if the pt has a hemovac/JP drain that is expected to be removed in 3-4 days

Answer 18

yes since its better to not get it wet

Question 19

when should a braden scale be preformed

Answer 19

within 8 hours of admission or upon return from ER
-if at risk every shift
-if not at risk at least daily

Question 20

what braden scale score means the client it at risk

Answer 20

any score less than 18 means the client is at risk

Question 20

if someone is at risk for pressure injuries what angle should the head to the bed be kept at

Answer 20

should be kept at less than 30 degrees since it distributes pressure better

Question 21

would you use a dressing on a stage 2 pressure ulcer

Answer 21

no since it can create more friction and sheer

Question 21

what type of wound is air fluidized therapy and non contact low frequency ultrasound therapy used for

Answer 21

Used for deep tissue injuries

Question 22

what are products used for an unstageable pressure injury with necrotic tissue

Answer 22

anything with iodine in it

Question 23

where do venous ulcers usually develop

Answer 23

usually distal medial 1/3 of lower leg and ankle

Question 24

would you use an absorbent or moisturizing dressing with a venous ulcer

Answer 24

most of the time an absorbent dressing since there is lots of drainage with a venous ulcer

Question 25

what percentage of leg ulcers are venous ulcers

Answer 25

81% of leg ulcers are venous ulcers

Question 26

how often do you need to replace compression stockings if worn daily

Answer 26

need to replace every six months if worn daily

Question 27

where are arterial ulcers usually located

Answer 27

-toes -metatarsal heads (bottom of foot) -outside ankle -heels

Question 28

how much drainage is there with an arterial ulcer

Answer 28

little to no drainage

Question 29

where would you put the legs in relation to the heart for a venous ulcer

Answer 29

raise the legs above the heart to minimize edema and pain

Question 29

what type of ulcer will have diminished or absent pedal pulses venous or arterial?

Answer 29

Arterial ulcer will have diminished or absent pedal pulses

Question 30

would you ever debride a non healable wound and why ?

Answer 30

NO because they are already at such a risk for compramised healing that it will only make it worse by disturbing it more

Question 31

where would you put the legs in relation to the heart for an arterial ulcer

Answer 31

lower the legs below the heart

Question 31

where are diabetic ulcers located

Answer 31

usually located on the bottom of the foot

Question 32

what is one way that you could tell a arterial ulcer and diabetic ulcer apart

Answer 32

diabetic ulcer the peripheral pulses will still be palpable whereas arterial ulcers they will not be

Question 33

should a person with a chronic wound shower

Answer 33

yes there is no reason not to and it may also assist in removing old dressings

Question 34

what are the 7 principles of wound care

Answer 34

1. assess and treat the underlying cause 2. Debride necrotic tissue 3. maintain moisture 4. Assess and protect periwound skin 5. promote and support granulation tissue 6. fill dead space 7.stop infection and trauma

Question 35

what are the 5 types of debridement

Answer 35

autolytic Enzymatic mechanical surgical/sharp natural

Question 36

what are 4 ways to promote and support granulation tissue

Answer 36

-encourage good nutrition -avoid frequent dressing changes -cleanse with each wound change -use non adherent dressing if dressing is sticking to wound

Question 37

when should a nurse obtain a C&S swab of a wound

Answer 37

when there are two or more signs and symptoms of local or systemic wound infection

Question 38

what is the diagnosis of a wound infection usually based off

Answer 38

usually based off an assessment not solely the C&S test

Question 39

what is a culture test

Answer 39

a test to find bacteria or a fungus that can cause infection

Question 40

what is a sensitivity test

Answer 40

a test to see what kind of drug/antibiotic will work best to treat the illness or infection

Question 41

what are 4 contraindications for doing a C&S swab

Answer 41

-wounds that have been cultured within the last 24-72 hours -inability to transport the culture within 12hrs of taking the swab -the absence of signs of infection or delayed healing (unless screening for ARO) -wound covered with necrotic eschar or slough

Question 42

when taking a C&S what tissue do you swab

Answer 42

only granulation tissue (ie not hard eschar exudate etc)

Question 43

how big of an area do you swab and for how long while taking a C&S

Answer 43

rotate swab over 1 cm square area of wound for a full 5 sec

Question 44

does cooling promote wound healing

Answer 44

no anything that cools the wound down slows healing (ie frequent dressing changes, saline solution)

Question 45

what is the goal of healing with red wounds

Answer 45

protect and keep moist

Question 46

what is the goal of healing with yellow wounds

Answer 46

debride slough reduce bacterial colonization

Question 47

what is the goal of healing with black wounds

Answer 47

remove eschar and keep dry

Question 48

usually how often is a dressing changed for a chronic wound

Answer 48

usually changed every 3-5 days

Question 49

how much fluid should someone drink per day to promote wound healing

Answer 49

2500 ml + per day

Question 50

what nutritional elements are important to wound healing

Answer 50

protein Vit B C D iron zinc calories

Question 51

can potable tap water be used to rinse wounds

Answer 51

YES

Question 52

if a pt has both a incision and a drain which do you clean first

Answer 52

clean the incision first and then the drain site

Question 53

where is one place you need to document only with drains

Answer 53

in/out record (all other types of wounds except open wounds just document in the 24 hour and narrative notes if necessary)

Question 54

where do you document open wounds

Answer 54

in the wound assessment and treatment flow sheet and narrative notes if concerned

Question 55

how often should a full assessment be done on a wound

Answer 55

every 7 days or there is a significant change

Question 56

how often should a partial assessment be done on a wound

Answer 56

when a dressing change is being preformed between the weekly assessments

Question 57

do you note the odor of the wound before or after cleaning

Answer 57

after cleaning

Question 58

what is a demarcated wound edge

Answer 58

when you can clearly see the edges of the wound

Question 59

what is a diffuse wound edge

Answer 59

when you can not see the wound edges

Question 60

when do you take a pain scale for a wound

Answer 60

while the dressing is being changed

Question 61

how deep does a wound have to be to start packing

Answer 61

any wound with a depth of greater than 1cm start packing

Question 62

What type of skin lesion is this

Answer 62

Macules/papules

Question 63

What type of skin lesion is this

Answer 63

Wheal

Question 64

what type of skin leasion is this

Answer 64

Papules/plaque

Question 65

REVIEW the week 10 class assignment about the different types of skin lesions