Lab 4 complex wound care

Question 1

what is a stage 1 pressure ulcer

Answer 1

Non blanchable patch of erythemic intact skin

Question 2

what is a stage 2 pressure ulcer

Answer 2

Partial thickness skin loss involving epidermis and/or dermis

Question 3

what is a stage 3 pressure ulcer

Answer 3

Full thickness skin loss which exposes the subcutaneous layer

Question 4

what is a stage 4 pressure ulcer

Answer 4

Full thickness skin loss where muscle bone or tendon can be seen

Question 5

What is a deep tissue injury

Answer 5

Purple localized area of discoloration of intact skin or blood filled blister that indicates deep tissue damage

Question 6

In order to irrigate a wound what characteristic of the wound must be present

Answer 6

The wound must have a known endpoint in order to irrigate it

Question 7

what temperature should wound irrigation fluid be

Answer 7

room temp

Question 8

what are three ways packing helps a wound heal

Answer 8

-Packing material absorbs excess drainage
-stops the wound from closing prematurely and forming an abscess
-Encourages the growth of granulation tissue from the base of the wound

Question 9

how many pieces of packing is best to use in a wound

Answer 9

Best to use 1 or tie them together to prevent them from getting lost

Question 10

how far past the opening of the wound can you pack without orders from the MRP

Answer 10

Nurses can pack 15 cm beyond the opening of a wound any further than that need direct orders from the MRP

Question 11

What is VAC therapy

Answer 11

Non invasive active therapy combining localized pressure and moisture to promote healing

Question 12

why is a VAC dressing contraindicated in necrotic wounds

Answer 12

Because they need to be debrided first before the initiation of VAC therapy

Question 13

what are contraindications for VAC therapy

Answer 13

-insufficient vascularity
-Necrotic wounds
-Wounds with osteomyelitis
-Cancer in the wound
-unpackable sinus tracts
-patient is at a high risk for bleeding

Question 14

how long do you leave a postoperative dressing in place for unless otherwise ordered

Answer 14

24-48 hrs unless otherwise ordered

Question 15

how long do sutures usually stay in for

Answer 15

5-14 days

Question 16

how long are staples usually left in for?

Answer 16

7-14 days

Question 17

what is dehiscence

Answer 17

the splitting open of a wound

Question 18

what would you do if wound dehisced

Answer 18

-Apply steri strips
-Apply a dressing to a wound
-Call surgeon

Question 19

what is evisceration

Answer 19

when internal organs come out through a wound

Question 20

what would you do if a wound eviscerated

Answer 20

-Cover with saline soaked sterile dressing
-don’t attempt to reposition organs
-Call surgeon

Question 21

can you shower with sutures or staples in

Answer 21

yes

Question 22

how long should you avoid hot tub or pools after a surgical incision

Answer 22

4-6 weeks

Question 23

should a patient pull off steri strips

Answer 23

No they will come of naturally in 1-3 weeks

Question 24

when removing sutures would you cut from above or underneath the knot

Answer 24

cut underneath the knot since this doesn’t drag bacteria under the skin when you remove the suture

Question 25

what are 5 things you should document after removing staples or sutures

Answer 25

-Wound assessment
-Number of closures removed
-The wound care you provided
-Number of steri strips applies
-Type of dressing applied

Question 26

if dressing supplies are taken to the bedside can they be put back in the supply room

Answer 26

No they have to be thrown out

Question 27

how long can dressing supplies that are stored properly remain at the bedside

Answer 27

can be left there if stored properly for two weeks

Question 28

why would you not want to use cold cleansing solution

Answer 28

because it can lower the temp of the wound bed and delay healing

Question 29

what would you do if while measuring a sinus tract you found the depth to be greater than 15 cm

Answer 29

stop the dressing change and notify physician or MRP and wait for new orders on how to proceed

Question 30

how tightly should a wound be packed

Answer 30

pack with enough material to fill the dead space but the wound should not stretch or bulge from the packing

Question 31

at what point do you start documenting about the wound depth

Answer 31

if it becomes greater than 1 cm

Question 32

is a pressure injury ever down staged and why or why not?

Answer 32

No they are never downstaged because the wound will only be filled in with granulation tissue and not the tissue that was originally there

Question 33

how would you clean an incision appropriately

Answer 33

-Clean from the incision line outwards
-Clean proximal to distal
-Keep tips of forceps pointed down

Question 34

If a wound had a large amount of drainage what type of dressing might be appropriate?

Answer 34

Foam dressing

Question 35

If a wound had a small amount of drainage what kind of dressing might be appropriate?

Answer 35

Hydrofiber dressing

Question 36

If a wound wasn’t dry but had no drainage what type of dressing might be appropriate

Answer 36

an alginate dressing

Question 37

If a wound was slightly dry what dressing might be appropriate

Answer 37

a Hydrocolloid dressing

Question 38

If a wound was extremely dry what type of dressing might be appropriate

Answer 38

A Gel dressing