Lab 4 complex wound care Flashcards
what is a stage 1 pressure ulcer
Non blanchable patch of erythemic intact skin
what is a stage 2 pressure ulcer
Partial thickness skin loss involving epidermis and/or dermis
what is a stage 3 pressure ulcer
Full thickness skin loss which exposes the subcutaneous layer
what is a stage 4 pressure ulcer
Full thickness skin loss where muscle bone or tendon can be seen
What is a deep tissue injury
Purple localized area of discoloration of intact skin or blood filled blister that indicates deep tissue damage
In order to irrigate a wound what characteristic of the wound must be present
The wound must have a known endpoint in order to irrigate it
what temperature should wound irrigation fluid be
room temp
what are three ways packing helps a wound heal
-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
how many pieces of packing is best to use in a wound
Best to use 1 or tie them together to prevent them from getting lost
how far past the opening of the wound can you pack without orders from the MRP
Nurses can pack 15 cm beyond the opening of a wound any further than that need direct orders from the MRP
What is VAC therapy
Non invasive active therapy combining localized pressure and moisture to promote healing
why is a VAC dressing contraindicated in necrotic wounds
Because they need to be debrided first before the initiation of VAC therapy
what are contraindications for VAC therapy
-insufficient vascularity
-Necrotic wounds
-Wounds with osteomyelitis
-Cancer in the wound
-unpackable sinus tracts
-patient is at a high risk for bleeding
how long do you leave a postoperative dressing in place for unless otherwise ordered
24-48 hrs unless otherwise ordered
how long do sutures usually stay in for
5-14 days
how long are staples usually left in for?
7-14 days
what is dehiscence
the splitting open of a wound
what would you do if wound dehisced
-Apply steri strips
-Apply a dressing to a wound
-Call surgeon
what is evisceration
when internal organs come out through a wound
what would you do if a wound eviscerated
-Cover with saline soaked sterile dressing
-don’t attempt to reposition organs
-Call surgeon
can you shower with sutures or staples in
yes
how long should you avoid hot tub or pools after a surgical incision
4-6 weeks
should a patient pull off steri strips
No they will come of naturally in 1-3 weeks
when removing sutures would you cut from above or underneath the knot
cut underneath the knot since this doesn’t drag bacteria under the skin when you remove the suture
what are 5 things you should document after removing staples or sutures
-Wound assessment
-Number of closures removed
-The wound care you provided
-Number of steri strips applies
-Type of dressing applied
if dressing supplies are taken to the bedside can they be put back in the supply room
No they have to be thrown out
how long can dressing supplies that are stored properly remain at the bedside
can be left there if stored properly for two weeks
why would you not want to use cold cleansing solution
because it can lower the temp of the wound bed and delay healing
what would you do if while measuring a sinus tract you found the depth to be greater than 15 cm
stop the dressing change and notify physician or MRP and wait for new orders on how to proceed
how tightly should a wound be packed
pack with enough material to fill the dead space but the wound should not stretch or bulge from the packing
at what point do you start documenting about the wound depth
if it becomes greater than 1 cm
is a pressure injury ever down staged and why or why not?
No they are never downstaged because the wound will only be filled in with granulation tissue and not the tissue that was originally there
how would you clean an incision appropriately
-Clean from the incision line outwards
-Clean proximal to distal
-Keep tips of forceps pointed down
If a wound had a large amount of drainage what type of dressing might be appropriate?
Foam dressing
If a wound had a small amount of drainage what kind of dressing might be appropriate?
Hydrofiber dressing
If a wound wasn’t dry but had no drainage what type of dressing might be appropriate
an alginate dressing
If a wound was slightly dry what dressing might be appropriate
a Hydrocolloid dressing
If a wound was extremely dry what type of dressing might be appropriate
A Gel dressing
