Lab Info: Wounds, Tubes, and IVs Flashcards
If a patient has a pressure ulcer- what should you do to alleviate the pressure?
Upload- raise and take pressure off
How is a stage 1 pressure ulcer described?
Intact skin with nonblanchable redness
Where do pressure ulcers usually occur?
Over boney prominences
On a patient with dark skin- how can you tell they have a stage one pressure ulcer?
It may be seen as color hue changes
How is stage 2 pressure ulcer described?
Partial thickness loss of dermis or open/ruptured serum-filled blister
A stage 2 pressure ulcer can also be called this from a sheer effect.
A skin tear
How is a stage 3 pressure ulcer described?
Full thickness tissue loss but bone and muscle ARE NOT EXPOSED
On a stage 3 pressure ulcer- the depth of the wound depends on what?
Anatomical area of ulcer
How is a stage 4 pressure ulcer described?
Full thickness tissue loss with exposed bone, tendon, or muscle.
In a stage 4 ulcer- what may be present?
Eschar or slough
What is often included in a stage 4 pressure ulcer?
Tunneling
What is eschar?
Necrotic area that must be debated
How is tunneling described and what must you do to it?
It tracks from one area to another creating a whole.
YOU MUST PACK IT
A hydrophobic dressing does not absorb what?
Water
A hydrophilic dressing does absorbed what?
Water
hat are the 6 categories of wound dressings?
- Wet-to-moist
- Hydrocolloid
- Impregnated Gauze
- Alginate
- Foams and Hydrophilic
- Non-adherent or Hydrophobic
When should a wet to moist dressing?
When it is still moist
Why is it important to remove a wet to moist dressing while it is still moist?
Because It will destroy the granulated tissue when removed if it is dry
What does a wet to moist dressing do?
Debrides the wound
How does a wet to moist dressing work?
Water evaporated creating hypertonic solution drawing the fluid from the wound
What makes up the moist part of a wet to moist dressing?
Sterile saline
When placing a wet to moist dressing- what should you avoid?
Placing the moist portion on healthy skin
What types of wounds would you use a hydrocolloid dressing on?
Non-infected partial or full thickness wounds
What does a hydrocolloid dressing absorb?
Exudate
Hydrocolloid dressings are impermeable to what?
Water and bacteria
Hydrocolloid dressings create what to help generate granulation tissue?
Moisture
What is a main perk of a hydrocolloid dressing?
It conforms to the body shape
What should you be careful of when using a hydrocolloid dressing?
Getting stool to sit on it.
What is alginate dressings made of?
Highly absorbent seaweed
What do you need to have when using an alginate dressing?
A secondary dressing to secure it
the alginate dressing’s fibers turn into what when placed on a wound.
Gel
What are alginate dressings used for?
- diabetic ulcers
- burns
- infected wounds
What is the down fall of using alginate dressings?
They’re really expensive
What must you need when using a foam/hydrophilic dressing and why?
A wrap or secondary bandage because there aren’t any adhesive boarders
What are the perks of foam/hydrophilic dressings?
- Cushions wounds
- Very absorbed
- Traps exudates
- Protects surrounding tissues
- Can remove without trauma
What is required when using a non-adherent/hydrophobic dressing?
Tape or cover dressing to secure
What are non-adherent/hydrophobic dressings used for?
- burns
- skin
- grafts
- donor sites
What are the advantages of gauze dressings?
- Inexpensive
- Easily accessible
- Can be impregnated with anti-microbial such as silver in use of burns
What are the disadvantages of gauze dressings?
- Non-occlusive
- Fibers left in wound can delay healing causing infection
- Non-selective in tissue removal-removes necrotic and granulation tissue
What types of wounds do you use transparent film dressings on?
non-draining wounds and IV sites
What is created when using a transparent film dressing?
A moist environment
What are the two perks of a transparent film dressing?
- impermeable to bacteria
- Easy to access wound
What does a wound V.A.C. increase and how?
Increased circulation by using negative pressure
What is the two perks of a wound V.A.C.?
Causes continuous debridement and increasing circulation
What is the perk of wound irrigation?
Removes bacteria without injury to healthy tissue
What supplies are need for wound irrigation?
- Irrigation kit
- Irrigation fluid
- Absorbent pad
- Clean gloves
- New dressing supplies
What type of syringe is provided in an irrigation kit?
A piston syringe
What type of solution is usually used when irrigating a wound?
Saline solution
When obtaining a wound culture what must you make sure you do with the swab?
Get all side of swab as well as all surfaces of wound
What are the steps of obtaining a wound culture?
- Rise wound with sterile saline
- Rotate swab while obtaining specimen
- Crisscross wound top to bottom
- Don’t take specimen from exudate or eschar
What are the supplies used for taking a wound?
- Wound packing gauze
- Clean and sterile gloves
- Sterile q-tips
- Sterile scissors and forceps
- Sterile dressings
What is packing used for?
A tunneling wound
What does packing a wound create?
A wick to pull the fluid from the bottom of the wound up
When removing a suture what should you do?
Pull up by the knot and just cut from there to slip up
How many prongs are on a staple remover?
3
What is montgomery straps used for?
A delayed incision closure
How often do dressing usually get changed when using a montgomery straps?
q4-6 h
What do spiral turns in spiral bandaging prevent?
Tourniquet effect
What is spiral bandaging used for?
TO secure a wound dressing or applying compression
What are the two things you should do when using a spiral bandaging technique?
- Elevate part to be bandaged
- Wrap extremity upward applying uniform pressure