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NURS 220 > LEC 1: Acute Surgical Wounds > Flashcards

LEC 1: Acute Surgical Wounds Flashcards

1
Q

Before changing a dressing, what do you need?

A

Need a Dr.’s order to change dressings

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2
Q

What are the four types of wound drainage?

A
  • Serous
  • Purulent
  • Serosanguineousd
  • Sanguineous
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3
Q

How does serous wound drainage look like?

A
  • Clear
  • Watert plasma
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4
Q

How does purulent wound drainage look like

A
  • Thick
  • Yellow, green, tan, or brown
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5
Q

What does purulent wound drainage indicate?

A

Purulent wound drainage indicates an infection

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6
Q

How does serosanguineous wound drainage look like?

A
  • Pale
  • Red
  • Watery
  • Mixture of clean and red fluid
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7
Q

How does sanguineous wound drainage look like

A

Bright red

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8
Q

What does sanguineous wound drainage indicate?

A

Sanguineous wound drainage indicates active bleeding; want to notify the Dr. right away

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9
Q

What are the six descriptions used for the amount of drainage?

A
  • None
  • Scant
  • Small
  • Moderate
  • Large
  • Saturated
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10
Q

What is the percentage for the amount of drainage description: None

A

0% of dressing soiled with drainage

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11
Q

What is the percentage for the amount of drainage description: Scant

A

<5% of dressing soiled with drainage

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12
Q

What is the percentage for the amount of drainage description: Small

A

5 to 25% of dressing soiled with drainage

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13
Q

What is the percentage for the amount of drainage description: Moderate

A

25 to 50% of dressing soiled with drainage

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14
Q

What is the percentage for the amount of drainage description: Large

A

50 to 75% of dressing soiled with drainage

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15
Q

What is the percentage for the amount of drainage description: Saturated

A

>75% of dressing soiled with drainage

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16
Q

What are the four main principle to keep in mind when cleaning and drying a wound?

A
  1. Cleanse in a direction from the least contaminated area to the most contaminated area
  2. Use gentle friction; do not dab wound, use one swift motion
  3. When irrigating, allow the solution to flow from the least to the most contaminated area
  4. Don’t use same gauze to clean across incision twice; one gauze, one swipe
17
Q

What do you do if a dressing sticks on a wet-to-dry dressing?

A

Do not moisten it; instead gently free dressing, and alert patient of potential discomfort

18
Q

When removing tape, what direction should you pull towards?

A

When removing tape, pull parallel to skin toward dressing

19
Q

How do you irrigate a wound?

A
  1. Pour ordered solution into sterile irrigation container
  2. Fill a syringe with solution and gently allow solution to flow over wound
  3. Continue until the irrigation flow is clear
  4. Dry surrounding area
20
Q

What acronym do you use when assessing a wound?

A

REEDA

21
Q

What does REEDA stand for?

A
  • Redness
  • Ecchymosis
  • Edema
  • Drainage
  • Approximation

*When charting need to describe REEDA

22
Q

What are key components for documentation of simple wounds?

A
  1. What did you do and why
  2. Pain assessment: pre/ intra/ post
  3. What dressing you took off wound
  4. Solution used to cleanse wound
  5. Wound assessment (REEDA)
  6. What dressing you covered wound with
  7. Patient tolerance

*Important to address the dressing post and pre

23
Q

What interventions is acceptable when wound appears inflamed, tender, with or without drainage?

A
  • Monitor patient for signs of infection
  • Obtain wound culture
  • Notify heath care provider
24
Q

What interventions is acceptable when wound bleeds during dressing change?

A
  • Notify health care provider, who may consider drain placement to facilitate wound drainage
  • Observe colour; if drainage is bright red and excessive, you will need to apply pressure
  • Inspect along dressing and underneath patient to determine amount of bleeding
  • Obtain vital signs, as needed
25
Q

What interventions is acceptable when patient stats that “something has given way under the dressing”?

A
  • Notify the health care provider
  • Observe wound for increased drainage or separation of sutures
  • Protect wound or cover with sterile moist dressing
  • Instruct patient to lie still

NURS 220 (41 decks)

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