Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

intro to geriatric nursing > safety/woundcare > Flashcards

safety/woundcare Flashcards

1
Q

What is Medical Asepsis/ “clean technique?
and what typical procedures is it used in?

A

-Eliminating microorganisms spread through practices
eg: standard precautions, hand washing, gloves,mask, appropriate linen handling
-Used in: administering non-parental medications
oral, rectal, or intranasal meds

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is Surgical Asepsis? and what typical procedures is it used for?

A

-Absence of microorganisms to prevent infections
eg: sterile field/sterile gloves, equipment sterilized
-Used in: starting an IV line, administering IM/SQ injections, inserting Foley catheters, bladder irrigation, dressing change/wound care, eye/ear drops

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

what are the 9 basic principles of surgical asepsis?

A
  1. All objects in a sterile field must be sterile
    2.sterile objects become unsterile when touched by unsterile
    3.out of sight/ below waist= unsterile
    4.prolonged exposure= unsterile
    5.fluid flows the direction of gravity (wet forceps =face down dry forceps=face up)
    6.moister from above or below sterile objects=unsterile
    7.one inch margin= nonsterile
    8.skin cannot be sterilized
  2. conscientiousness, alertness, and honesty are essential in maintaining surgical asepsis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are HAI? What are common ones seen?

A

HAI: hospital aquired infections
Common ones seen are:
-Central Line associated Bloodstream infections(CLABSI)
-Catheter associated Urinary tract infections (CAUTI)
- Selected Surgical site Infections (SSI)
-C-diff
-MRSA
-Hospital aquired pressure ulcers

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

How does the Braden Scale work?

A

Pressure sore risk scale
lower number= higher risk
measures:
-Sensory/Mental
-Moisture
-Activity
-Mobility
-Nutrition
-Friction/Shear

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

How is wound thickness classified?

A

1.Superficial (loss of epidermis)
2.Partial thickness (involves epidermis&dermis)
3.Full thickness (epidermis, dermis, and subcutaneous fat)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Incised wound

A

Intentional or accidental cut (scalpel/knife= even edges)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Contused wound

A

Blunt blow (ecchymosis, hematoma)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Abraded wound

A

Friction on skin (road rash)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Puncture wound

A

stab by blunt instrument (IM injection/ insertion of drain)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Laceration wound

A

torn tissue (irregular edges)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Penetrating wound

A

probing through skin (bullet)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Yellow wound care?

A

-contains pus, debris,fibrin and yellow exudate
-Care: usually infected and requires cleansing and or topical medication

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Red wound care?

A

-“red and ready to heal”
-defined borders/ granulation tissue present
-care: keep wound moist and protected

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Black wound care?

A

-necrotic tissue/eschar may be present
-Care: mechanical, surgical or chemical debridement to dissolve remaining black tissue

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Stage 1 wound

A

-closed and intact skin
-Red but no blanching
- warm

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Stage II wound

A

-skin not intact
-partial thickness
-superficial abrasion, blister, concave/hole
-absent of bruising

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Stage III wound

A

-Full thickness skin loss
-Subcutaneous tissue damage or necrotic
-no tendon or muscle visible
-tunneling may be present

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Stage IV wound

A

-Loss full thickness
-Expose muscle, tendon, or bone
-often tunneling/sinus tracts
-sough & eschar present

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Unstagable wound

A

-Involves subcutaneous tissue/full thickness stage III or IV
-complete cover with slough or eschar (deeper than eye can see)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Suspected Deep Tissue Injury (DTI)

A

-Intact area in purple or maroon
-Discolored or blood filled blister
-Pain, boggy, warmer or cooler than surrounding tissue area

22
Q

Serous (wound drainage)

A

Clear, yellow=plasma &water (blister)

23
Q

Sanguineous (wound drainage)

A

Bright red= new/ fresh blood
contains higher RBCs

24
Q

Purulent (wound drainage)

A

Thick, yellow,green, greyish-bule=microorganisms (necrotic tissue) need to send to culture

25
Serosanguinous (wound drainage)
Clear/watery red/ pink= plasma with some RBCs
26
Primary Intention
-Tissue edges approximated, no tissue loss -like surgical incision/clan laceration -wound is closed but underlying tissue still needs to heal
27
Secondary Intention
Deeper tissue injuries -tissue edges not approximated, loss of tissue integrity -requires gradual filling into dead space with connective tissue -drainage=longer to heal -needs protection & moisture to facilitate healing -ex: chronic pressure & moisture to facilitate healing
28
Tertiary Intention
-delayed primary closure -left open after debridement & inflammation subsides -Ex: Dog bites, lacerations from foreign bodies, contaminated traumatic wounds
29
Partial Thickness healing
Heal by re-epitheliazation -fibrin clot form & release of growth factors -takes approx. 5-7 days -heals better in hydrated skin, well oxygenated, and
30
Full thickness healing
-loss of tissue integrity -damage =lower layer of dermis & subcut. tissue -Unable to heal by re-epithialization -Healing occurs with filling in w/ granulation (cell regeneration)
31
Assessing and evaluating a wound?
1. NANDA (impaired tissue integrity) 2. Assessment 3.Documentation 4.Nursing Safety priority
32
Factors affecting wound healing?
-Age/Development -Nutrition -Lifestyle -Medications -Infection
33
Geriatric factors affecting wound healing?
-Vacular changes -Collagen: less flexible -Immune system: Low production of WBC and antibodies =risk for infection -Nutrition deficiencies -Scar tissue= less elastic
34
Wound healing complications?
-Hemorrhage -Hematoma -Infection -Dehiscence -Evisceration -Fistula
35
Dehiscence
partial or complete separation of outer wound layers
36
Eviseration
Wound layers total separation & protrusion of internal organs
37
Nursing interventions for wound healing complications?
-Stay with pt - Cover site with sterile dressing soaked in sterile NS - Contact MD -Teach pt splinting when TCDB
38
what is a Fistula?
abnormal opening between two or more organs
39
Surgical drains what are they and what is their purpose? what types are there?
-purpose: assist in removing built up fluid in a wound to promote healing -Types: -hemovac -penrose -JP drain
40
How do you clean a wound?
1. Remove debris 2.use NS (unless something else is ordered) 3. cleanse from clean->dry 4.top to bottom 5.outward laterally 6.new sterile swab for each stroke 7.if drain, clean wound first then drain 8.position so no dripping goes into wound
41
what is a dry dressing used for?
-protect & absorb -prevents contamination -promotes epithelial movement
42
what is a synthetic dressing used for?
-semi-permiable (allows 02 exchange) -change Q3 days or PRN -comfortable/less cost
43
what is a wet-dry dressing used for?
-Often ordered to be changed 1-2x/day -Removes ecudate/debris -as sponge dries, assist in debridement
44
what does wound packing do and how do you do it?
-Facilitates the removal of exudate and debris & promotes granulation from wound base to prevent premature closure & abscess formation 1.use gauze/roll/strip (preferably one piece) 2. loosely fill in space 3.use sterile forceps or applicators (measure tunnel first) 4. don't allow gauze to drag on outside skin (contamination) 5. after packing, cover with dressing
45
What does the wound vac do?
-decreases air pressure -gently pulls fluid -reduces swelling -removes bacteria and cleans wound -promotes faster healing
46
what does heat therapy help with?
Vasodilation/inflammation (muscle spasms, joint stiffness,contractures, pain) -lowers muscle tension -increases tissue metabolism -increases circulation to the area -reduces pain -decreases muscle/joint stiffness
47
What does cold therapy help with?
Vasoconstriction (Trauma, control bleeding,inflammation, muscle spasm,pain) -decrease inflammation -decrease bleeding -decrease muscle tension -reduces edema -lowers pain (local anesthesia
48
what is rebound phenomenon?
when heat or cold therapy exceed 15-20 mins opposite effect= can cause tissue damage especially in sensory impairment
49
what are some heat contraindications? (when not to use)
first 24hr after trauma, active bleeding, edema/inflamed area, blisters
50
what are some cold contraindications? (when not to use)
open wounds, hypersensitivity to cold, asthma/allergies

intro to geriatric nursing (5 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions