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FUNDAMENTALS > Skin Integrity & Wound Care (Test 4) > Flashcards

Skin Integrity & Wound Care (Test 4) Flashcards

1
Q

Hemorrhage Causes & Care

A

Causes: trauma, erosion of a vessel
Care: direct pressure, elevation, fluid replacement, monitor VS & LOC, tourniquet (last option)

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2
Q

Infection Cause/Prevention & Care

A

Causes/Prevention: contamination, clean gloves; hand hygiene

Care: Cleanse wound, wash hands, sterile dressing, TT Or TD (tetanus toxoid or tetanus diphtheria)

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3
Q

Wound Culture (to identify organism) Care

A

Cleanse wound with saline
Swab wound with culturette swab
Crush culture medium at bottom of culturette tub, take to lab
For anaerobic: use special kit to aspirate, send immediately to lab

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4
Q

Dehiscence S/S & Care

A

separation of layers of a surgical wound
S/S: sudden increase in serosanguineous drainage, sudden sense of “pop” or tear by patient
Cover would with sterile saline dressing covered by dressing
Call Physician
Document appearance, time , activity occured

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5
Q

Evisceration (MEDICAL EMERGENCY)

A

Bowel/tissue coming out of a surgical wound
Cover with saline-soaked sterile dressings or sterile towels
Decrease wound strain by: Place patient with hips and knees bent, elevate HOB slightly
NPO for surgery
Monitor VS for shock
CALL SURGEON, NOTIFY OR

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6
Q

Stage I Ulcer

A

Skin is NOT broken

  • position patient off affected side
  • may apply skin care products that lubricate, but do not massage
  • non blanchable redness
Film Dressings(Tegaderm, Op-Site)
Hydrocolloidal Dressing (Duoderm)- may be left on 7 days
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7
Q

Stage II Ulcer

A

Skin Broken, Superficial Wound
Debridement: removal of necrotic tissue or eschar so healthy tissue can grow.

Wet-to-dry dressings: moisten gauze with saline, let dry and remove(q 8hrs)
Enzymes: Collagenase(place on necrotic/eschar only, cleanse q day)
Hydrocolloidal dressings(Duoderm)
Hydrogel Dressings(J&J Gel)
Absorptive Dressings(Gauze, Foams)
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8
Q

Stage III & IV Ulcer Care

A 
Saline Irrigation
Whirlpool may be ordered if infected
Wound packing with iodoform gauze or absorptive foam 
Hydrocolloidal Dressings
Hydrogel Dressings
Gauze dressings if infected
Surgery
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9
Q

Unstageable/Unclassified Ulcer

A

Full Thickness skin or tissue loss (Loss-depth unknown)

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10
Q

Suspected deep-tissue injury

A

Depth known

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11
Q

Dry Gauze function

A

absorb & cover

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12
Q

Wet-to-dry dressing

A

Debridement (removal of damaged tissue or foreign objects from wound)

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13
Q

Self- Adhesive dressing

A

Transparent, semipermeable

Allows wound to breathe, but keeps water out

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14
Q

Occlusive Dressing

A

Maintains moisture, liquefy necrotic tissue

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15
Q

Occlusive Dressing

A

Maintains moisture, liquefy necrotic tissue

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16
Q

Tegaderm Dressing

A

Cover and protect catheter sites and wound

Maintain moist environment for healing

17
Q

When to use Wound Vac

A

Ulcers, Wounds, Incisions

18
Q

Hydrocolloidal dressing

A

Moist and Insulating healing environment which protect uninfected wounds

19
Q

Hydrocolloidal dressing

A

Moist and Insulating healing environment which protect uninfected wounds

20
Q

Serous

A

Clean, Watery plasma

21
Q

Sanguineous

A

Thick, yellow, green, tan, brown,

22
Q

Serosanguineous

A

Pale, Pink,; mixture of clear and red fluid

23
Q

Purulent

A

Bright red; indicates active bleeding

24
Q

Purulent

A

Bright red; indicates active bleeding

25
Q

Causes of Pressure Ulcers

A

Develops when soft tissue is compressed:

  • between bony prominence and external surface
  • for prolonged period of time
26
Q

Causes of Pressure Ulcers

A

Develops when soft tissue is compressed:

  • between bony prominence and external surface
  • for prolonged period of time
27
Q

What is Braeden Scale?

A 
Predicting Pressure Sore Risk
Higher Score= Lower Risk
Max 23
Min 6
-Sensory reception
-moisture
-activity
-mobility
-Nutrition
-Friction and shear
28
Q

What is Braeden Scale?

A 
Predicting Pressure Sore Risk
Higher Score= Lower Risk
Max 23
Min 6
-Sensory reception
-moisture
-activity
-mobility
-Nutrition
-Friction and shear (1-3)
29
Q

Purpose of Heat Therapy

A

Vasodilation, reduce muscle tension, increase blood flow (remove waste, deliver nutrients)
Used with local pains & strains

30
Q

Purpose of Cold Therapy

A

Vasoconstriction, local anesthesia, increases viscosity

Use with direct trauma injury(strain, sprain, fractures)

FUNDAMENTALS (15 decks)

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