Terms and Knowledge Flashcards
A state of being that people define in relation to their own values, personality, and lifestyle.
Health
Provides science-based, 10-year national objectives for promoting health and preventing disease
Healthy People
The actualization of inherent and acquired human potential through goal-directed behavior, competent self-care, and satisfying relationships with others while adjustments are made as needed to maintain structural integrity and harmony with the environment.
Health (as defined by Pender, Murdaugh, and Parsons)
A person’s ideas, convictions, and attitudes about health and illness.
Health Beliefs
Four goals for Healthy People 2020
1- Attain high-quality, longer lives free of preventible disease
2- Achieve healthy equity, eliminate disparities, and improve the health of all groups
3- Create social and physical environments that promote good health for all
4- Promote quality of life, healthy development, and healthy behaviors across all life stages
Health Model: Addresses the relationship between a person’s beliefs and behaviors.
Health Belief Model (Rosenstoch, Becker, and Maiman)
Health Model: Directed at increasing a patient’s level of well-being, describes the multidimensional nature of persons as they interact within their environment to pursue health.
Health Promotion Model (Pender)
Model of Health: Promotes optimal health by considering emotional and spiritual well-being and other dimensions of an individual as important aspects of physical wellness
Holistic Health Models
Internal Variables Influencing Health, Health Beliefs, and Health Practices
Developmental Stage Intellectual Background Perception of Functioning Emotional Factors Spiritual Factors
External Variables Influencing Health, Health Beliefs, and Health Practices
Family Practices
Socioeconomic Factors
Cultural Background
Three components of the Health Belief Model
- Individual’s perception of susceptibility to an illness
- Individual’s perception of the seriousness of an illness
- Likelihood that an individual will take preventative action
Teaches people how to care for themselves in a healthy way and includes topics such as physical awareness, stress management, and self-responsibility.
Wellness Education
State of complete physical, mental, and social well-being, not merely the absence of disease or infirmity
Health (as defined by WHO)
Activities such as routine exercise and good nutrition that help patients maintain or enhance their present levels of health.
Health Promotion
Immunization programs that protect patients from actual or potential threats to health.
Illness prevention
When individuals gain from the healthful activities of others without acting themselves.
Passive strategies of health Promotion
Flouridation of municipal drinking water is an example of:
Passive strategies of health promotion
Health Model: Attempt to meet patient’s basic needs by prioritizing those needs.
Maslow’s Hierarchy of Needs
Fortification of homogenized milk with vitamin D is an example of which type of health promotion strategy?
Passive strategies of health promotion
Individuals motivated to adopt specific health programs
Active strategies of health promotion
Weight-reduction is an example of which type of health promotion strategy?
Active strategy for health promotion
Smoking-cessation is an example of which strategy of health promotion?
Active strategies of health promotion .
True prevention before it precedes disease or dysfunction and is applied to patients considered physically and emotionally healthy.
Primary Prevention
Type of prevention that focuses on individuals who are experiencing health problems or illnesses and are at risk for developing complications of worsening conditions; focuses on prompt intervention to allow patient to return to a normal level of health.
Secondary Prevention
Smoking cessation to minimize health risks before they happen is an example of which LEVEL of prevention?
Secondary Prevention
A health behavior stage in which the patient is not interested in information about the behavior changes and may be defensive
Pre-contemplation
Receiving Immunizations is an example of which level of prevention?
Primary Prevention
Healthy eating and regular exercise by a healthy individual is an example of which level of prevention?
Primary
Risk Factors concerning Health
Genetic and Physiological Factors
Age
Environment
Lifestyle
A state in which a person’s physical, emotional, intellectual, social, developmental, or spiritual functioning is diminished or impaired.
Illness
A stage of health behavior change in which ambivalence may be present but patient may accept information as a result of a belief in the value of change.
Contemplation
A stage of health behavior change in which the patient has no intention of making a change in the next 6 months.
Pre-contemplation
A stage of health behavior change in which a patient believes that advantages outweigh disadvantages of behavior change, but may need assistance in planning to change.
Preparing
A stage of health behavior change in which a patient is making small changes in order to make a change in the next month.
Preparation
A stage of health behavior change in which previous habits may prevent taking action and the patient identifies barriers and facilitators of change.
Action
A stage of health behavior change in which the patient is actively engaged in strategies to change behavior.
Action
A stage of health behavior change in which the changes must be integrated into the patient’s lifestyle
Maintainence
A stage of health behavior changes in which the patient has sustained change over 6 months after beginning and continues indefinitely
Maintenance
An illness that is usually reversible, has a short duration and is often severe
Acute illness
An illness that persists usually longer than 6 months and is irreversible and affects functioning in one or more systems.
Chronic illness
Losing weight to reduce health risks before they happen is an example of which level of prevention?
Secondary Prevention
Results from a patient being released from roles, social expectations, or responsibilities.
Illness Behavior
A patient’s perception of illness and the nature of the illness are: internal or external variables?
Internal
A patient’s visible symptoms, social group, culture or background related to an illness are: internal or external variables?
External
Impact of an illness on the patient and family includes which 5 things?
Impact on Body Image Impact on Self-Concept Behavioral and Emotional Changes Impact on Family Roles Impact on Family Dynamics
List Maslow’s Hierarchy of Needs
- -Physiological (Oxygen, Fluids, Nutrition, Body Temp, Elimination, Shelter, Sex)
- -Safety and Security (Physical safety, Psychological safety)
- -Love and Belonging
- -Self-esteem
- -Self-actualization
Illnesses that guide behavioral responses
Illness Behaviors
Allopathic Medicine
Conventional western Medicine
Therapies used in addition to conventional treatment recommended by the person’s health care provider.
Complementary Therapies
Five stages of Health Behavior Changes
Pre-contemplation Contemplation Preparation Action Maintenance
Therapies that become the primary treatment instead of conventional western medicine.
Alternative Therapies
Prevention that occurs when a defect or disability is permanent or irreversible and focuses on preventing complications and deterioration.
Tertiary prevention
Health education programs is an example of which level of promotion?
Primary
A stage of health behavior change in which the patient is considering a change within the next 6 months.
Contemplation
A person who uses yoga to ease chronic pain instead of using opioid medications is demonstrating a use of…
Alternative therapy
A patient receives monthly massages to help back pain while using medication regularly as well. This is an example of….
Complementary therapy
Ayurveda and TCM (Total Chinese Medicine) that are based on different philosophies and whole life systems are examples of….
Whole Medical Systems
A free school lunch program is an example of:
Integrative health care program
The concept of holistic medicine integrate _____, ______, and ______.
Mind, Body, and Spirit
A group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.
CAM- Complementary and Alternative Medicine
The three Nursing-accessible therapies are…
Relaxation Therapy
Meditation and breathing
Imagery
Dietary supplements, macrobiotic diets, and Herbal medicines are examples of….
Biologically Based Therapies (Natural Products)
Reiki therapy and Therapeutic Touch are examples of….
Energy Therapies (Use or manipulation of energy fields)
Respiratory therapy for a person with COPD is an example of which level of prevention?
Tertiary prevention
Massage, chiropractic medicine, and craniosacral therapy are examples of….
Manipulative and body-based methods (Involve movement of body with focus on body structures and systems)
Breathwork, biofeedback, and Guided imagery are examples of….
Mind-body interventions (Honor connections between thoughts and physiological functioning using emotion to influence health and well-being)
Some physical responses to the relaxation response are…
Arousal reduction
Elongating of Muscle fibers (decrease of muscle tension)
Reducing of neural impulses
Decrease of heart rate, respiratory rate, O2 consump.,& blood pressure
Increase of alpha brain activity
Increase in peripheral skin temperature
Limitations of Relaxation Therapy
May increase sensitivity
Can cause increased fatigue in patients with AIDS or Cancer (Progressive Relaxation)
The four components of meditation
- A quiet space
- A comfortable position
- A receptive attitude
- A focus of attention
Any activity that limits stimulus input by directing attention to a single unchanging or repetitive stimulus so the person is able to become more aware of self.
Meditation (Self directed and differs from relaxation because of MINDFULNESS)
Clinical application of Meditation
Reduction of hypertensive risk
Less depression, anxiety and distress
Patients with cancer, PTSD, chronic pain, stress
Increases productivity, mood, sense of identity
Lowers irritability
Emphasizes the importance of the relationship between practitioner and patient.
Integrative health care
Limitations of Meditation
Those who are afraid to lose control
May become hypersensitive to drugs
Clinical applications of Imagery
Controls/Relieves pain in adults and children
Decreases Nightmares/Improves sleep
Helps treat certain chronic diseases
Limitations of Imagery
Increased anxiety and fear (PTSD)
Increased airway constriction (COPD, asthma)
Training specific Therapies include:
Biofeedback Therapeutic touch TCM Acupuncture Chiropractic Therapy Natural products/Herbal Therapies
Clinical applications of Biofeedback:
Helpful in: stoke recovery, smoking cessation, ADHD, epilepsy, headache disorders, and GI and Urinary disorders
Limitations of Biofeedback:
Precautions in psychological or neurological conditions
Repressed emotions/Difficulty coping surface
Sometimes lowers blood pressure and heart rate
Clinical Applications of Acupuncture:
Modifies the body’s response to pain
Helpful for many types of pain (Lower back pain, myofacial pain, migraines and headaches, osteoarthritis, heel pain, chronic shoulder pain)
Limitations of Acupuncture
- Unsterile needles cause complications
- Puncture of internal organs, bleeding, fainting, seizures, and drowsiness
- Infection
Therapeutic Touch clinical applications
May help with pain in adults and children
May help with dementia, trauma, and anxiety during illness
Limitations of Therapeutic touch
Sensitivity to human interaction (physically abused/psychiatric disorders)
Pregnant, neonates, cardiovascular, neurological instability, and older patients may be sensitive to re patterning
Mycotherapies, Orthomolecular medicine, Probiotics, and the “zone” are examples of….
Biologically Based Therapies (Natural products)
Healing touch and Magnet therapy are examples of….
Energy Therapies (Use or manipulation of energy fields)
Acupressure and Simple touch are examples of….
Manipulative and Body-based Methods (Involve movement of body with focus on body structures and systems)
Acupuncture, Art therapy, Healing intention (prayer), and meditation are examples of….
Mind-body interventions (Honor connections between thoughts and physiological functioning using emotion to influence health and well-being)
Music therapy, Psychotherapy, Tai chi, and yoga are examples of…
Mind-Body interventions
Dance therapy, Feldenkrais method, and Pilates are examples of….
Movement therapies
Ayurvedc medicine, Homeopathic medicine, and Naturopathic medicine are examples of….
Whole Medical systems
Use of conscious mind to create mental images to stimulate physical changes in the body
Imagery
Self-directed imagery based on the mind-body connection
Creative visualization
Use of instruments to self-regulate and voluntarily self-control specific physiological responses
Biofeedback
Vital energy flowing through the body in channels
Qi (pronounce chi)
System of pathways made up of channels of vital energy
Meridians
Specific areas along channels used for acupuncture
Acupoints
Therapeutic touch- The five phases
Centering Assessing Unruffling Treating Evaluating
Restoring structural and functional imbalances and realignment of the spine to allow energy to flow and innate healing of the body to begin.
Chiropractic Therapy
Clinical applications of Chiropractic therapy
Improves acute pain and disability in some patients
May reduce low back pain and joint pain (osteoarthritis)
May enhance the effects of conventional treatment in pediatric asthma
Treats headaches, dysmenorrhea, vertigo, tinnitus, and visual disorders
The most important concept of Chinese medicine is:
Yin (Cool)
Yang (Hot)
A whole medicine system that includes moxibustion, cupping, tai chi, qi gong, and acupuncture.
TCM- Total Chinese medicine
Clinical applications of Chinese Medicine
Some evidence shoes helpfulness in treating fibromyalgia and reducing pain and spasticity in children with Cerebral Palsy
Limitations of Chinese Medicine
Not regulated in most states (acupuncture is)
Herbs, teas, remedies and supplements are not regulated by the FDA
Labels may be inconclusive and products may be potent causing complications- Always ask about use of ALL OTC medicines including herbs.
Clinical Applications of Herbal therapy
Cranberry supplements help prevent UTIs
Chamomile promotes sleep and relaxation and helps treat minor GI disturbances and pre-menstrual problems
Many herbs are safe and beneficial
Limitations of Herbal Therapy
Not regulated by FDA and no safe limits established
May contain toxic products linked to cancer
May be contraindicated with other medications
Which of these herbs are safe for use?
- Life root
- Comfrey
- Ginger
- Garlic
- Saw palmetto
- Licorice
- Ginger
- Garlic
- Saw palmetto
- Licorice
Which of these herbs are safe for use?
- Aloe
- Echinacea
- Coltsfoot
- Ginseng
- Valerian
- Pokeweed
- Aloe
- Echinacea
- Ginseng
- Valerian
Limitations of chiropractic therapy
Cannot treat bone and joint infections
Contraindicated in: acute myelopathy, fractures, dislocations, rheumatoid arthritis, and osteoporosis
Includes risk of injury
Top layer of the skin
Epidermis
A state of generalized decreased cognitive, physiological and behavioral arousal
Relaxation Response
Inner layer of the skin that provides tensile strength and mechanical support
Dermis
A tough, fibrous protein
Collagen
Localized injury to the skin and underlying tissue over a bony prominence.
Pressure Ulcer
Occurs when normal red tones of the light skinned patient is absent
Blanching
Three pressure-related factors that contribute to pressure ulcer development:
- Pressure intensity
- Pressure duration
- Tissue tolerance
Hyperemia
Redness
Blanching hyperemia
Redness or erythema that blanches and then the redness returns
Sliding movement of skin and subcutaneous tissue while underlying muscle and bone are stationary.
Shear
Which of these are Safe Herbs to use:
- Chamomile
- Feverfew
- Calamus
- Gingko biloba
- Chaparral
- Ephedra
- Chamomile
- Feverfew
- Gingko biloba
A non-blanchable redness of intact skin
Stage 1 pressure ulcer
6 Risk factors that contribute to pressure ulcer development
Impaired Sensory Perception Impaired Mobility Alteration in Level of Consciousness Shear Friction Moisture
Partial-thickness skin loss or blister
Stage 2 pressure ulcer
Full-thickness skin loss with visible fat
Stage 3 pressure ulcer
Full-thickness Tissue loss with muscle and/or bone visible
Stage 4 pressure ulcer
Full thickness skin or tissue loss with unknown depth
Unstageable/Unclassified pressure ulcer
A purple or maroon localized area of discolored intact skin OR blood-filled blister caused by damage of underlying soft tissue from pressure and/or shear.
Suspected Deep Tissue Injury (sDTI)
Assessment of a pressure ulcer includes: ________ of ulcer, ______ involvement (staging), type and approximate _______ of tissue in wound bed, wound ________, _______ description, and _______ of surrounding skin.
Depth, Tissue, percentage, dimensions, exudate, condition
What is the correct intervention concerning a pressure ulcer covered with necrotic tissue?
Debride necrotic tissue in order to assess and stage the ulcer (will be stage 3 or 4)
A pressure ulcer presents as a red nonblanchable area on the patient’s sacrum. The skin is discolored, intact, warm, with localized edema. What stage is this ulcer?
Stage 1
A patient has an intact serosangineous filled blister. What stage is this pressure ulcer?
Stage 2
The patient has a shallow ulcer with a red-pink wound bed. There is no slough preset and is only affecting the dermis. What stage is this ulcer?
Stage 2
A patient has an ulcer with no slough present. The wound is shallow and there is subcutaneous fat visible. What stage is this ulcer?
Stage 3
The patient has a deep pressure ulcer with subcutaneous fat visible. There is slough present. What stage is this ulcer?
Stage 3
The patient has a shallow ulcer on the bridge of the nose due to glasses wear. The bone is visible and there is slough present. What stage is this ulcer?
Stage 4
The patient has a large ulcer in the sacral area. Tendons are visible and eschar is present. There is deep tunneling and undermining present. What stage is this ulcer?
Stage 4
The patient has an open ulcer on the heel. It is completely black with no slough present. What stage is this ulcer?
Unstageable
A patient has a large ulcer on the sacral area. Although the area is covered with slough, you guess that the ulcer is probably deep with tunneling. Which stage is this ulcer?
Unstageable (until you remove the slough and assess more thoroughly)
A patient has an area of deep purple intact skin. The area is warmer than the adjacent skin. What stage is this ulcer?
sDTI
The patient has intact skin over a cool, dark-red area. What stage is this ulcer.
sDTI
Red, moist tissue composed of new blood vessels, presence indicates direction towards healing.
Granulation Tissue
Soft, yellow or white tissue that is stringy and attached to the wound bed.
Slough
Black or brown necrotic tissue
Eschar
Describes the amount, color, consistency, and odor of wound drainage and is part of the wound assessment. May indicate presence of infection.
Exudate
Describe Primary Intention, its causes, and the healing process:
- Wound that is closed- minimal tissue loss
- Surgical incision- wound is sutured or stapled
- Healed by epithelialization- heals quickly, minimal scarring
Describe Secondary Intention, its causes, and its healing process:
- Wound edges not approximated
- Pressure ulcers, burns, and surgical wounds with tissue loss
- Wound heals by granulation, wound contraction, then epithelialization- Scarring present
Describe Tertiary Intention, its causes, and its healing process:
- Wound left open for several days, then closed (approximated)
- Wounds that are contaminated and require observation for infection
- Closure of wound delayed until risk of infection is resolved.
Three stages of healing in Partial-Thickness wound repair:
Inflammatory Response
Epithelial Proliferation and Migration
Reestablishment of the Epidermal layers
Four phases to Full-thickness wound repair:
Hemostasis
Inflammatory
Proliferative
Remodeling
Healing Phase: A series of events designed to control blood loss, establish bacterial control, and seal the defect that occurs when there is an injury
Hemostasis
Healing Phase: Clots form a fibrin matrix, blood vessels constrict, and platelets gather to stop bleeding.
Hemostasis
Healing Stage: Involves WBCs that clean the wound and promote collagen formation.
Inflammatory Phase
Healing Phase: Vasodilation of capillaries causes redness, warmth, throbbing and edema as the body secretes histamine.
Inflammatory
Healing Phase: Begins with appearance of new blood vessels, the wound fills with granulation tissue and collagen, and the surface is repaired by epithelialization.
Proliferative stage
Healing Phase: Collagen scar continues to reorganize and gain strength. May last up to a year.
Remodeling
List the Four complications with wound healing:
Hemorrhage
Infection
Dehiscence
Evisceration
Bleeding from the wound site that occurs internally or externally occurring after hemostasis stage.
Hemorrhage
Hemorrhage may indicate….
Slipped surgical suture
Dislodged clot
Infection
Erosion of blood vessel by a foreign object (drain)
Localized collection of blood underneath the tissues.
Hematoma (very dangerous near major artery/vein)
A wound is infected if _________ __________is present.
Purulent Drainage
A patient has an infection of a surgical wound. What assessment data might you suspect to see?
- Fever
- Tenderness and pain of wound site
- Elevated WBC count
- Edges of wound inflamed
- Odorous, purulent drainage (yellow, green, or brown)
Serous drainage appearance:
Clear, water plasma
Purulent drainage appearance:
Thick, yellow, green, tan or brown
Serosanguineous drainage appearance:
Pale, pink, watery, mixture of clear and red fluid.
Sanguineous drainage appearance:
bright red, indicates active bleeding
A partial or total separation of wound layers.
Dehiscence
Identify patients at risk for Dehiscence
OBESITY
Poor nutrition
Infection
Recent abdominal wound
If a wound has a sudden increase in serosanguineous drainage, you should be alert for…
Dehiscence
A total separation of wound layers with protrusion of visceral organs through the wound opening.
Evisceration
What are the correct interventions for evisceration?
- Place sterile saline-soaked towels over protruding organs (to prevent bacterial infection and drying of tissues)
- Immediately contact the surgical team
- Do not allow the patient anything by mouth (NPO)
- Observe the patient for signs and symptoms of shock
- Prepare the patient for emergency surgery
What are the six assessment categories used on the Braden Scale?
- Sensory perception (ability to respond to pressure)
- Moisture (degree to which skin is exposed to moisture)
- Activity (Amount of physical activity)
- Mobility (Ability to change body position)
- Nutrition (Quality of food intake)
- Friction and Shear (amount of shear movement)
Briefly describe the Braden Scale:
An assessment tool used to determine a patient’s risk for impaired skin integrity. Scores range from 6-23, Lower scores equal higher risk. (Score of 18 is considered cutoff for risk of pressure ulcer onset)
List the Five factors that influence pressure ulcer formation:
Nutrition Tissue Perfusion Infection Age Psychosocial impact of wounds
A patient who has undergone surgery and is well-nourished requires at least ______ calories/day
1500
What are the four most important nutritional factors for wound healing?
Calories
Protein
Vitamin C
Vitamin A
What are good sources of protein to promote wound healing?
Poultry
Fish
Eggs
Beef
What are good sources of Vitamin C to promote good wound healing?
Citrus Fruits
Tomatoes
Potatoes
Fortified Fruit Juices
What are good Sources of Vitamin A to promote optimal wound healing?
Green leafy veggies (spinach) Broccoli Carrots Sweet Potatoes Liver
Best measure for nutritional status is:
Prealbumin
What factors do you Assess when identifying a patient at risk for pressure ulcer formation? (5)
Using appropriate Predictive measures (ex. Braden Scale) Mobility Nutritional Status Body Fluids Pain
What patients are at risk for pressure ulcer formation?
- Neurologically impaired patients
- Chronically ill patients in long-term care
- Patients with diminished mental status
- Patients in ICU, oncology, hospice, or orthopedic patients
When you note hyperemia, what do you document (3 things)
Location
Size
Color
**Reassess in 1 hour
When you suspect abnormal reactive hyperemia, what do you do?
Outline the area with a marker to make reassessment easier.
Which of these bodily fluids carry the Highest risk for skin breakdown? Select all that apply:
- Bile
- Saliva
- Urine
- Gastric drainage
- Ascitic fluid
- Pancreatic drainage
- gastric drainage
6. Pancreatic drainage
A superficial, partial-thickness wound with little bleeding.
Abrasion
A patient has a “weepy” shallow wound. You know this is…
An abrasion
A more serious wound that bleeds profusely (depending on depth and location)
Laceration
A wound in which the skin is pierced with an object- internal bleeding is a risk.
Puncture wound
A tetanus injection may be necessary for a patient with a dirty wound and who has not had one in ___ years.
5
If you anticipate the removal of a dressing to be painful, you should….
Consider giving analgesic at least 30 minutes prior
You should not the _____, _____, ______, and ________ of wound drainage.
Amount, Color, Odor, Consistency
___ g of drainage weighed is usually equal to ____ mL of volume.
1, 1
Four items to assess concerning Drains include:
Number of drains
Drain placement
Character of drainage
Condition of collecting equipment
A sudden decrease in drainage through the tubing may indicate…
A blocked drain- notify health care provider
Is a frequent skin closure and provides more strength than nylon or silk sutures.
Staple (stainless-steel)
Edema is normal around sutures for the first ___ to ___ days.
2-3
*Continued swelling indicates too-tight sutures
A tissue adhesive that forms a strong bond across apposed wound edges, allowing normal healing to occur below.
Dermabond
Extreme tenderness upon palpating a wound edge indicates….
Infection
If drainage occurs when palpating a wound area, you should….
Note the character of the drainage
If you detect purulent or suspicious-looking drainage, you should…
Obtain a specimen of the drainage for culture.
When obtaining a wound specimen for a culture, you should…
Clean the wound first with normal saline
Use a method of specimen collection according to agency policy
Know that tissue biopsy is the best method.
When choosing a nursing diagnosis related to normal wound healing, you should choose diagnosis that…
relate to risk-factors that could impair healing
impaired nutrition, ineffective tissue profusion, pain
In the event of an acute wound, what is the priority?
Immediate Intervention
In the event of a chronic wound, what is the priority?
Patient’s hygeine.
In the even of a risk for pressure ulcer development, what are the nursing priorities?
-Preventative interventions (skin care, elimination of shear, and positioning)
Three major nursing interventions for prevention of pressure ulcers are:
- Skin care and management of Incontinence
- Mechanical loading and support devices (proper positioning and therapeutic surfaces)
- Education
When cleaning the skin related to pressure ulcer prevention, you should…
- Avoid soap and hot water
- Use cleaners with nonionic surfactants
- Completely dry skin
- Apply moisturizer (do not oversaturate)
- Apply thick layer of barrier cream if needed
Positioning to prevent pressure ulcer formation includes…
- Raising the bed to 30degrees or LESS
- Repositioning at least every 2 hours (if allowed by condition)
- A 30-degree lateral position is optimal to avoid pressure on bony prominences
- Limit sitting time to 2 hours or less- instruct patient to shift position every 15 minutes
- Avoid donut and rigid cushions and use foam, gel, or air cushions instead.
List the principles to address to maintain a healthy wound environment: (6)
Prevent and manage infection Clean the wound Remove nonviable tissue Manage exudate Maintain the wound in a moist environment Protect the wound
Acute wounds require monitoring every ___ hours.
8
Dakin’s solution, acetic acid, hydrogen peroxide, and povidone-iodine are cytotoxic solutions and should….
NOT be used in clean, granulating wounds
Removal of nonviable, necrotic tissue
Debridement
When debriding a wound, normal observations include increase in ___, ___, and ___.
Exudate, odor, size
____ _____ may be necessary when you debride a wound.
Pain Management
Three purposes of debridement:
- Rid the wound of infection
- Enable visualization of wound bed
- Provide a clean wound base- necessary for healing
Four methods of debridement:
Mechanical
Autolytic
Chemical
Surgical-removal
Wet to dry saline gauze dressing is an example of which type of debridement?
Mechanical
*never use on wounds with granulation tissue
Placing synthetic dressings over a wound to allow the eschar to self-digest (due to enzymes present in the wound fluids) is an example of which type of debridement?
Autolytic
Use of Dakin’s solution or sterile maggots to reduce necrotic tissue are examples of which type of debridement?
Chemical
Removal of devitalized tissue by scalpel, scissors, or other sharp instruments is an example of which type of debridement?
Surgical
- Quickest
- when patient has signs of cellulitis or sepsis
A patient can lose as much as ___ g of protein a day from an open, weeping pressure ulcer.
50
Recommended protein intake of ____ g/kg/day is necessary for wound healing.
1.8
Low hemoglobin levels decrease delivery of oxygen to tissues and lead to ischemia. It is therefore important to maintain hemoglobin levels at ____g/100mL
12
*Can give iron supplement to help
First aid for Wounds includes: (4)
- Stabilizing cardiopulmonary function
- Promoting hemostasis
- Cleaning the wound
- Protect from further injury
When concerning a wound healing by primary intention, the dressing should be removed…
when drainage stops
Concerning a wound healing of secondary intention, the dressing should…
remain in place to promote a moist environment to the wound for healing.
List the 7 purposes of dressings:
Protect wound from microorganism contamination
Aids in hemostasis
Promotes healing by absorbing drainage and debriding
Supports or splints the wound site
Protects patients from seeing the wound
Promotes thermal insulation of the wound surface
Provides a moist environment
Factors that affect tissue tolerance:
Nutrition
Age
Hydration
Low BP
Factors that impair wound healing:
Age
Anemia
Low protein
Low zinc
You should allow a wound to bleed freely when….
There is a risk for infection (Dog bite, dirty wound)
What types of dressings are appropriate for a stage 1 ulcer?
None
Transparent
Hydrocolloid
What types of dressing are appropriate for a clean stage 2 ulcer?
Composite film
Hydrocolloid
Hydrogel
What types of dressings are appropriate for a clean stage 3 ulcer?
Hydrocolloid Hydrogel (with foam) Calcium Alginate Gauze Growth Factors (with gauze)
What types of dressings are appropriate for a clean stage 4 ulcer?
Hydrogen (with foam)
Calcium Alginate
Gauze
Growth factors (with gauze)
What types of dressings are appropriate for an eschar covered unstageable ulcer?
Adherent film
Gauze plus ordered solution
Enzymes
None (Heel ulcer w/ eschar)
List the 6 advantages of a Transparent film dressing:
- Adheres to undamaged skin
- Serves as a barrier to external fluids and bacteria while allowing wound surface to breath
- Promotes a moist environment that speed epithelial cell growth
- Can be removed without damaging underlying tissue
- Permits viewing of t he wound
- Does not require secondary derssing
What types of wounds are transparent dressings ideal for?
small superficial wounds (partial-thickness wounds) OR to protect high risk skin
What are the functions of a hydrocolloid dressing? (7)
- Absorbs drainage through use of exudate absorbers in the dressing
- Maintains moisture
- Slowly liquifies necrotic debris
- Is impermeable to bacteria and other contaminants
- Is self-adhesive and molds well
- Acts as a preventive dressing for high-risk friction areas
- May be left in place for 3-5 days, minimizing trauma of skin healing
Hydrocolloid dressings are best on which types of wounds?
Granulating wounds
Autolytically debrided necrotic wounds
Shallow to moderately deep dermal ulcers
Hydrocolloid dressings are contraindicated in which types of wounds?
Heavily draining wounds
Full-thickness wounds
Infected wounds
List the four advantages of hydrogel dressings:
- Soothing, can reduce wound pain
- Provides a moist environment
- Debrides necrotic tissue (softens the tissue)
- Does not adhere to the wound base and is easy to remove
Hydrogel dressings are best for which types of wounds?
Partial-thickness or full-thickness wounds Deep wounds with SOME exudate Necrotic wounds Burns Radiation damage to skin
Alginate dressings are best for which types of wounds?
Wounds with large amounts of exudate
**DO not use in dry wounds!
Foam dressings are best used in which type of wounds?
Wounds with large amounts of exudate
Around drainage tubes to absorb drainage
Functions of bandage and binders (5):
- Create pressure
- Immobilize body part and/or support a wound
- Reduce or prevent edema
- Secure a splint
- Secure dressings
List the guidelines to follow during a dressing change (4):
- Asses the skin beneath the tape
- Perform hand hygiene before and after care
- Wearing sterile gloves before directly touching a fresh or open wound
- Removing or changing dressings over closed wounds when they become wet, as ordered or if S/S of infection are present
Summarize the principles of packing a wound (4):
- Assess size and depth and shape: determines type of dressing used
- Entire wound must be in contact with part of the moist gauze dressing
- Don’t pack too tightly- causes pressure
- Should not overlap wound edges
Activation of negative pressure of a wound through suction to facilitate healing and collect wound fluids. Worn 24hours- 5days
NPWT- Negative pressure wound therapy (Wound Vacuum-assisted closure device)
Heat applications cause which physiological responses?
- Reduces edema by vasodilation
- Reduces blood viscosity
- Reduced muscle tension
- Increased tissue metabolism
- Increased capillary permeability
Cold applications cause which physiological responses?
- Vasoconstriction
- Local anesthesia
- Reduced cell metabolism
- Increased blood viscosity
- Decreased muscle tension
Before applying hot or cold therapies….
Assess the patient’s physical condition for signs of potential tolerance to heat and cold.
Cold therapies are contraindicated in….
Impaired skin integrity Neuropathy Edema Impaired circulation Shivering
Heat therapies are contraindicated in….
Impaired skin integrity
Neuropathy
Active areas of bleeding
Acute localized inflammation (Appendicitis)
Cardiovascular problems (do not put heat on large portions of the body)
True or False: A health care provider’s order needs to be obtained before removing a bandage applied by a health care provider.
True
If a patient has peripheral disease, ensure you assess the __________ before applying heat or cold therapies
Extremities
If a patient has an order for a heat or cold therapy to the legs and has poor circulation to the area, you should…
Question the order
If a patient has a decreased Level of Consciousness and is receiving a hot or cold therapy, you should….
Assess skin integrity frequently during therapy
Pain occurs during heat and cold therapies when the temperature is less than ______F or greater than _______F
59, 113
Heat therapies should not be applied for longer than _______.
1 hour
True or False: The patient should adjust the temperature of the cold or heat therapy as needed.
False
A type of warm therapy that improves circulation, relieves edema, and promotes consolidation of purulent drainage.
Warm, moist compress
A type of warm therapy that promotes circulation, lessens edema, increases muscle relaxation, and provides a means to apply medicated solution.
Warm soaks
A type of warm therapy for a patient who has recently had rectal surgery, episiotomy, painful hemorrhoids, or vaginal inflammation (such as pregnancy).
Sitz bath
A warm therapy that uses a prepared disposable pack to apply dry heat to an injured area
Commercial hot packs
A cold therapy that applies cold for 20 minutes to relieve inflammation and swelling.
Cold, moist, and dry compresses
A type of cold therapy which uses water at a temperature of 59*F
Cold soaks
A cold therapy used for patients who have a muscle sprain, localized hemorrhage, hematoma, or has undergone dental surgery. Prevents edema formation, controls bleeding, and anesthetizes the body part.
Ice bag or collar
When a patient has a binder applied, it is important to assess the skin every ___ hours.
2
