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Rachael > Test 4--Chapter 35 Wound Care > Flashcards

Test 4--Chapter 35 Wound Care Flashcards

1
Q

What is the body’s first line of defense against injury?

A

Skin

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2
Q

What is a break in the skin or mucous membrane called?

A

A wound

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3
Q

A wound or injection are a major portal of entry for _________.

A

microbes

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4
Q

˜Wound care involves:

  • Preventing _______
  • Preventing further ______ to the wound and nearby tissues
A

˜Wound care involves:

  • Preventing infection
  • Preventing further injury to the wound and nearby tissues
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5
Q

What are common causes of wounds?

A
  • Surgery
  • Trauma
  • Pressure ulcers from unrelieved pressure
  • Decreased blood flow through the arteries or veins
  • Nerve damage
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6
Q

Older and disabled persons are at great risk for skin ___________

A

Older and disabled persons are at great risk for skin breakdown

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7
Q

break or rip in the skin

A

Skin tear

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8
Q

What are common sites for skin tears?

A
  • hands,
  • arms, and
  • lower legs
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9
Q

What are the four causes of skin tears?

A
  • Friction and shearing
  • Pulling or pressure on the skin
  • Falls or bumping a hand, arm, or leg on any hard surface
  • Holding the person’s arm or leg too tight
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10
Q

How do you prevent skin tears?

A

Follow the care plan

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11
Q

Who is at risk for skin tears?

A
  • Need moderate to total help in moving
  • Have poor nutrition
  • Have poor hydration
  • Have altered mental awareness
  • Are very thin
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12
Q

˜What are open sores on the lower legs or feet that are
˜caused by decreased blood flow in the circulatory system called?

A

Circulatory (vascular) ulcers

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13
Q

What are the three types of circulatory or vascular ulcers?

A
  • Venous ulcers
  • Arterial ulcers
  • Diabetic foot ulcers
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14
Q

Edema

A

•is swelling caused by fluid collecting in tissues.

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15
Q

Gangrene

A

condition in which there is death of tissue.

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16
Q

What are four consequences of poor circulation?

A
  • Pain
  • Open wounds
  • Edema
  • Infection and gangrene
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17
Q

˜What are open sores on the lower legs or feet caused by poor blood flow through the veins called?

A

Venous (Stasis) ulcers

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18
Q

Stasis

A

stopped or slowed fluid flow

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19
Q

What are common sites for venous (stasis) ulcers?

A
  • The heels and
  • inner aspect of the ankles
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20
Q

phlebitis

A

inflammation of a vein

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21
Q

˜Prevention and treatment of venous ulcers involve:

  • Follow the person’s __________ to prevent skin breakdown.
  • Prevent ______.
  • Handle, move, and transfer the person carefully and gently.
  • Persons at risk need professional ______ care.
  • Drugs for _________ and to decrease ________
  • Medicated ________ and other wound care products
  • Devices used for ______ ulcers
  • Elastic _________ or elastic bandages
A

˜Prevention and treatment of venous ulcers involve:

  • Follow the person’s care plan to prevent skin breakdown.
  • Prevent injury.
  • Handle, move, and transfer the person carefully and gently.
  • Persons at risk need professional foot care.
  • Drugs for infection and to decrease swelling
  • Medicated bandages and other wound care products
  • Devices used for pressure ulcers
  • Elastic stockings or elastic bandages
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22
Q

What are the benefits of elastic stockings or anti-embolism stockings?

A
  • Exert pressure on the veins
  • Promote venous blood return to the heart
  • Help prevent venous ulcers and blood clots (thrombi) in leg veins
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23
Q

˜Thrombi

  • Can form in ____ ___ veins
  • Can break _____ and travel in the _________ (embolus)
  • An embolus can lodge in a vein in the ______ (pulmonary embolus)
A

˜Thrombi

  • Can form in deep leg veins
  • Can break loose and travel in the bloodstream (embolus)
  • An embolus can lodge in a vein in the lungs (pulmonary embolus)
24
Q

Elastic bandages

  • Have the same purpose as elastic ________
  • Support and reduce _______ from injuries
  • Can be used to hold ________ in place

˜

A

Elastic Bandages

  • Have the same purpose as elastic stockings
  • Support and reduce swelling from injuries
  • Can be used to hold dressing in place
25
Q

˜Open wounds on the lower legs or feet caused by poor blood flow through the arteries.

A

Arterial ulcers

26
Q

Where are arterial ulcers found?

A
  • Found between the toes,
  • on top of the toes, and
  • on the outer side of the ankle
27
Q

How do you treat arterial ulcers?

A
  • Treating the disease causing the ulcer
  • Drugs and wound care
  • A walking and exercise program
  • Professional foot care
28
Q

˜Open wounds on the foot caused by complications from diabetes

A

Diabetic Foot Ulcers

29
Q

With a diabetic resident, you should:

  • Check the person’s ____ every day.
  • Report any sign of a ____ problem to the nurse at once.
  • Follow the ____ ____.
A
  • Check the person’s feet every day.
  • Report any sign of a foot problem to the nurse at once.
  • Follow the care plan.
30
Q

Dehiscence

A

the parting of the sutured lips of a surgical wound

a person will describe the wound as popping open

31
Q

Evisceration

A

dehiscence plus protrusion of abdominal organs

32
Q

What is drainage that is a clear, watery fluid called?

A

Serous

33
Q

Bloody drainage

A

Sanguineous

34
Q

Thin, watery drainage that is blood-tinged

A

Serosanguineous

35
Q

drainage that is thick green, yellow, or brown drainage.

A

purulent

36
Q

When large amounts of drainage are expected, the doctor inserts a _____

A

When large amounts of drainage are expected, the doctor inserts a drain.

37
Q

How is drainage measured?

A
  • Noting the number and size of dressings with drainage
  • Weighing dressings before applying them to the wound
  • •Dressings are then weighed after removal.
  • Measuring the amount of drainage in the collection container if closed drainage is used
38
Q

˜Delayed healing and infection are risks for persons who:

  • Are older or _____
  • Have poor _______
  • Have poor _______ and _______
A

˜Delayed healing and infection are risks for persons who:

  • Are older or obese
  • Have poor nutrition
  • Have poor circulation and diabetes
39
Q

__________ ____________ is needed for healing.

A

Good nutrition

40
Q

˜Wound dressings have many functions.

  • Protect wounds from injury and _______.
  • Absorb _______.
  • Remove ____ tissue.
  • Promote _____
  • Cover unsightly wounds.
  • Provide a _______ environment for wound healing.
  • Apply __________ (pressure dressings) to help control bleeding.
A

˜Wound dressings have many functions.

  • Protect wounds from injury and microbes.
  • Absorb drainage.
  • Remove dead tissue.
  • Promote comfort.
  • Cover unsightly wounds.
  • Provide a moist environment for wound healing.
  • Apply pressure (pressure dressings) to help control bleeding.
41
Q

What are used to secure dressings?

A

tape

Montgomery ties

42
Q

How do binders promote healing?

A
  • Supporting wounds
  • Holding dressings in place
  • Preventing or reducing swelling
  • Promoting comfort
  • Preventing injury
43
Q

What are the benefits of heat and cold applications?

A
  • ˜Promote healing and comfort
  • ˜Reduce tissue swelling
  • ˜Heat and cold have opposite effects on body function.
  • ˜Doctors order heat and cold applications.
44
Q

˜When heat is applied to the skin:

  • Blood vessels in the area ______
  • Blood _____ increases
  • Tissues have more _______ and ________ for healing.
  • Excess _______ is removed from the area faster.
  • The _____ is red and warm.
A

˜When heat is applied to the skin:

  • Blood vessels in the area dilate.
  • Blood flow increases.
  • Tissues have more oxygen and nutrients for healing.
  • Excess fluid is removed from the area faster.
  • The skin is red and warm.
45
Q

dilate

A

expand or open wider.

46
Q

Do not apply heat to an ______ area

A

Do not apply heat to an implant area

47
Q

Heat is not applied to a pregnant woman’s _______; it can affect fetal growth.

A

abdomen

48
Q

Complications with heat application

A

burns

Report excessive redness or blisters

49
Q

Who is at risk for complications with heat?

A
  • Older and fair-skinned persons
  • Persons with problems sensing heat and pain (nervous system damage, loss of consciousness, circulatory disorders, confusion, some medications)
  • Persons with dementia
  • Persons with metal implants
50
Q

When are cold applications used?

A
  • ˜Are often used to treat sprains and fractures
  • ˜Reduce pain, prevent swelling, and decrease circulation and bleeding
  • ˜Cool the body when fever is present
  • ˜Have the opposite effect of heat
  • Are useful right after an injury
51
Q

What kind of effect does cold treatment have on the skin?

A

numbing

52
Q

What are the complications of cold application?

A

pain, burns, blisters, and poor circulation.

53
Q

Who is at risk for complications with cold treatments?

A
  • Older and fair-skinned persons
  • Persons with sensory impairments
  • Persons with dementia
54
Q

˜body temperature that is much higher than the person’s normal range.

A

hyperthermia

55
Q

very low body temperature

A

hypothermia

56
Q

What is used to treat hypothermia?

A

a warming blanket

It is called a hyperthermia blanket when it is used to warm someone up

57
Q

What is used to treat hyperthermia?

A

a cooling blanket

It’s called a hypothermia blanket when it is used to cool someone down

Rachael (25 decks)

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