Test 4--Chapter 35 Wound Care Flashcards
What is the body’s first line of defense against injury?
Skin
What is a break in the skin or mucous membrane called?
A wound
A wound or injection are a major portal of entry for _________.
microbes
Wound care involves:
- Preventing _______
- Preventing further ______ to the wound and nearby tissues
Wound care involves:
- Preventing infection
- Preventing further injury to the wound and nearby tissues
What are common causes of wounds?
- Surgery
- Trauma
- Pressure ulcers from unrelieved pressure
- Decreased blood flow through the arteries or veins
- Nerve damage
Older and disabled persons are at great risk for skin ___________
Older and disabled persons are at great risk for skin breakdown
break or rip in the skin
Skin tear
What are common sites for skin tears?
- hands,
- arms, and
- lower legs
What are the four causes of skin tears?
- 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
How do you prevent skin tears?
Follow the care plan
Who is at risk for skin tears?
- Need moderate to total help in moving
- Have poor nutrition
- Have poor hydration
- Have altered mental awareness
- Are very thin
What are open sores on the lower legs or feet that are
caused by decreased blood flow in the circulatory system called?
Circulatory (vascular) ulcers
What are the three types of circulatory or vascular ulcers?
- Venous ulcers
- Arterial ulcers
- Diabetic foot ulcers
Edema
•is swelling caused by fluid collecting in tissues.
Gangrene
condition in which there is death of tissue.
What are four consequences of poor circulation?
- Pain
- Open wounds
- Edema
- Infection and gangrene
What are open sores on the lower legs or feet caused by poor blood flow through the veins called?
Venous (Stasis) ulcers
Stasis
stopped or slowed fluid flow
What are common sites for venous (stasis) ulcers?
- The heels and
- inner aspect of the ankles
phlebitis
inflammation of a vein
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
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
What are the benefits of elastic stockings or anti-embolism stockings?
- Exert pressure on the veins
- Promote venous blood return to the heart
- Help prevent venous ulcers and blood clots (thrombi) in leg veins
Thrombi
- Can form in ____ ___ veins
- Can break _____ and travel in the _________ (embolus)
- An embolus can lodge in a vein in the ______ (pulmonary embolus)
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)
Elastic bandages
- Have the same purpose as elastic ________
- Support and reduce _______ from injuries
- Can be used to hold ________ in place
Elastic Bandages
- Have the same purpose as elastic stockings
- Support and reduce swelling from injuries
- Can be used to hold dressing in place
Open wounds on the lower legs or feet caused by poor blood flow through the arteries.
Arterial ulcers
Where are arterial ulcers found?
- Found between the toes,
- on top of the toes, and
- on the outer side of the ankle
How do you treat arterial ulcers?
- Treating the disease causing the ulcer
- Drugs and wound care
- A walking and exercise program
- Professional foot care
Open wounds on the foot caused by complications from diabetes
Diabetic Foot Ulcers
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 ____ ____.
- Check the person’s feet every day.
- Report any sign of a foot problem to the nurse at once.
- Follow the care plan.
Dehiscence
the parting of the sutured lips of a surgical wound
a person will describe the wound as popping open
Evisceration
dehiscence plus protrusion of abdominal organs
What is drainage that is a clear, watery fluid called?
Serous
Bloody drainage
Sanguineous
Thin, watery drainage that is blood-tinged
Serosanguineous
drainage that is thick green, yellow, or brown drainage.
purulent
When large amounts of drainage are expected, the doctor inserts a _____
When large amounts of drainage are expected, the doctor inserts a drain.
How is drainage measured?
- 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
Delayed healing and infection are risks for persons who:
- Are older or _____
- Have poor _______
- Have poor _______ and _______
Delayed healing and infection are risks for persons who:
- Are older or obese
- Have poor nutrition
- Have poor circulation and diabetes
__________ ____________ is needed for healing.
Good nutrition
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.
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.
What are used to secure dressings?
tape
Montgomery ties
How do binders promote healing?
- Supporting wounds
- Holding dressings in place
- Preventing or reducing swelling
- Promoting comfort
- Preventing injury
What are the benefits of heat and cold applications?
- Promote healing and comfort
- Reduce tissue swelling
- Heat and cold have opposite effects on body function.
- Doctors order heat and cold applications.
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.
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.
dilate
expand or open wider.
Do not apply heat to an ______ area
Do not apply heat to an implant area
Heat is not applied to a pregnant woman’s _______; it can affect fetal growth.
abdomen
Complications with heat application
burns
Report excessive redness or blisters
Who is at risk for complications with heat?
- 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
When are cold applications used?
- 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
What kind of effect does cold treatment have on the skin?
numbing
What are the complications of cold application?
pain, burns, blisters, and poor circulation.
Who is at risk for complications with cold treatments?
- Older and fair-skinned persons
- Persons with sensory impairments
- Persons with dementia
body temperature that is much higher than the person’s normal range.
hyperthermia
very low body temperature
hypothermia
What is used to treat hypothermia?
a warming blanket
It is called a hyperthermia blanket when it is used to warm someone up
What is used to treat hyperthermia?
a cooling blanket
It’s called a hypothermia blanket when it is used to cool someone down
