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NSG 1101 > Unit 2 Physical Integrity > Flashcards

Unit 2 Physical Integrity Flashcards

1
Q

Give examples of an intentional wound.

A

Therapies, such as surgical incisions or venipuncture.

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2
Q

What defense does the skin use to protect and heal itself?

A

Inflammatory Response

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3
Q

What is the primary difference between the inflammatory response and infection?

A

Infection will often have purulent drainage, where are the inflammatory response will not.

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4
Q

What is another name for a pressure sore?

A

Decubitus ulcer.

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5
Q

What causes pressure sores/decubitus ulcers to form?

A

Unrelieved pressure to an area that leads to damage of underlying tissue.

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6
Q

In what stage is an area of skin that remains red after pressure has been relieved (no blister or open areas of skin present).

A

Stage I

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7
Q

What stage is an area of skin that has full thickness tissue loss to the subcutaneous layers?

A

Stage III

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8
Q

What stage is an area that has a superficial blister surrounded by reddened skin?

A

Stage II

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9
Q

What stage is an area what has extensive tissue damage extending to the underlying muscle and bone?

A

Stage IV

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10
Q

What stage is necrosis often present?

A

Stage IV

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11
Q

Where on the body is evisceration typically seen?

A

On the abdomen.

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12
Q

What is the difference between evisceration and dehiscence?

A

Dehiscence involves separation of the tissues (re-opening of the wound). Evisceration occurs when the visceral tissues protrude from the opening.

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13
Q

What factors contribute to increase risk of dehiscence and evisceration?

A

Obesity, Excessive Coughing, Vomitting, Poor Nutrition, Infection, and Suturing Problems.

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14
Q

What type of drainage is considered abnormal?

A

Purulent.

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15
Q

What diagnostic study/lab value reveals the bloods oxygenation carrying capacity?

A

CBC

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16
Q

What is the significance of CBC ‘With Differential’?

A

Differential addresses the 5 types of white blood cells.

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17
Q

What diagnostic study/lab value uses the rate at which Red Blood Cells settle or fall to indicate the presence of a pathological condition?

A

ESR/Erythrocyte Sedimentation Rate (Sed Rate)

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18
Q

What is the significance of an elevated WBC (White Blood Cell) count?

A

Suggests a local or systemic infection.

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19
Q

What diagnostic study/lab value identifies elements not typically found in the blood that are indicative of the inflammatory response and infection process?

A

C-Reaction Protein, CRP

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20
Q

What diagnostic Study is performed to identify a specific microbe causing infection within a wound?

A

Wound Culture & Sensitivity

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21
Q

Hot -or- Cold

Which provides vasodilation?

A

Hot

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22
Q

Hot -or- Cold

Which provides increased viscosity?

A

Cold

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23
Q

Hot -or- Cold

Which provides reduced cell metabolism?

A

Cold

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24
Q

Hot -or- Cold

Which provides increased capillary permeability?

A

Hot

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25
Q

Hot -or- Cold

Which provides local anesthesia?

A

Cold

26
Q

Hot -or- Cold

Which provides increased tissue perfusion?

A

Hot

27
Q

Hot -or- Cold

Which provides vasoconstriction?

A

Cold

28
Q

Hot -or- Cold

Which provides decreased blood viscosity?

A

Hot

29
Q

What type of dressing allows the wound to be visualized, and is impermeable to bacteria and other contaminants?

A

Transparent Dressings

30
Q

What type of dressing is typically used for wounds healing by primary intention following surgery?

A

Gauze Dressings

31
Q

What must be done to gauze dressings if the dressing adheres to a wound?

A

Gauze must be moistened if it adheres to wound.

32
Q

What type of dressing provides autolytic debridement of necrotic wounds?

A

Hydrocolloid dressings. Maintains a moist environment . Used for venous stasis arterial and pressure ulcers can be left in place three to five days.

33
Q

What type of dressing has cooling and soothing properites that make it useful on burns?

A

Hydrogel dressings. Water based non adherent dressing promotes wound debridement rehydrates the wound.

34
Q

Name the three types of drains.

A

Penrose, Jackson-Pratt, Hemovac.

35
Q

What drain is considered an open drainage system?

A

Penrose drain.

36
Q

What drains are considered closed drainage systems?

A

Jackson-Pratt & Hemovac.

37
Q

What primary action is used in closed drainage systems?

A

Suction/Vacuum.

38
Q

What primary action is used in an open drainage system?

A

Gravity.

39
Q

When changing a dressing and cleaning a wound with a drain, give the order of what areas are cleaned.

A

1) Center of incision site.
2) Side of incision away from drain.
3) Side of incision near the drain
4) Skin surrounding the drain

40
Q

How can items be added to the sterile field?

A

Carefully grasping the edge of the closed package, peel it open, and items dropped onto the sterile field.

41
Q

How is the sterile field opened?

A

Away from the nurse first. Sides are second, making sure not to pass over the sterile field. Toward the nurse last.

42
Q

What signs and symptoms are important to record and report regarding wound care?

A

Status of dressing.
Integrity of suture line.
Changes in skin color.
Presence and character of drainage.

43
Q

When are W/D dressings used?

A

Open wounds requiring debridement.

44
Q

What types of wounds is the wound vac useful for?

A

Stage III & IV pressure ulcers, skin flaps, chronic surgical wounds, and traumatic wounds.

45
Q

When is the use of heat contraindicated?

A 
24 hours after traumatic injury.
Active hemorrhage.
Non inflammatory edema.
Localized malignant tumors.
Redness/Blisters.
46
Q

When is the use of cold contraindicated?

A

Open wounds.
Impaired circulation.
Allergy/Hypersensitivity to cold.

47
Q

Give an example of dry heat.

A

Hot water bottle, heating pad.

48
Q

Hive an example of moist heat.

A

Soaks, compresses, hot packs.

49
Q

What are the primary principles for applying a bandage?

A 
Position in anatomical alignment.
Separate skin surfaces.
Pad bony prominences.
Observe medical asepsis (Clean technique)
Apply equal tension.
50
Q

What type of turn is used to immobilize a joint?

A

Figure-8.

51
Q

A dressing contains a large amount of brightly colored red exudate. How would the nurse describe the exudate?

A

Sanguineous exudate.

52
Q

A dressing contains only clear watery drainage. How would the nurse describe the drainage?

A

Serous exudate.

53
Q

A dressing is observed to have green tinged exudate. How would the nurse describe the exudate?

A

Green purulent exudate.

54
Q

A dressing is observed to have light pink drainage. How would the nurse describe the drainage?

A

Serosanguineous drainage.

55
Q

A nurse who washes hands and puts on clean gloves when administering a bolus feeding is using what type of technique?

A

Medical Asepsis (Clean Technique)

56
Q

When changing a dressing, the nurse uses what technique to prevent introduction of microorganisms into the wound?

A

Surgical Asepsis (Sterile Technique)

57
Q

When preparing to change a dressing, the nurse notes the sterile solution bottle was opened 12 hours ago on the previous shift. If the solution still usable/sterile?

A

Yes. Sterile solutions are only good for 24 hours after opening.

58
Q

When changing a dressing and assessing the wound, what four things should the nurse record and report?

A

1) Status of dressing.
2) Integrity of suture line.
3) Changes in skin color
4) Presence and character of drainage.

59
Q

A patient with a chronic stage 3/4 surgical wound may be a candidate for what type of wound treatment?

A

Wound Vac

60
Q

A patient asks how the wound vac is going to help the wound heal. How would the nurse respond?

A

A wound vac improves tissue perfusion, removes drainage, and mechanically debrides tissue.

61
Q

Why are bandages applies distal to proximal?

A

Support circulation, Risk of edema is minimalized.

62
Q

When assessing for the tightness of a bandage, what should the nurse look for?

A

Color and temperature of skin, capillary refill, and patient comfort.

NSG 1101 (12 decks)

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