Unit 2 Physical Integrity Flashcards
Give examples of an intentional wound.
Therapies, such as surgical incisions or venipuncture.
What defense does the skin use to protect and heal itself?
Inflammatory Response
What is the primary difference between the inflammatory response and infection?
Infection will often have purulent drainage, where are the inflammatory response will not.
What is another name for a pressure sore?
Decubitus ulcer.
What causes pressure sores/decubitus ulcers to form?
Unrelieved pressure to an area that leads to damage of underlying tissue.
In what stage is an area of skin that remains red after pressure has been relieved (no blister or open areas of skin present).
Stage I
What stage is an area of skin that has full thickness tissue loss to the subcutaneous layers?
Stage III
What stage is an area that has a superficial blister surrounded by reddened skin?
Stage II
What stage is an area what has extensive tissue damage extending to the underlying muscle and bone?
Stage IV
What stage is necrosis often present?
Stage IV
Where on the body is evisceration typically seen?
On the abdomen.
What is the difference between evisceration and dehiscence?
Dehiscence involves separation of the tissues (re-opening of the wound). Evisceration occurs when the visceral tissues protrude from the opening.
What factors contribute to increase risk of dehiscence and evisceration?
Obesity, Excessive Coughing, Vomitting, Poor Nutrition, Infection, and Suturing Problems.
What type of drainage is considered abnormal?
Purulent.
What diagnostic study/lab value reveals the bloods oxygenation carrying capacity?
CBC
What is the significance of CBC ‘With Differential’?
Differential addresses the 5 types of white blood cells.
What diagnostic study/lab value uses the rate at which Red Blood Cells settle or fall to indicate the presence of a pathological condition?
ESR/Erythrocyte Sedimentation Rate (Sed Rate)
What is the significance of an elevated WBC (White Blood Cell) count?
Suggests a local or systemic infection.
What diagnostic study/lab value identifies elements not typically found in the blood that are indicative of the inflammatory response and infection process?
C-Reaction Protein, CRP
What diagnostic Study is performed to identify a specific microbe causing infection within a wound?
Wound Culture & Sensitivity
Hot -or- Cold
Which provides vasodilation?
Hot
Hot -or- Cold
Which provides increased viscosity?
Cold
Hot -or- Cold
Which provides reduced cell metabolism?
Cold
Hot -or- Cold
Which provides increased capillary permeability?
Hot
Hot -or- Cold
Which provides local anesthesia?
Cold
Hot -or- Cold
Which provides increased tissue perfusion?
Hot
Hot -or- Cold
Which provides vasoconstriction?
Cold
Hot -or- Cold
Which provides decreased blood viscosity?
Hot
What type of dressing allows the wound to be visualized, and is impermeable to bacteria and other contaminants?
Transparent Dressings
What type of dressing is typically used for wounds healing by primary intention following surgery?
Gauze Dressings
What must be done to gauze dressings if the dressing adheres to a wound?
Gauze must be moistened if it adheres to wound.
What type of dressing provides autolytic debridement of necrotic wounds?
Hydrocolloid dressings. Maintains a moist environment . Used for venous stasis arterial and pressure ulcers can be left in place three to five days.
What type of dressing has cooling and soothing properites that make it useful on burns?
Hydrogel dressings. Water based non adherent dressing promotes wound debridement rehydrates the wound.
Name the three types of drains.
Penrose, Jackson-Pratt, Hemovac.
What drain is considered an open drainage system?
Penrose drain.
What drains are considered closed drainage systems?
Jackson-Pratt & Hemovac.
What primary action is used in closed drainage systems?
Suction/Vacuum.
What primary action is used in an open drainage system?
Gravity.
When changing a dressing and cleaning a wound with a drain, give the order of what areas are cleaned.
1) Center of incision site.
2) Side of incision away from drain.
3) Side of incision near the drain
4) Skin surrounding the drain
How can items be added to the sterile field?
Carefully grasping the edge of the closed package, peel it open, and items dropped onto the sterile field.
How is the sterile field opened?
Away from the nurse first. Sides are second, making sure not to pass over the sterile field. Toward the nurse last.
What signs and symptoms are important to record and report regarding wound care?
Status of dressing.
Integrity of suture line.
Changes in skin color.
Presence and character of drainage.
When are W/D dressings used?
Open wounds requiring debridement.
What types of wounds is the wound vac useful for?
Stage III & IV pressure ulcers, skin flaps, chronic surgical wounds, and traumatic wounds.
When is the use of heat contraindicated?
24 hours after traumatic injury. Active hemorrhage. Non inflammatory edema. Localized malignant tumors. Redness/Blisters.
When is the use of cold contraindicated?
Open wounds.
Impaired circulation.
Allergy/Hypersensitivity to cold.
Give an example of dry heat.
Hot water bottle, heating pad.
Hive an example of moist heat.
Soaks, compresses, hot packs.
What are the primary principles for applying a bandage?
Position in anatomical alignment. Separate skin surfaces. Pad bony prominences. Observe medical asepsis (Clean technique) Apply equal tension.
What type of turn is used to immobilize a joint?
Figure-8.
A dressing contains a large amount of brightly colored red exudate. How would the nurse describe the exudate?
Sanguineous exudate.
A dressing contains only clear watery drainage. How would the nurse describe the drainage?
Serous exudate.
A dressing is observed to have green tinged exudate. How would the nurse describe the exudate?
Green purulent exudate.
A dressing is observed to have light pink drainage. How would the nurse describe the drainage?
Serosanguineous drainage.
A nurse who washes hands and puts on clean gloves when administering a bolus feeding is using what type of technique?
Medical Asepsis (Clean Technique)
When changing a dressing, the nurse uses what technique to prevent introduction of microorganisms into the wound?
Surgical Asepsis (Sterile Technique)
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?
Yes. Sterile solutions are only good for 24 hours after opening.
When changing a dressing and assessing the wound, what four things should the nurse record and report?
1) Status of dressing.
2) Integrity of suture line.
3) Changes in skin color
4) Presence and character of drainage.
A patient with a chronic stage 3/4 surgical wound may be a candidate for what type of wound treatment?
Wound Vac
A patient asks how the wound vac is going to help the wound heal. How would the nurse respond?
A wound vac improves tissue perfusion, removes drainage, and mechanically debrides tissue.
Why are bandages applies distal to proximal?
Support circulation, Risk of edema is minimalized.
When assessing for the tightness of a bandage, what should the nurse look for?
Color and temperature of skin, capillary refill, and patient comfort.
