Week 4- Wound Care

Question 0

To maintain a sterile field, the nurse must

Answer 0

Keep inside the 1" border sterile
Only add sterile items
Keep it dry
Prepare it close to the procedure time
Keep it above waist level
Not turn his or her back

Question 1

Sterile technique is used for

Answer 1

Cathetors
Acute wounds
Body cavity procedures

Question 2

When conducting wound care list the time and type of gloves worn

Answer 2

Clean gloves before removing dressing

Sterile gloves when assessing, packing, and putting on the new dressing

Question 3

Evisceration and the nursing actions associated

Answer 3

An impairment in wound healing where the incision line is broken so far as organs are protruding outwards.
Nrsg action: sterile saline and towels onto site. Call for emergency surgery

Question 4

Dehiscence and the nursing actions

Answer 4

When the incision line is splitting open from the ends. Could be a result of removing sutures or staples, coughing or repositioning, or improper wound healing.
Nrsg action: when removing sutures or staples remove every second one. Apply sterile saline covered towels to the site. Call the physician.

Question 5

Infection and how it presents itself

Answer 5

Infection is shown with purulent drainage and odor

Question 6

Hemorrhage and how it presents

Answer 6

Can be internal or external bleeding. Be alert for edema and change in drainage to sanguinous.

Question 7

True or False: the use of cytotoxic cleaning solutions is frowned upon.

Answer 7

True.

Question 8

When is risk for infection highest? Risk for hemorrhage?

Answer 8

Infection risk is high up to three days following surgery. Patient is immunosuppressed (potentially), due to medications, and/or due to natural flora being eliminated at the site. However, infection can occur up to one year after surgery.
Hemorrhage risk is highest the following two days of surgery.

Question 9

True or False: debridement removes exudate by a 35mL syringe, 19G with saline.

Answer 9

False. Debridement removes necrotic tissue. This can be from wet to dry dressings or _________.
Irrigation removes exudate with a 35mL, 19G syringe with saline.

Question 10

What are the types of wound evacuation systems?

Answer 10

Penrose
Hemovac
Jackson-Pratt

Question 11

True or False: a wound healing by secondary intention heals by regeneration?

Answer 11

False. That is characteristic of primary intention

Question 13

True or False: a wound healing by secondary intention has a longer proliferation phase due to the necrotic tissue.

Answer 13

True

Question 14

What does the patient need in order for appropriate wound healing?

Answer 14

Oxygenation and nutrition

Question 15

Discuss the initial phase of wound healing.

Answer 15

This phase is characterized by inflammation, as the area fills with blood, WBCs migrate to the site, macrophages digest material and remove the fibrin clot. This phase lasts 3-5 days in healing by primary intention.