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Nurs 1165 > Week 6: Wound Care > Flashcards

Week 6: Wound Care Flashcards

1
Q

a swollen area within body tissue, containing an accumulation of pus.

A

Abcess

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2
Q

Biofilm

A

thin, slimy film of bacteria that adheres to a surface.

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3
Q

Dehiscence

A

thesplittingorburstingopen of apodor wound.

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4
Q

the removal of moisture from something.

A

Desiccation

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5
Q

superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries.

A

Erythema

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6
Q

Eschar

A

dry, dark scab or falling away of dead skin, typically caused by a burn, or by the bite of a mite, or as a result of anthrax infection.

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7
Q

Evisceration

A

Uncontrolled exteriorization of intraabdominal contents through the dehisced surgical wound outside of the abdominal cavity.

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8
Q

Exudate

A

a mass of cells and fluid that hasseepedout of blood vessels or an organ, especially ininflammation.

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9
Q

Fistula

A

an abnormal or surgically made passage between a hollow or tubular organ and the body surface, or between two hollow or tubular organs

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10
Q

Granulation tissue

A

New connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process.

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11
Q

solid swelling of clotted blood within the tissues.

A

Hematoma

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12
Q

an inadequate blood supply to an organ or part of the body, especially the heart muscles.

A

Ischemia

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13
Q

Maceration

A

Process of skin softening and breaking down as a result of prolonged exposure to foreign fluids.

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14
Q

optimization of wound healing through the application of sub-atmospheric pressure to help reduce inflammatory exudate and promote granulation tissue

A

Negative Pressure Wound Therapy
(NPWT)

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15
Q

thick, foul smelling white, yellow, or green discharge indicating an unhealthy wound or infection

A

Purulent drainage (exudate)

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16
Q

Serosanguineous

A

Discharge that contains both blood and a clear yellow liquid known as blood serum

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17
Q

serous fluid

A

Any of various body fluids resembling serum, that are typically pale yellow or transparent and of a benign nature

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18
Q

n action or stress resulting from applied forces which causes or tends to cause two contiguous internal parts of the body to deform in the transverse plane

A

Shear

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19
Q

Serous Drainage

A

Clear & Watery

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20
Q

Fistulas are formed from…

A

Abcesses

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21
Q

Liquefied dead tissue

A

Slough

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22
Q

Undermining

A

Bigger area of tissue damage than can be seen. (Exteneds under the edge)

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23
Q

Drain catagories

Open
No collection device
Empties into absorptive dressing.
Passively drains
Moving from area of greater pressure

A

Penrose drain

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24
Q

Drain catagories

Closed
Suction Device
Negative Pressure
Prevents Microorganisms from Entering

A

Jackson-Pratt / Hemovac Drain

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25
Q

Kerflex vs regular gauze

A

Kerflex is more absorbent

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26
Q

Jackson Prat (JP) drain vs hemovac

A

Both closed systems

Hemovac can hold more blood

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27
Q

Types of wound dressings

A

Telfa, Gauze, Retentive Dressings

28
Q

The _________ is designed for the treatment of lightly draining wounds. They are made of a highly absorbent cotton fabric but are coated on both sides with a film that prevents the dressing from sticking to the wound when it is placed over the opening.

A

Telfa Non Adherent Dressing

29
Q

What are the disadvantages of transparent dressing?

A

Do not absorb blood or exudate well.

If used on deep or infected wounds, healing may take longer, or infection may spread.

Not sterile and are only suitable for one-time use.

30
Q

Hydrocolloid dressings

Use

Non-uses

A

Use: abrasions, postoperative wounds, pressure and venous ulcers, burn wounds, and donor sites.

Non-use: wounds that have limited drainage or in wounds with copious amounts of drainage

31
Q

Hydrogel Dressing

Use

Non-use

A

Use: Dry to mildly exudating and can be used to degrade slough on the wound surface

Non-use: wounds that are infected or require drainage.

32
Q

Alginate Dressing

Use

Non-use

A

Use: treatment of exuding wounds. In addition to antibacterial activity, alginate takes up wound exudates, through creation of a gel surface that absorbs moisture and maintains a moist environment

Non-use: dry or mildly exuding wounds

33
Q

Transparent
Hydrocolloid
Hydrogen
Alginate

Are this type of dressing

A

Moisture-Retentive

34
Q

Bathe client everyday for good skin care

True or False

A

False

Bathing everyday can Breakdown skin

35
Q

How often to turn a client to prevent pressure ulcers

A

2 hrs

36
Q

Type of dressing “turn” used on ankle and around joints

A

Figure of eight

37
Q

A circular turn is primarily used to

A

Anchor a bandage

38
Q

A recurrent bandage is used for..

A

Fingers, head, and residual Limb after amputation

39
Q

Pressure ulcer

Intact skin with a localized nonblanchable redness, usually over Bony prominence

A

Stage 1

40
Q

Pressure Ulcer

Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed.

A

Stage 2

41
Q

Pressure ulcer

Full-thickness loss without bone, tendon, muscle exposure

A

Stage 3

42
Q

Pressure ulcer

Full thickness loss with exposed bone, tendon, and muscle

A

Stage 4

43
Q

Separation of skin and tissue in which the edges are torn and irregular

A

Laceration

44
Q

Clean separation of skin and tissue with a smooth, even edge

A

Incision

45
Q

Wound in which the surface layers of skin are scrapped away

A

Abrasion

46
Q

Shallow crater in which skin or mucous membrane is missing

A

Ulceration

47
Q

Which type of dressing is used over a IV catheter site

A

Transparent film

Allows for visualizar

48
Q

Best used for partial - full thickness wounds, burns, dry wounds, min exudate, necrotic wounds, infected wounds

A

Hydrogel sheets

49
Q

Best used in wounds with light to moderate drainage

A

Hydrocolloid

50
Q

Being pulled up in bed rather than lifted puts clients at risk for Decubitus Ulcer.

What factor is responsible for this risk

A

Shearing force

51
Q

Onset, peak, & duration of insulin

Short

Aspart (Novolog)
Glulisine (Apidra)
Lispro (Humalog)

A

Onset 5 - 15 min
Peak 1 - 2 to 3 hrs
Duration 3 - 5 hrs ish

52
Q

Regular insulin (fast-acting)

Humulin R
Novolin R

Onset, Peak, Duration

A

Onset: 0.5 - 1 hr
Peak 2 - 4 hrs
Duration: 6 - 8 hrs

53
Q

Intermediate-Acting Insulin

NHP Insulin
Humulin N
Novolin N

Onset, peak, & duration of insulin

A

Onset: 1 - 2 hrs
Peak: 6 -12 hrs
Duration: 12 - 18 hrs

54
Q

Long-Acting Insulin

determir (Levemir)
glargine (Lantus)

Onset, peak, & duration of insulin

A

Onset: 1 - 2 hr
Peak: 6 - 8 (possibly no peak)
Duration: 14 - 24

55
Q

Insulin syringes are orange capped

They are measured in Units

What is the mL equivalent to the following needle sizes

30 units
50 units
100 units

A

30 units = 0.3 mL
50 units = 0.5 mL
100 units = 1 mL

56
Q

How is insulin administrated

A

Subcutaneous
45 ° thin person
90° obese person

57
Q

Neutral Protamine Hagedorn insulin, also known as isophane insulin, is an _______ acting insulin

A

Immediate

58
Q

Insulin that controls blood glucose between meals is known as

A

Basal insulin

59
Q

Insulin that controls blood glucose when someone eats is referred to as…

A

Bolus or mealtime insulin

60
Q

Immediate/ long acting insulins are (basal / bolus)

A

Basal

61
Q

Rapid / fast acting insulins are ( basal / bolus)

A

Bolus

62
Q

Which types of insulin can be given IV & SubQ

A

Rapid / Fast acting

63
Q

What type of insulin should never be mixed

A

Long acting

Levemir / Lantus

64
Q

Ranger for hyperglycemia

Fasting / post meal

Give (Insulin or Glucogon) for hyperglycemia

A

Fasting >99
Post meal >140

Insulin

65
Q

Hypoglycemia value

Give (Insulin or Glucogon)

A

<60

Glucogon

66
Q

Continous subcutaneous insulin pump uses which kind of insulin

A

Rapid, fast acting

Nurs 1165 (10 decks)

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