Week 6: Wound Care Flashcards
a swollen area within body tissue, containing an accumulation of pus.
Abcess
Biofilm
thin, slimy film of bacteria that adheres to a surface.
Dehiscence
thesplittingorburstingopen of apodor wound.
the removal of moisture from something.
Desiccation
superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries.
Erythema
Eschar
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.
Evisceration
Uncontrolled exteriorization of intraabdominal contents through the dehisced surgical wound outside of the abdominal cavity.
Exudate
a mass of cells and fluid that hasseepedout of blood vessels or an organ, especially ininflammation.
Fistula
an abnormal or surgically made passage between a hollow or tubular organ and the body surface, or between two hollow or tubular organs
Granulation tissue
New connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process.
solid swelling of clotted blood within the tissues.
Hematoma
an inadequate blood supply to an organ or part of the body, especially the heart muscles.
Ischemia
Maceration
Process of skin softening and breaking down as a result of prolonged exposure to foreign fluids.
optimization of wound healing through the application of sub-atmospheric pressure to help reduce inflammatory exudate and promote granulation tissue
Negative Pressure Wound Therapy
(NPWT)
thick, foul smelling white, yellow, or green discharge indicating an unhealthy wound or infection
Purulent drainage (exudate)
Serosanguineous
Discharge that contains both blood and a clear yellow liquid known as blood serum
serous fluid
Any of various body fluids resembling serum, that are typically pale yellow or transparent and of a benign nature
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
Shear
Serous Drainage
Clear & Watery
Fistulas are formed from…
Abcesses
Liquefied dead tissue
Slough
Undermining
Bigger area of tissue damage than can be seen. (Exteneds under the edge)
Drain catagories
Open
No collection device
Empties into absorptive dressing.
Passively drains
Moving from area of greater pressure
Penrose drain
Drain catagories
Closed
Suction Device
Negative Pressure
Prevents Microorganisms from Entering
Jackson-Pratt / Hemovac Drain
Kerflex vs regular gauze
Kerflex is more absorbent
Jackson Prat (JP) drain vs hemovac
Both closed systems
Hemovac can hold more blood
Types of wound dressings
Telfa, Gauze, Retentive Dressings
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.
Telfa Non Adherent Dressing
What are the disadvantages of transparent dressing?
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.
Hydrocolloid dressings
Use
Non-uses
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
Hydrogel Dressing
Use
Non-use
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.
Alginate Dressing
Use
Non-use
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
Transparent
Hydrocolloid
Hydrogen
Alginate
Are this type of dressing
Moisture-Retentive
Bathe client everyday for good skin care
True or False
False
Bathing everyday can Breakdown skin
How often to turn a client to prevent pressure ulcers
2 hrs
Type of dressing “turn” used on ankle and around joints
Figure of eight
A circular turn is primarily used to
Anchor a bandage
A recurrent bandage is used for..
Fingers, head, and residual Limb after amputation
Pressure ulcer
Intact skin with a localized nonblanchable redness, usually over Bony prominence
Stage 1
Pressure Ulcer
Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed.
Stage 2
Pressure ulcer
Full-thickness loss without bone, tendon, muscle exposure
Stage 3
Pressure ulcer
Full thickness loss with exposed bone, tendon, and muscle
Stage 4
Separation of skin and tissue in which the edges are torn and irregular
Laceration
Clean separation of skin and tissue with a smooth, even edge
Incision
Wound in which the surface layers of skin are scrapped away
Abrasion
Shallow crater in which skin or mucous membrane is missing
Ulceration
Which type of dressing is used over a IV catheter site
Transparent film
Allows for visualizar
Best used for partial - full thickness wounds, burns, dry wounds, min exudate, necrotic wounds, infected wounds
Hydrogel sheets
Best used in wounds with light to moderate drainage
Hydrocolloid
Being pulled up in bed rather than lifted puts clients at risk for Decubitus Ulcer.
What factor is responsible for this risk
Shearing force
Onset, peak, & duration of insulin
Short
Aspart (Novolog)
Glulisine (Apidra)
Lispro (Humalog)
Onset 5 - 15 min
Peak 1 - 2 to 3 hrs
Duration 3 - 5 hrs ish
Regular insulin (fast-acting)
Humulin R
Novolin R
Onset, Peak, Duration
Onset: 0.5 - 1 hr
Peak 2 - 4 hrs
Duration: 6 - 8 hrs
Intermediate-Acting Insulin
NHP Insulin
Humulin N
Novolin N
Onset, peak, & duration of insulin
Onset: 1 - 2 hrs
Peak: 6 -12 hrs
Duration: 12 - 18 hrs
Long-Acting Insulin
determir (Levemir)
glargine (Lantus)
Onset, peak, & duration of insulin
Onset: 1 - 2 hr
Peak: 6 - 8 (possibly no peak)
Duration: 14 - 24
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
30 units = 0.3 mL
50 units = 0.5 mL
100 units = 1 mL
How is insulin administrated
Subcutaneous
45 ° thin person
90° obese person
Neutral Protamine Hagedorn insulin, also known as isophane insulin, is an _______ acting insulin
Immediate
Insulin that controls blood glucose between meals is known as
Basal insulin
Insulin that controls blood glucose when someone eats is referred to as…
Bolus or mealtime insulin
Immediate/ long acting insulins are (basal / bolus)
Basal
Rapid / fast acting insulins are ( basal / bolus)
Bolus
Which types of insulin can be given IV & SubQ
Rapid / Fast acting
What type of insulin should never be mixed
Long acting
Levemir / Lantus
Ranger for hyperglycemia
Fasting / post meal
Give (Insulin or Glucogon) for hyperglycemia
Fasting >99
Post meal >140
Insulin
Hypoglycemia value
Give (Insulin or Glucogon)
<60
Glucogon
Continous subcutaneous insulin pump uses which kind of insulin
Rapid, fast acting
