Would Care, Sterile Technique, Ostomy Care, & Foley Catheters Flashcards
Incision
made from a sharp instrument
Contusion
blow from an object; BRUISE
Abrasion
surface scrape
Puncture
penetration of skin and underlying tissues by a sharp object
can’t see bacteria inside
PIN/NAIL/ ETC
Laceration
tissues torn apart
Penetrating
penetration of skin and underlying tissues (bullet or metal fragments)
can’t see extensive injuries from outside
Pressure Ulcers
redness, sores or ulcers over a bony prominence
Wound Assessment: Appearance
signs of healing or infection
foreign bodies
Wound Assessment: Drainage
location, color, consistency, odor, amt
serous (thin, clear)
serosanguineous (thin, watery, pale red or pink)
purulent (thin/thick, opaque tan, yellow, or green)
Wound Assessment: Other
size (measure w/ disposable ruler)
depth and tunneling
edema
peri area
pain
drains and tubes in place and functioning
Dressings should be inspected regularly to ensure they are:
clean, dry, intact
Dressing Changes
sterile vs. clean technique
prevent growth of microorganisms
Post Op Considerations for Dressing Changes
surgeon may want to change first dressing
if excess drainage, contact HCP
Type of dressing is determined by:
location, size, and type of wound
Closed wounds
post op or laceration
dry dressing
Open wounds
no dry packing (bc will stick to healed tissue)
moist dressing (wet to dry)
Telfa Dressing
slick/shiny surface that is absorbent
non-adherent
have to put outside dressing to cover it
pulls drainage away from wound
Island Dressing
telfa with an adhesive border, eliminates need for an outer dressing
Surgipads or Abdominal (ABD) Pads
very absorbent; often used over additional dressings (outside)
blue stripe faces outward
Transparent Film (Tegaderm)
semipermeable, nonabsorbent
used to cover IV sites
can see site
Impregnated Nonadherent (Vaseline Gauze)
material is impregnated with petroleum jelly (vaseline gauze) or other agents
covers partial and full-thickness wounds without drainage
requires an outer dressing
Hydrocolloids (DuoDerm)
waterproof adhesive wafer
gelatinous/rubbery
absorbs drainage and forms an occlusive seal
can stay on up to 7 days
used for pressure ulcers
Alginate (Algiderm, Curasorb)
nonadherent dressing available in many forms
very absorbent (up to 20x their wt)
made from seaweed
all previous alginate must be removed prior to adding new
need something on top of it
VAC means
vacuum assisted closure
Wound VAC Purpose
applies a negative pressure to a variety of wounds using suction equipment
pulls fluid from the wound and helps wound edges pull together
provides a moist protected environment for wound healing
Wound VAC Use
sterile pieces of foam and vacuum tubing are inserted into wound and covered with transparent, occlusive dressing to create an artificial seal
very important the seal is maintained (maintains the negative pressure)
Drains Use
permit drainage of excessive serosanguineous fluid/purulent material
promote healing of underlying tissue