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Medical Surgical Nursing - First Sem > Wound Care > Flashcards

Wound Care Flashcards

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1
Q

Identify the 6 types of wounds and match them to their description

A. Surgical cut
B. Tearing of the soft tissue
C. From a pointed object
D. Body structure is torn off due to trauma and surgery
E. Removal of body part due to trauma, surgery, or medical condition
F. Gasgas due to rubbing

A 
Laceration
Amputation
Avulsion
Abrasion
Puncture
Incision
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2
Q

Identify the 4 characteristics of

Primary intention wound healing:

Secondary intention wound healing:

A

Primary intention wound healing: clean, uninfected, linear margin, scanty granulation

Secondary intention wound healing: unclean, infected, irregular margin, exuberant granulation

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3
Q

Match the wound healing phase to its description

  1. Vascular Activity
  2. Cellular Activity
A. No remodeling
B. Angiogenesis
C. Phagocytosis
D. GF release
E. Constriction
F. Dilation
G. Epithelialization
H. Collagen formation
A

1: E, F, B, A
2: D, C, G, H

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4
Q

What are the 3 factors that affect the etiology of a wound?

A

Wound bed: TEI
Wound edge: MDUR
Periwound skin: MEDHCE

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5
Q

What are the 3 things that should be assessed in the wound bed?

A

Tissue type: necrotic, sloughy, etc

Exudate: level, type, color, odor

Infection: local or systemic

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6
Q

Differentiate local and systemic infection

A

Local: pain, edema, bleeding, delayed healing

Spreading/systemic: fever, pus, increased WBC count, body malaise

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7
Q

Why should we remove non-viable tissue?

A

Reduce risk for infection and promote new tissue growth

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8
Q

Match the ff criteria in assessing the wound edge to its description:

  1. Maceration
  2. Dehydration
  3. Undermining
  4. Remodeling

A. Collagen creates new blood vessels
B. Use clock positions to record extent, refer to specialist
C. Assess moisture level, establish cause, refer to specialist

A

1C
2C
3B
4A

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9
Q

What is the difference between maceration and dehydration?

A

Maceration: excess fluid = soft soggy and light skin

Dehydration: lack fluid = dry cracked skin

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10
Q

What should we do with a bloody wound? (3)

A

Record color, consistency

Dry to prevent spread/contamination

Compression therapy

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11
Q

What is an exception to management of moisture balance?

A

Dry gangrene

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12
Q

“weeping wounds” mean?

A

Has a lot of exudates with malodor

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13
Q

Match the ff criteria in assessing the periwound skin to its description:

  1. Maceration
  2. Excoriation
  3. Dry skin
  4. Hyperkeratosis
  5. Callus
  6. Eczema

A. Establish cause and correct via rehydration or minimizing moisture
B. Avoid allergens
C. Remove skin plaques and rehydrate
D. Remove and offload to prevent occurrence since it is deeper

A 
1A
2A
3A
4C
5D
6B
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14
Q

Where is the periwound area located?

A

1-4 cm of the wound edge

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15
Q

Pressure ulcers are aka?

A

Bedsores or decubitus ulcer

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16
Q

What are the causes of pressure ulcers?

A

Prolonged pressure
Shearing and friction
Medical conditions

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17
Q

What medical conditions predispose a client to developing pressure ulcers?

A

Bedridden/critically ill = cannot move

Diabetes mellitus = slow blood flow leads to impaired skin integrity and higher risk for infection

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18
Q

Place in order the description of the stages of pressure ulcers

A. Partial thickness with skin loss, exposed dermis
B. Full thickness tissue loss, may reach bones
C. Non-blanchable erythema/redness, intact skin
D. Full thickness skin loss

A

C
A
D
B

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19
Q

Identify the 5 clinical manifestations of pressure ulcers

A 
Warm, tender to touch
Damaged tissue
Local pain
Protective behavior
Edema
20
Q

Identify at least 3 related factors to developing pressure ulcers

A 
Alteration in fluid volume
Alteration in sensation
Immunodeficiency
Impaired circulation
Impaired nutrition
Pressure over bony prominence
21
Q

What is the management for pressure ulcers? (4, RNDC)

A

Reposition: to sides

Nutrition: high protein for healing

Positioning devices: protective positioning = less pressure

Pressure ulcer care: hypoallergenic soap and water

22
Q

(T/F) We can use hydrogen peroxide or iodine for pressure ulcer care

A

FALSE, can irritate skin

23
Q

Why do we need to dress wounds?

A

To keep certain moisture

24
Q

Classify the ff types of wound dressing

  1. Foams
  2. Collagenase
  3. Gauze
  4. Monofilament fiber
  5. Alginates
  6. Hydrogel and hydrocolloids

A. Non-selective/mechanical
B. Debridement continuum/autolytic
C. Selective/enzymatic

A 
1B
2C
3A
4A
5B
6B
25
Q

Provide a sample nursing diagnosis

A

Impaired skin integrity related to impaired mobility, circulation, and sensation

26
Q

When removing OLD dressings, we wear ___ gloves

A

CLEAN

27
Q

How should we remove the dressing layers?

A

Layer by layer

28
Q

(T/F) All wound dressing changes are done by nurses

A

FALSE, the first is usually done by the surgeon

29
Q

What motion should we follow when cleaning the wound?

A

Inner to outer

Wound itself is the least contaminated

30
Q

What should be included in the label on the dressing?

A

Time
Date
Initials of nurse

31
Q

It is the most common type of dressing – a transparent film that allows us to observe the wound properly

A

TEGADERM

32
Q

(T/F) Tegaderm can be wet

A

TRUE

33
Q

What should be included in the FDAR for wound care?

A

F: Nursing diagnosis

D: Related factors, subjective and objective

A: Nursing interventions (dressing used, positioning, monitoring)

R: Client’s response (tolerance, appetite, wound healing progression)

34
Q

(T/F) Wound drainage may be seen in patients who underwent surgery such as emergency appendectomy.

A

TRUE

35
Q

Match the type of wound drainage to its description

  1. Hemovac
  2. Jackson Pratt
  3. Penrose Drain

A. Sutured in the px, gauze is placed over it
B. Drain is placed inside wound, is held by sterile safety pin and sutures
C. Applies negative pressure = suction, need a calibrated glass to measure accurately

A

1C
2A
3B

36
Q

This is used during the process of wound healing especially those from abdominal surgeries

A

Binder as reinforcement

37
Q

How is wet-to-dry dressing done? Why is it done?

A

Pack pressure ulcer or deep wound with sterile gauze WET with NSS

Cover with DRY dressing (gauze or hydrocolloid)

Matter will stick to the sterile gauze = clean/debridement

38
Q

Involves introducing the cleaning solution directly into the wound with a syringe,
catheter, or a handheld shower.

A

Wound irrigation

39
Q

Why is wound irrigation done?

A

Debridement for open surgical wounds or chronic wounds

40
Q

How are they treated (method)?

Surgical wound:
Infected wound:

A

Surgical wound: aseptic method

Infected wound: clean method

41
Q

Weak solution: (example, how it is poured)

Strong solution: (example, how it is poured)

A

Weak solution: PNSS, kidney basin first before bowl

Strong solution: betadine, straight to bowl

42
Q

One cotton ball per ____

A

stroke

43
Q

In applying antiseptic spray

Non dominant:
Dominant:

A

Non dominant: spray

Dominant: handle sterile equipment

44
Q

When should the analgesic be administered?

A

30 minutes before wound care

45
Q

We should ask if the px has any allergies to?

A

Antiseptics and latex/gloves

46
Q

What should we observe for? (7, APREBDO)

A 
Appearance of wound
Pain
Redness
Edema
Bleeding
Drainage
Odor
47
Q

Common wound dressing categories

  1. Hydrogel
  2. Alginate
  3. Foams
  4. Gauze
  5. Hydrocolloids

A. Maintain moisture
B. Provide moisture
C. Absorb
D. Protect

A 
1B
2C
3C
4D
5A

Medical Surgical Nursing - First Sem (9 decks)

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