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wound care Flashcards

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1
Q

basic terminology

medical asepsis/clean technique

A

reduce or prevent the spread of microorganisms

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2
Q

basic terminology

surgical asepsis/sterile technique

A

eliminate all microorganisms

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3
Q

basic terminology

clean

A

removal of all soil from an object or surface

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4
Q

basic terminology

disinfect and antiseptic

A

elimination of many germs from inanimate objects (disinfect) or living surfaces (antiseptic)

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5
Q

basic terminology

sterilization

A

elimination of germs from inanimate objects

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6
Q

basic terminology

leukocytosis

A
  • increased WBC
  • > 11000
  • likely fighting infection
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7
Q

neutropenia

A
  • decreased WBCs
  • increased risk for infection
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8
Q

basic terminology

normal range for WBC

A

4500-11000

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9
Q

describe wound assessment

A

-identify type of wound (surgical, traumatic, pressure, burn, other)
-identify location using anatomical location or bony prominence
-remove dressing and examine wound (visual and olfactory assessment)
-observe for drainage, signs of infection, signs of healing
-determine size of wound, especially important for pressure ulcers (measure length (head to toe), width (left to right), depth); note any tunneling, undermining
-observe the wound edges and surrounding skin

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10
Q

what is the basic dressing change procedure

A

-check order
-medicate and position PRN
-gather supplies
-move garbage can close to bed
-wash hands
-don clean gloves
-remove old dressing
-assess wound
-doff used gloves
-wash hands
-open all supplies
-don gloves (sterile or clean)
-cleanse wound
-dry surrounding skin
-dress wound
-date, time and initial dressing
-remove used gloves
-wash hands
-document

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11
Q

describe wound cleansing

A

-if ordered, follow orders
-if not ordered, you may use a sommerically available wound cleanser such as normal saline to clean the wound
-generally clean from areas of least contamination to areas of greater contamination (use new swab for each stroke)
-remember to dry peri-wound skin

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12
Q

how do you clean incisions

A

clean down the incision line then moving away from the incision

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13
Q

how do you clean open wounds

A

clean from the center of the wound outward in circles

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14
Q

what is the purpose of irrigation

A

-to clean the area and promote healing
-to instill sntiseptic solution or medication
-to remove excess drainage or other materials

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15
Q

what syringes are used for irrigation

A

-asepto or bulb syringe
-piston syringe
-catheter tip syringe
-bulb syringe aspirator

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16
Q

describe isotonic solutions

A

-no antibacterial action
-removes exudates
-moisturizes wound surfaces
-commonly used to cleanse wounds
-sterile normal saline (SNS)
-lactated ringers (LR)
-gentle on granulation tissue

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17
Q

describe chlorohexadine gluconate

A

-skin antiseptic (kills bacteria, spores, viruses, fungi)
-used preoperatively, before invasive procedures, and sometimes daily
-toxic to granulation tissue (nonselective debrider)
-can be used as a weaker concentration for wounds
-other names: CHG, hibiclens, chroraprep

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18
Q

describe hydrogen peroxide (H2O2)

A

-used for mechanical debridement of open wounds
-causes too much trauma with effervescent action for deep tunneling wounds
-removes blood clots
-no sustained antseptic actions
-not used at full strength

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19
Q

is irrigation a clean or sterile procedure?

A

sterile

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20
Q

how do you position the pt when irrigating a wound?

A

-position pt with wound exposed
-place waterproof pad under area to be irrigated

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21
Q

describe preparing supplies for irrigation

A

-open syringe container
-pour irrigating solution into sterile container
-open supplies needed for dressing change
-place collection basin distal to the wound to catch contaminated fluid

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22
Q

describe where to direct the solution when irrigating

A

-direct solution to all areas of the wound from superior to inferior edges
-allow gravity to drain fluid from superior to inferior edges
-keep tip of syringe at least 1 inch away from wound
-use consistent pressure

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23
Q

describe the wound irrigation procedure

A

-position pt with wound exposed
-don clean gloves, remove existing dressing, inspect wound
-doff gloves, perform hand hygiene
-prepare supplies
-perform hand hygiene, don sterile gloves, consider other PPE
-fill syringe with sterile solution
-direct solution to all areas of the wound from superior to inferior edges
-flush until all debris is cleared or until the ordered volume is instilled
-dry surrounding skin with sterile gauze
-apply sterile dressing

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24
Q

what are some different types of dressings

A

-simple (dry sterile dressing)
-complex/deep (packing, negative pressure/vacuum)
-pressure

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25
Q

describe simple dressings

A

-wound with luttle to no drainage
-protects wound from injury
-prevents introduction of bacteria
-reduces discomfort
-speeds healing
-used on abrasions, non draining post op incisions
-moisten with SNS to reduce trauma when removing dressing if it is adhered to the wound

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26
Q

describe complex or deep dressings

A

-long pieces of gauze or dressing materials are used to fill the wound bed
-keeps wound moist or helps absorb excess drainage
-packing is then covered by a DSD
-negative pressure or vacuum dressings

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27
Q

describe using long pieces of gauze or dressing materials to fill a wound bed

A

-open or unroll gauze
-fluff it loosely, but completely fill the wound bed

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28
Q

wounds that are dry will usually be packed with…

A

wet or moist gauze

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29
Q

wounds that are draining will usually be packed with…

A

dry gauze

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30
Q

describe putting and taking out gauze in a wound with slough

A

-wounds with slough will be mechanically debrided with gauze that is placed into the wound wet and left in plae until it is dry
-as it removed, some nonviable tissue will come out with the gauze

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31
Q

describe negative pressure or vacuum dressings

A

-requires an roder and special equipment (often rented)
-assists in wound closure by applying negative pressure to draw the edge of the wound together

-accerlerates healing
-reduces edema
-improves circulation
-reduces bacterial counts in the wound

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32
Q

describe a pressure dressing

A

-used for temporary control of excessive bleeding following trauma, surgery, puncture (intentional and unintentional)
-may stop bleeding
-may be combined with sandbag use

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33
Q

name some different dressing materials

A

-gauze
-ABD pads
-hydrocolloids/silicone dressings
-trannsparent films
-skin barriers
-tape
-cleansing solutions
-advanced dressing supplies

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34
Q

name some advanced dressing supplies

A

-hydrogels
-alignates
-collagens
-composites
-contact layers
-silver
-honey

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35
Q

what is the purpose of dressings

A

-protecting a wound from microorganism contamination
-aiding hemostasis
-promoting healing by absorbing drainage and debriding a wound
-supporting or splinting the wound site
-promoting thermal insulation of the wound surface
-providing a moist environment

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36
Q

describe gauze pads

A

-2x2s, 4x4s, gauze squares
-can be used sterile or clean
-gauze is primary dressing, used on top of wound
-special types: lodoform, vaseline, xeroform, nugauze

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37
Q

describe fluffed or rollled gauze

A

-may be referred to as: kerlex, fluff, bulkee
-large or long pieces of loosely woven gauze
-can be layerd or folded to absorb drainage
-used for packing wounds or wrapping extremities

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38
Q

describe ABD pads

A

-sometimes referred to as combine pads or combination pads
-large, absorbent pads
-generally used as a secondary dressing (over another dressing)

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39
Q

what is the brand name for hydrocolloid dressings

A

duoderm

40
Q

what is a hydrocolloid dressing and what does it do

A

-soft wafer that can be cut to fit
-absorbs small amounts of drainage
-provides protection for autolytic debridement of small wounds
-can be used to protect skin from tape
-can be used to treat stage 1 and 2 pressure injuries
-maintains adequate moist environment fo healing clean, shallow wounds

41
Q

how long can a hydrocolloid dressings remain in place when kept clean and dry

A

5-7 days

42
Q

describe nonadherant dressings

A

-brand name is telfa (and band aid)
-used directly on the ound bed or incision to prevent injury to granulation tissue when dressings are removed
-may be impregnated with petroleum or antimicrobial ointment

43
Q

describe transparent dressings

A

-brand names: opsite, tegaderm
-used to manage superficial wounds or provide skin protection
-allows visualization of wound or IV insertion site
-it is moisture and vapor permeable (allows gas to pass through dressing)
-leave top, supportive paper on the dressing until after adhesive side is applied to the skin

44
Q

what different forms may skin protectants/skin barriers come in

A

-solutions
-pastes
-powders
-wafers

45
Q

what are skin protectants/skin barriers used for

A

to protect skin from:
-drainage
-urine
-stool
-tape

46
Q

describe tape

A

-various widths
-variety of materials (paper, silk, plastic, adhesive)
-steri strips

47
Q

what are steri strips used for

A

used to approxiate incisions of lacerations not requiring stitches

48
Q

name some different drains

A

-hemovac
-jackson-pratt (JP)
-penrose

49
Q

what do drains do

A

-promotes wound healing
-enhance the flow of drainage out of the wound

50
Q

describe hemovac

A

-spring activated self suction
-empty every 4-8hrs

51
Q

describe JP drain

A

bulb activated self suction

52
Q

describe penrose drain

A

passive drainage only, no collection device

53
Q

name 4 drainage types

A

-sangioneous
-sero-sanguineous
-serous
-purulent

54
Q

describe sanguineous drainage

A

-bloody
-thick drainage
-not transparent

55
Q

describe sero-sanguineous drainage

A

-blood and serum
-red-pink
-thinner than sanguineous, thicker than serous

56
Q

describe serous drainage

A

-serum from the body
-pale yellow
-water
-fluid blister like

57
Q

describe purulent drainage

A

-pus
-pale yellow to green
-white blood cells
-infection

58
Q

what interventions would be used for stage 1 pressure injuries

A

-relieve pressure
-may apply protective dressing
-be vigilant of hygiene
-turn Q2hrs
-pay attention to nutrition
-educate

59
Q

what interventions would be used for stage 2 pressure injuries

A

basically the same as stage 1

60
Q

what interventions would be used for stage 3 pressure injuries

A

-need expert opinion -> usually infected and complicated
-therapeutic bed
-dietary consult
-extensive education
-most likely needs packed with gauze and require dressing changes several times a day

61
Q

what interventions would be used for stage 4 pressure injuries

A

-usualy require sharp debridement by a provider
-may require a graft
-huge nutritional demand and educational demand
-super duper frequent dressing changes and super duper pressure relieving surfaces

62
Q

describe unstageable pressure injuries

A

-full thickness tissue loss
-wound covered by slough or eschar
-must be debrided to remove slough or eschar before it can be staged

63
Q

describe 1st degree burns

A

-least severe
-reddened area (ex. sunburn)

64
Q

describe 2nd degree burns

A

-blisters form/painful
-moderate to deep partial thickness
-involves epidermis and portions of the dermis

65
Q

describe 3rd degree burns

A

-skin is charred or nonexistent
-no pain
-severe fluid loss, nerve destruction
-full thickness
-destruction of epidermis and dermis
-requires drebridement and grafting

66
Q

describe 4th degree burns

A

-deep burn necrosis
-extensive damage involving fascia, muscles, and/or bone

67
Q

describe nutrition for healing

A

-vitamins A and C, minerals
-protein
-calories
-adequate hydration

68
Q

what are some possible nursing diagnoses for wound care

A

-risk for infection
-pain
-impaired skin integrity
-impaired tissue integrity
-body image disturbance
-imbalanced nutrition (less than body requirement)
-risk for injury
-ineffective thermoregulation
-hyperhtermia
-hypothermia
-auditory sensory deficit

69
Q

what is the purpose of wraps

A

-creating pressure over a body part
-immobilizing a body part
-supporting a wound
-reducing or preventing edema
-securing a splint
-securing a dressing

usually rolled gauze (kerlix) or ace wrap

70
Q

describe assessment before applying a wrap

A

-inspect the skin (abrasions, discoloration, or exposed wound edges)
-cover exposed wounds or open abrasions with sterile dressing (assess condition of underlying dressings and changing if soiled)
-assessing the 5 Ps

71
Q

what are the five Ps

A

-assess the extremity distal to bandage for:
pallor
paresthesia (numbness/tingling)
pain
pulselessness
paralysis

-assess before and after applying bandage

72
Q

describe implementation of a wrap

A

-wrap does not need to be sterile
-wrap tight enogh to hold without constricting blood flow
-apply wrap distal to proximal (facilitates venous return)
-avoid bandaging over wrinkled dressing to prevent pressure
-avoid bandaging over soiled dressings
-prolonged heat and moisture on skin may cause epithelial cells to dteriorate (avoid unnecessarily thick bandages)

73
Q

describe slings and braces

A

-fasten slings off center, behind the neck to avoid rubbing on cervical vertebra (distal extremity should be elevated to prevent edema)
-place and support the body part to be bandaged in normal functioning position (prevents deformities and discomfort and enances circulation)
-places pins or knots well away from wound, tender areasm or pressure points
-frequently assess skin where there is contact with the brace for irritation or damage from friction

74
Q

describe binders

A

-used to support, immobilize, or splint
-used around the chest, abdomen, or pelvis
-used to hold a dressing in place
-generally made of cloth or elastic material

75
Q

true or false:
blood vessels in the skin dilate to dissipate heat

A

true

76
Q

what does application of cold do to the blood vessels

A

causes vasoconstriction

77
Q

what is the application of cold used for

A

used in early wound management
-reduces hemorrhage
-reduces edema
-reduces muscle spasm
-reduces pain

78
Q

describe application of cold

A

-alternated 1/2 hr cold then 1/2 hr warm to reduce swelling, pain, and increase perfusion

79
Q

what are some indications for cold application

A

-trauma (puncture wounds, sprains, sports injuries, fractures, lacerations, muscle strains)
-arthritis

80
Q

why is cold used 30mins at a time

A

to prevent trauma to the skin

81
Q

what does the application of heat do

A

-causes vasodilation/dilates peripheral blood vessels
-promotes healing by increasing O2, nutrients, and leikocytes to tissues
-eliminates toxic waste products that accumulate in swollen areas (can reduce swelling by increasing circulation
-relieves pain from muscle spasms or injured joints. reduces muscle tension/promotes muscle relaxation
-increases tissue metabolism

82
Q

what are some indications for application of heat

A

-arthritis
-muscle spasms
-cramps
-low back pain
-surgical wounds
-hemorrhoids
-episiotomies
-phlebitis
-IV infiltration

83
Q

what is important to consider for safe use of cold or heat

A

-age of pt/sensory deficits
-LOC
-circulatory impairment
-skin integrity
-patient diagnosis
-degree of heat and cold applied
-amount of body surface covered by the application

84
Q

when is sterile irrigation used

A

-eye
-urinary bladder
-wounds (both traumatic and surgical)

if in doubt, sterile is always acceptable

85
Q

when is clean irrigation used

A

-ear
-GI track (stomach and bowel)

86
Q

what is the purpose of ear irrigation

A

-to remove objects (cerumen) or foreign bodies
-instill med

87
Q

is ear irrigation clean or sterile

A

clean

88
Q

should you irrigate if there is a suspected perforated membrane (eardrum)

A

no

89
Q

what position should the pt be in for ear irrigation

A

sitting or laying down

90
Q

what temo should the solution be for ear irrigation

A

warm - body temp

91
Q

describe the ear irrigation procedure

A

-warm solution
-tilt head forward and away from the side to be irrigated
-straighten ear canal (up and back for adults and dwn and back for kids)
-direct tip of the syringe toward top of ear canal (use circular motion to aid in the evacuation of contents)
-STOP if pt reports severe pain or dizziness
-irrigate until canal is clean, or ordered volume is instilled

92
Q

what is the purpose of eye irrigation

A

to remove foreign bodies (sand, fiberglass, dirt), injurious fluids, or secretions (conjunctivitis)

93
Q

is eye irrigation clean or sterile

A

sterile

94
Q

describe pt position for eye irrigation

A

-supine
-or with head turned with the eye to be irrigated down

95
Q

describe the eye irrigation procedure

A

-place kidney basin beneath eye
-retract lower eyelid with gloved hand
-introduce sterile irrigation fluid into lower conjunctival sac at inner canthus
-slution and syringe tip remain sterile

96
Q

describe evaluation of wound care

A

-prevention of skin damage
-evidence of healing (epithelialization)
-absence of infection
-minimization of edema, pain, bleeding
-no compromise to circulation or nerve function
-reduction of pain
-removal of debris
-return of function

nursing 20030 (31 decks)

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