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NURSING EXAM 3 > WOUND CARE > Flashcards

WOUND CARE Flashcards

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1
Q

medical clean asepsis/ clean technique

A

Reduce or prevent the spread of microorganisms

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2
Q

surgical asepsis/ sterile technique

A

Eliminate microorganisms

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3
Q

clean

A

Removal of all soil from an object or surface

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4
Q

disinfect and antiseptic

A

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

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5
Q

sterilization

A

Elimination of germs from inanimate objects

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6
Q

leukocytosis

A

high white blood cells. have infection or inflammation

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7
Q

neutropenia

A

decrease white blood cells. risk of infection/ disease

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8
Q

WBC range

A

4500-11000

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9
Q

identify wound

A

Surgical, Traumatic, Pressure, Burn, Other (dermatitis, vascular, arterial, etc.)

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10
Q

determine size of wound

A

Measure length (head to toe), width (left to right), depth (use cotton tip) cm
Note any tunneling, undermining

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11
Q

wound cleaning

A

If ordered, follow orders
If not ordered, you may use a commercially available wound cleanser, an isotonic solution such as 0.9% Sodium Chloride (Normal Saline) to clean the wound
Generally clean from areas of least contamination to areas of greater contamination
- Use a new swab or cloth for each stroke
remember to dry peri-wound skin

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12
Q

incision cleaning

A

clean down the incision line then moving away from the incision

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13
Q

open wound cleaning

A

clean from the center of the wound outward in circles

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14
Q

purpose of irrigation

A

To clean the area and promote healing
To instill antiseptic solution or medication
To remove excess drainage or other materials

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15
Q

isotonic solutions

A

No antibacterial action **
Removes exudates
Moisturizes wound surfaces
Commonly used to cleanse wounds
- ex. Sterile normal saline or Lactated ringers

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16
Q

chlorhexidine gluconate

A

Skin antiseptic
Kills bacteria, spores, viruses, fungi
- Toxic to granulation tissue. **
Used preoperatively, before invasive procedures and sometimes daily
Can be used as a weaker concentration to irrigate wounds
Other names: CHG, hibiclens, chloraprep

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17
Q

hydrogen peroxide

A

Used for mechanical debridement of open wounds
Causes too much trauma with effervescent action for deep tunneling wounds
Removes blood clots → but we do want the blood to clot so it can heal
No sustained antiseptic action
Not used in full strength
Half strength is half specimen cup of sterile water and the other half hydrogen peroxide

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18
Q

is wound irrigation clean or sterile procedure

A

Sterile procedure

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19
Q

simple dressing

A

dry sterile dressing DSD

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20
Q

complex/ deep dressing

A

Packing
Wet to dry
Damp to dry
Dry
Negative pressure/ vacuum

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21
Q

simple dressing do what

A

Wound with little 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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22
Q

wounds that are dry are typically packed…

A

with wet or moist gauze

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23
Q

wounds that are draining will usually be packed…

A

packed with dry gauze

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24
Q

wounds with slough will be…

A

mechanically debrided with gauze that is placed in the wound wet, and left in place until it is dry. As it is removed, some non-viable tissue will come out with the gauze

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25
Q

negative pressure or vacuum dressings

A

Requires an order and special equipment (often rented)
Assists in wound closure by applying negative pressure to draw the edge of the wound together
- Accelerates healing
- Reduces edema
- Improves circulation
- Reduces bacterial counts in the wound

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26
Q

wound vacuum

A

Clear tape will go over the wound and a tube will go inside the tape/wound and will provide negative pressure and it will pull and collapse the foam into the wound.
Helpful for pt. With complex wounds

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27
Q

pressure dressing

A

Used for temporary control of the excessive bleeding following
Trauma
Surgery
Puncture
may stop bleeding
may be combined with sandbag use

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28
Q

intentional dressing

A

sandbags on the groin after cardiac catheterization to ensure a hematoma does not form

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29
Q

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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30
Q

gauze pads

A

2 x 2’s, 4 x 4’s, gauze squares
Can be used sterile or clean
Gauze is a primary dressing
- Used on top of the wound
Special types: Iodoform, Vaseline, Xeroform, Nuguaze

31
Q

fluffed or rolled gauze

A

May be referred to as: Kerlex, Fluff, Bulkee
Large or long pieces of loosely woven gauze
Can be layered or folded to absorb drainage
Used for packing wounds or wrapping extremities

32
Q

ABD pads

A

Sometimes referred to as Combine Pads or Combination Pads
Large, absorbent pads
Generally used as a secondary dressing (over another dressing)

33
Q

hydrocolloid dressings

A

Brand name: Duoderm
Soft wafer that can be cut to fit
Absorbs small amounts of drainage
Provides protection for autolytic debridement of small wounds
- Keeps wound, warm moist and allows to heal on own
Can be used to protect the skin from tape
Can be used to prevent or treat Stage I & II pressure injuries
Maintains an adequate moist environment for healing clean, shallow wounds
Can remain in place for 5 -7 days if kept clean and dry

34
Q

non-adherent dressings

A

The brand name is Telfa (and Band-aide!)
Used directly on the wound bed or incision to prevent injury to granulation tissue when dressings are removed
May be impregnated with petroleum or antimicrobial ointment

35
Q

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 the adhesive side is applied to the skin

36
Q

skin protectants/ barriers protect skin from…

A

Drainage
Urine
Stool
Tape

37
Q

tape

A

Various widths
Variety of materials
- Paper
- Silk
- Plastic
- Adhesive
Steri-strips: Used to approximate incisions of lacerations not requiring stitches

38
Q

drains

A

Promotes wound healing
Enhance the flow of drainage out of the wound

39
Q

hemovac

A

Spring activated self suction → pulls fluid out of body
Empty every 4-8 hours

40
Q

Jackson-pratt JP drain

A

Bulb activated self suction

41
Q

penrose

A

Passive drainage only, no collection device
Like a tourniquet so the driangae can passively have blood drip into the gauze. Bobby pins keep it from going back inside the body.

42
Q

stage 1 sanguineous

A

bloody , thick drainage, not transparent
Interventions:
Relieve pressure, protective dressing, hygiene, moisturizing the skin, nutrition of pt.

43
Q

stage 2: sero-sanguineous

A

Blood and serum, red-pink, thinner than sanguineous, thicker than serous
Interventions:
Apply silicone dressing to help create the auto lytic debridement. , offloading devices (wedges, heel pads), nutrition, educate Notify the provider because it has become a never event.

44
Q

stage 3: serous

A

Serum from the body, pale yellow, watery, fluid blister-like
Interventions:
- Need expert opinion on how to handle wound. Speciality surface (therapeutic bed to reduce pressure all over bed) nutrition physician, educate pt. Will need packing and dressing changes several times throughout the day.

45
Q

stage 4: purulent

A

Pus, pale yellow to green, white blood cells, infection
Interventions:
Graph to heal, huge nutritional demand to regrow tissue. Extensive dressing changes and the most available intensive pressure relieving services.

46
Q

burns: first degree

A

Least severe
Reddened area (sunburn)

47
Q

burns: stage 2

A

Blisters form/ painful
Moderate to deep partial thickness
Involves epidermis and portions of the dermis

48
Q

buns: stage 3

A

No pain
Skin is charred or non-existent
Severe fluid loss, nerve destruction
Full thickness
- Destruction of epidermis and demis
- Requires debridement and grafting

49
Q

burns: 4th degree

A

Deep brun necrosis
Extensive damage involving fascia, muscles or bone

50
Q

nutrition for healing

A

Vitamins A & C, Minerals
Protein
Calories
Adequate hydration

51
Q

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, Kling) or Ace wrap

52
Q

assessment before applying the wrap

A

Inspect the skin
- Abrasions, edema, discoloration, or exposed wound edges
Cover exposed wounds or open abrasions with a sterile dressing
- Assess the condition of underlying dressings and changing if soiled
Assessing the 5 “P’s”
- Neurovascular assessment
- Circulation, Movement, Sensation (CMS) assessment

53
Q

the 5 P’s

A

Assess the extremity distal to the bandage for:
1. Pallor: paleness
2. Paresthesia: numbness or tingling
3. Pain: nerve function
4. Pulselessness: circulatory function
5. Paralysis: motor and nerve function
Assess before and after applying bandage

54
Q

implementation of wraps

A

Wraps need not be sterile
Wrap tight enough to hold without constricting blood flow
Apply wrap distal to proximal
- Facilitates venous return → towards heart**
Avoid bandaging over wrinkled dressing to prevent pressure
Avoid bandaging over soiled dressings
Prolonged heat & moisture on skin may cause epithelial cells to deteriorate
- Avoid unnecessarily thick bandages

55
Q

slings and braces

A

Fasten slings off-center, behind the neck to avoid rubbing on the cervical vertebra
- Distal extremity should be elevated to prevent edema
Place & support the body part to be bandaged in normal functioning position
- Prevents deformities and discomfort and enhances circulation
Place pins or knots well away from wound, tender areas, or pressure points
Frequently assess skin where there is contact with the brace for irritation or damage from friction

56
Q

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

57
Q

application of cold

A

Causes vasoconstriction
Used in early wound management
- Reduces hemorrhage
- Reduces edema
- Reduces muscle spasm
- Reduces pain
Alternate ½ hr cold, then ½ hr warm to reduce swelling, pain, increase perfusion.
Apply for 30 mins, let the blood rebound and apply an hour or so later.

57
Q

indications for cold application

A

Trauma
- Puncture wounds
- Sprains
- Sports injuries
- Fractures
- Lacerations
- Muscle strains
Arthritis: apply after activity to reduce hematoma or edema from occurring

58
Q

application of heat

A

Causes vasodilation/dilates peripheral blood vessels to dissipate heat.
- Promotes healing by increasing oxygen, nutrients & leukocytes to tissue
- 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

59
Q

indications for heat

A

Arthritis: apply before activity to get circulation following
Muscle spasms
Cramps
Low back pain
Surgical wounds
Hemorrhoids
Episiotomies
Phlebitis
IV Infiltration

60
Q

safe use of cold or heat

A

Age of the patient/Sensory deficits
Level of consciousness
Circulatory impairment
Skin integrity
Patient diagnosis
Degree of heat and cold applied
Amount of body surface covered by the application

61
Q

clean or sterile irrigation?

A

if in doubt, sterile is always acceptable

62
Q

ear irrigation purpose

A

To remove objects (cerumen) or foreign bodies; or to instill medication. Do not irrigate if there is a suspected perforated membrane

63
Q

is ear irrigation clean or sterile

A

clean because we are touching the outside and the ear drum protects

64
Q

how do you position the pt. with ear irrigation

A

sitting or laying down

65
Q

cold or warm solution for ear irrigation

A

Warm the solution to body temperature

66
Q

straighten the ear canal

A

Adult: pull pinna up and back
Child: pull pinna down and back

67
Q

STOP irrigation if…

A

the patient reports severe pain or dizziness

68
Q

eye irrigation purpose

A

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

69
Q

is eye irrigation sterile or clean?

A

sterile procedure

70
Q

how do you position pt. during eye irrigation

A

Supine or
With head turned with the eye to be irrigated down

71
Q

where do you introduce the sterile irrigation fluid in the eye?

A

Introduce sterile irrigation fluid into lower conjunctival sac at inner canthus
Solution and syringe tip remain sterile

72
Q

evaluation

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 EXAM 3 (6 decks)

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