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201B Exam #3 > Wound Care > Flashcards

Wound Care Flashcards

1
Q

do nurses stage wounds?

A

no, b/c of financial implications for the hospital

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2
Q

what causes wounds (6)?

A
  1. pressure
  2. truma
  3. surgery
  4. burns
  5. infections (skin contaminated)
  6. arterial/venous insufficiency
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3
Q

wounds need to be protected from what three things?

A
  1. mechanical injury
  2. pressure
  3. microbial contamination
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4
Q

are wounds cared for using “sterile” or “clean” techniques?

A

it depends, we mostly see clean

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4
Q

what are the 6 objectives wound care is meant to do?

A
  1. protect
  2. enhance healing
  3. absorb drainage
  4. splint/immobilize
  5. prevent premature closure of infected wounds
  6. debride wound site
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5
Q

after surgery who changes the dressing on surgical incisions for the first time?

A

physicians, unless otherwise ordered

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6
Q

what is an example of a wound that requires clean technique?

A

decubitous (pressure injury)

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7
Q

what is an example of a wound that would use sterile technique?

A

a wound in the abdomen or chest

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8
Q

what is tunneling?

A

when a wound extends deeper than its surface creating tunnel or channel

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9
Q

what is undermining?

A

a wound complication where the edges of a wound separate from the healthy tissue around it, creating a pocket of dead space under the skin.

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10
Q

what are the 10 aspects of a wound that might need to be documented?

A
  1. location
  2. size/shape
  3. appearance/color
  4. approximation
  5. drainage
  6. odor
  7. undermining/tunneling
  8. suture/ staples
  9. dressing type
  10. drains
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11
Q

what is dehiscence?

A

separation of wound edges

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12
Q

what is evisceration?

A

abdominal contents protrude through wound opening

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13
Q

what are some wound complications that require immediate intervention?

A

dehiscence and evisceration

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14
Q

what are the three types of wound healing?

A

primary, secondary
and tertiary

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15
Q

what is secondary wound healing?

A

will not be closed by sutures, heals from the inside out
-wound gaping and irregular
-granulation occurs over time
-epithelium fills in scar (bigger)

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15
Q

what is primary wound healing?

A

-clean wound (most wounds)
-sutured early
-results in a hairline (small) scar

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16
Q

what is tertiary wound healing?

A

will be closed by sutures
-wound not sutured but needs to be
-granulating tissue sutured together

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17
Q

what is the Braden scale for?

A

-used to help predict skin breakdown
-scoring charted each shift
-used to guide care and prevent skin breakdown

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18
Q

what are three causes of pressure wounds?

A

-pressure (bony prominences)
-compromised blood flow
-shearing forces

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18
Q

what are shearing forces?

A

friction from moving pt. around

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19
Q

the Braden score assesses which 6 areas?

A
  1. sensory perception
  2. moisture
    3.activity
  3. mobility (pt. demo)
  4. nutrition
  5. friction and shear
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20
Q

what are some bony prominences to look out for in regards to pressure wounds?

A

back or side of head
scapulae
elbows
sacrum
heels
knee
ear
malleous (ankle)
hip
shoulder
vertebrae
pelvis
toes
breasts
cheek

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21
Q

with the Braden scale a lower score equals _______ risk

A

higher
range 6-23

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22
Q

<18 score on the braden scale means what?

A

at risk for skin breakdown and begin skin preventative interventions

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23
Q

hat are preventative intervention for someone who is at risk for skin breakdown?

A

turn/ reposition
protect bony prominences
increase activity
nutrition/ HYDRATION
MANAGE MOISTURE
use pressure redistribution surfaces

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24
Q

Pressure injuries staging 1-4

A

1 red skin
2 broken skin
3 deep, through sub-q tissue
4 to bone

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25
Q

what is eschar?

A

eschar is dead tissue that forms a scab-like covering over wounds and eventually falls off

unstageable

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26
Q

describe a stage 1 pressure injury

A

reddened area
localized
nonblanchable
usually over bony prominence
painful
hard/soft
warmer/cooler

dark skin may be diff.color

27
Q

describe a stage 2 pressure wound

A

-partial thickness loss of dermis
-open but shallow
-pink wound bed

28
Q

describe a stage 3 pressure wound

A

-deep crater
-full thickness skin loss
-may extend into adipose layer

29
Q

what are 5 other types of wounds besides pressure?

A
  1. skin tears
  2. arterial ulcers
  3. venous ulcers
  4. diabetic foot ulcers
  5. incontinence associated dermatitis
29
Q

what are medical devices that can cause skin breakdown?

A

nasal cannula
o2 face mask
o2 sat probes
tracheostomy parts
feeding tubes
vascular lines/hubs
urinary and fecal tubing
chest tubes
cervical collars
braces/splints/casts
SCDs
bedpans

30
Q

describe a stage 4 pressure wound

A

full thickness skin loss
-very deep
- may extend into muscle or bone
- slough/eschar may be present (dead tissue)

30
Q

who stages pressure wounds and how do they do it?

A

a wound care expert
photos taken w/ facility camera, measured (tunnels too)

31
Q

what is undermining/tunneling?

A

a wider are of wounding that lies beneath the wound opening

31
Q

who directs wound care?

A

MD order supersedes
PT/RN wound specialist

32
Q

what are some types of wound dressings that are commonly used?

A

transparent adhesive wound barriers (tegaderm)

impregnated npn-adherent dressings (adaptic or vaseline gauze, xeroform)

33
Q

what are some different types of gauze?

A

2x2
4x4
fluffs
kerlix
ABD pads
split drain sponge

34
Q

what are some example s of hydrocolloids? why is it not used often?

A

mepilex
duoderm

must be specifically ordered. not used often due to possible damage upon removal

used for bedsores (mildly exuding wounds) maintain moisture and protect from bacteria

35
Q

what is hydrogel and how does it help wounds?

A

it is a 90% water in a gel base.

creates a moist healing environment and fills in dead space

36
Q

what does hydrogel promote?

A

-granulation
-epithelialization
-autolytic debridement (enzymes break down necrotic tissues)

37
Q

can hydrogel be used with infection present?

A

yes

38
Q

should hydrogel be applied directly to wounds or to dressings?

A

can do both

38
Q

what are some wound irrigation solutions?

A

normal saline
hydrogen peroxide (full/partial strength)
dakins solution

38
Q

what are the 8 steps in wound care planning?

A
  1. review order
  2. determine clean vs. sterile
  3. pre-medicate
  4. source doc.
  5. explain procedure/consent
  6. necessary supplies to rm.
  7. extra help?
  8. lucky gloves
39
Q

it is important to move from ________ to __________ areas in wound care

A

Clean to contaminated

40
Q

pressure injuries are considered __________, so we use ____________ with them

A

colonized
clean technique

41
Q

a wound itself is considered what?

A

sterile

42
Q

what is the purpose of wet-to-dry dressings?

A

to gently debride the area

43
Q

wet to dry dressings are actually supposed to be what?

A

moist to dry

avoid placing wet dressing on healthy skin, it will macerate (break down)

44
Q

what is the procedure for changing a wound dressing? 14 steps

A
  1. hand hygiene
  2. prepare sterile field
  3. add necessary sterile supplies
  4. pour cleansing solution
  5. remove outer dressing with clean gloves
  6. remove inner dressing with sterile tweezers
  7. discard tweezers/ non-sterile gloves
  8. apply sterile gloves/use new suture kit
  9. insert guaze w/ sterile tweezers/sterile q tips and gloves
  10. DO NOT TOUCH OUTSIDE OF WOUND
  11. fill entire wound with gauze
  12. cover wound with absorbent pad/gauze
    13.cover with protective dressing
  13. secure dressings
45
Q

what are three ways to secure dressings?

A

tapes
wraps
montgomery straps

46
Q

what are three kinds of tape?

A

paper
plastic
cloth

47
Q

what are three kinds of wraps?

A

gauze
stretch netting
ace bandage

48
Q

what is sanguineous drainage?

A

bloody

49
Q

what is serous wound drainage?

A

watery

50
Q

what is serosanguineous drainage?

A

watery/bloody

51
Q

what are abdominal binders commonly used for?

A

to help pt. feel better and supported after surgery

52
Q

how to wrap ace bandage?

A

diagonally back and forth, secure with hooks

53
Q

what are the two suture types?

A

plain interrupted
plain continuous

54
Q

when removing plain interrupted sutures what part do the tweezers hold onto?

A

the knot side

55
Q

what are three ways to close a wound?

A

sutures
staple
cyanoacrylate glue (derma bond)hat is

56
Q

a penrose drain?

A

drain that allows for open drainage through capillary action to skin surface through tube, drainage absorbed in dressing (not for lg. amts. of drainage)w

57
Q

What is a JP suction drain?
and what does it do?

A

(jackson pratt)
provides gentle suction
must be compressed
150 mL max (sm amt.)
keep track of amt.

58
Q

what is a hemovac? and what does it do?

A

used for lg. volumes
placed in vascular cavity
must be compressed
stronger and larger than JP

59
Q

what is cold therapy good for? what does it do?

A

-controls bleeding
-decreases edema
-pain control
-anti-inflammatory effect

60
Q

what is heat therapy good for? what does it do?

A

-facilitates soft tissue -repair
-relaxes skeletal muscles
-increases blood flow to area

61
Q

what are the safety factors with heat therapy?

A

order required
intact sensory function
assess response

62
Q

what are the safety factors for cold therapy?

A

order required
not applied directly to skin
discontinue when numbness is achieved
assess response
15 min on/ 15 min off

63
Q

what is generally applied first to a wound? hot or cold therapy?

A

cold therapy for about 2 days then move on to hot therapy

201B Exam #3 (3 decks)

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