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Wound Care Flashcards

1
Q

Medical asepsis

A

eliminating microorganism spread through practices

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2
Q

examples of medical asepsis

A

handwashing
cleaning equipment
using PPE
holding linen away from you

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3
Q

surgical asepsis

A

absence of microorganisms to prevent infection

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4
Q

examples of surgical asepsis

A

sterile field/gloves
equipment is sterilized
perform sterile techniques

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5
Q

What are nursing interventions that would require sterile technique?

A

starting an IV line
administering IM/SQ injection
Inseriting Foley catheter/baldder irrigation
performing dressing changes on incision wound
administering eye/ear drops

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6
Q

what are examples of aseptic/clean technique that nurses use in the field

A

administering non-parental medications
oral,rectal,sublingual, intranasal meds

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7
Q

what is rule #1 of the basic principles of surgical asepsis?

A

all objects in sterile field must be sterile

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8
Q

what must you observe when receiving a package of sterile equipment inside of it

A

check the package, make syre its unopened and dry

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9
Q

what is rule #2 of the basic principles of surgical asepsis?

A

sterile objects become unsterile when touched by unsterile objects

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10
Q

whats a good rule of thumb when questioning sterility?

A

if questioning sterility assume it is contaminated

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11
Q

what is rule #3 of the basic principles of surgical asepsis?

A

sterile items out of sight or below waist/table level are considered unsterile

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12
Q

what are body mechanics or placements that will keep you sterile?

A

do not leave/ turn back to sterile field
keep gloved hands above waist, out in front, within vision

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13
Q

Why does table positioning matter?

A

tables are sterile at surface level only

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14
Q

what is rule #4 of the basic principles of surgical asepsis?

A

Sterile objects can become unsterile by prolonged exposure to air

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15
Q

what is rule #5 of the basic principles of surgical asepsis?

A

Fluid flows in the direction of gravity

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16
Q

how do you hold forceps when putting fluid on it?

A

hold tips downward (unsterile fluid drips off)

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17
Q

where do I want water running from and down to when washing my hands using sterile technique?

A

from your finger tips to your wrists

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18
Q

what is rule #6 of the basic principles of surgical asepsis?

A

moisture passing through sterile objects draws microorganisms from unsterile surfaces above or below to the sterile surface

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19
Q

what can help reduce microorganisms from passing through moisture?

A

waterproof barriers under sterile field

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20
Q

what is rule #7 of the basic principles of surgical asepsis?

A

edges of the sterile field are considered unsterile

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21
Q

how big is the margin at the edge of an opened drape is considered unsterile?

A

1 inch margin

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22
Q

what is rule #8 of the basic principles of surgical asepsis?

A

Skin cannot be sterilized and is unsterile

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23
Q

what can you do to combat hands being unsterile?

A

wear gloves

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24
Q

when applying new dressings and cleaning a wound, what would you want to wear to prevent infection?

A

sterile gloves

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25
to hold sterile objects, what should you only use to hold it with?
sterile applicators or forceps
26
do antiseptics make skin sterile
no, only makes skin clean
27
what is rule #9 of the basic principles of surgical asepsis?
conscientiousness, alertness, and honest when maintaining surgical asepsis
28
what does rule #9 look like in practice?
evaluate your own mistakes and communicate that you have contaminated the field in any way
29
what does CLABSI mean
Central line associated Bloodstream infection
30
what does CAUTI mean
catheter associated UTI
31
what does SSI mean
select surgical site infection
32
what does a score of 15-16 on the Braden Risk Assessment mean?
Mild Risk
33
what does a score of 12-14 on the Braden Risk Assessment mean?
moderate risk
34
what does a score of <12 on the Braden Risk Assessment mean?
high risk
35
If a wound is considered superficial what is lost on the skin?
loss of epidermis
36
if a wound is classified as partial thickness, what is lost on the skin?
epidermis and dermis loss
37
if a wound is considered full thickness, what is lost on the skin?
epidermis, dermis, subcutaneous fat
38
what does incised mean?
intentional/accidental cut
39
what does contused mean
blunt blow
40
what does abraded mean
friction on skin (road rash)
41
what does puncture mean?
stab by blunt instrument
42
what does a laceration mean?
torn tissue (irregular edges)
43
what does penetrating mean?
entering through skin into tissues
44
whats an example of a penetrating wound
GSW
45
what is the difference between a incised wound and a laceration?
incised wound is intentional with even edges where as lacerations have irregular edges
46
what does a red wound mean
red = good reddy to heal
47
what does a yellow wound mean?
pus, debris, fibrin may need a cleaning may need a topical antimicrobial to get rid of yellow gunk
48
what does a black wound mean
necrotic tissue/ black eschar No healing to this, needs to be removed till they reach healthy tissue
49
T/F When treating wounds you always want to treat the wound on the most sever condition present
T
50
what is a stage 1 pressure ulcer
closed and intact inflammation red not blanched
51
what should you do when you see a stage 1 pressure injury. What may you need to assess?
touch the wound and see if skin blanches. If you touch skin and it doesnt go white for a second then back to red and it just stays red then it is a stage 1
52
what is a stage 2 pressure ulcer
skin is not intact partial thickness skin loss absence of bruising
53
what is a stage 3 pressure ulcer
full thickness skin loss subcutaneous tissue damage or nectrotic tunneling may be present Damage extends down to subcutaneous tissue but not muscle/bone
54
what is a stage 4 pressure ulcer
loss of full thickness expose to muscle, tendon, or bone often tunneling sinus tracts may develop slough and eschar present
55
What is a unstageable ulcer?
something is interfering with ability to classify damage can be deeper than eye can see
56
what is a suspected deep tissue injury? (DTI)
intact area in purple discolored or blood filled blister pain, boggy, warmer/cooler than surrounding tissue in the area
57
with the braden scale, the lower the # means what?
Patient is more at risk
58
If im caring for a patient and their wound drainage is yellow, what would you call that? What is it?
serous fluid, clear/yellow can be plasma and water
59
If im caring for a patient and their wound drainage is thick yellow/green/greyish blue, what would you call that? What is it?
purulent, means microorganisms are in wound may indicate nectrotic tissue
60
If im caring for a patient and their wound drainage is red, what would you call that? What is it?
Sanguineous contains high # of RBCs
61
if I have sanguineous drainage and its bright red, what does that indicate?
new/fresh blood from a wound drain
62
If i have sanguineous wound drainage, and the color of the blood is dark red, what does taht indicate?
Old blood
63
If im caring for a patient and their wound drainage is clear/watery red, what would you call that? What is it?
Serosanguinous plasma+RBCs
64
What is a primary intention wound when talking about wound healing classifications?
wound edges are close together and sealed closed but underlying tissues still need time to heal to regain strength
65
give me an example of primary intention when dealing with wound healing
surgical incision clean laceration
66
What is secondary intention when talking about wound healing classifications?
deeper tissue injuries tissue edges are not close together so there is a gap Requires gradual filling into dead space with connective tissue
67
when dealing with a secondary intention wound, if drainage is present, what can that do to the time it takes to heal?
prolong the healing process
68
give me examples of secondary intention wound healing
chronic pressure ulcer, venous stasis ulcer
69
What is tertiary intention when talking about wound healing classifications?
left open after debridement and inflammation subsides
70
what does a tertiary intention help ensure?
no infection is present
71
what are examples of when a tertiary intention is applied?
dog bites, lacerations from foreign bodies, contaminated traumatic wounds
72
how can partial thickness wounds heal better?
hydrated well oxygenated skin with little microorganisms
73
typically, how long does a partial thickness wound take to heal
5-7 days
74
How far does damage extend to with a full thickness wound?
lower layers of dermis & subcutaneous tissue
75
Can a partial thickness wound heal via re-epithelialization?
Yes
76
Can a Full thickness wound heal via re-epithelialization?
No
77
How can healing occur with full thickness wounds?
filling in with granulation (cell regeneration)
78
When you are documenting a wound, what are you documenting? (4 things)
location wound length, width & depth describe drainage type & amount Define wound appearance & surrounding areas
79
what are some patient factors that affect healing of a wound?
age DM (diabetes mellitus) PVD (peripheral vascular disease) decreased mobility (high pressure on skin)
80
what are malnurished pts more at risk for with wound healing
damage and slow healing
81
what are obese patients more at risk for with wound healing?
high risk of infection due to low tissue perfusion
82
What are lifestyle choices that affect wound healing
exercise promotes healing (better circulation) Smoking causes more clots Stress lowers tissue perfusion Caffeine lowers tissue perfusion
83
What medications can affect wound healing
Anti-inflammatory agents delay healing prolonged antibiotic use is high risk for superinfection
84
Whats recommended fluid intake for wound healing?
2-3000mL per day
85
What are all the supplements and vitamins you can take to promote healing
Vitamine A,C,E Iron Zinc
86
what does vitamin A do to help with wounds
collagen production, epithelialization
87
What does Vitamin C do to wound healing?
Collagen production, capillary formation, lowers risk of infection
88
What does vitamin E do to wound healing
fibroblast development
89
What does iron do to promote wound healing
functional hemoglobin to prevent anemia
90
what does zinc to do wound healing
increases healing rate
91
What physiologic factors can inhibit wound healing in Geriatric patients
Vascular change collagen is less flexible immune system is impaired nutritional deficiency (anemia) more likely to have scar tissue
92
what is a hemorrhage
persistent bleeding & clot dislodgement
93
what is a hematoma
blood accumulation under skin at wound site
94
what may you see in a severe hemorrhage in your patient?
hypovolemic shock low BP High HR High RR diaphoretic (sweating a lot) clammy
95
what is dehiscence
partial/complete seperation of outer wound layers
96
evisceration
wound layers total seperation, internal organs can pop out
97
what are risk factors to have an evisceration
obesity malnutrition DM immune deficiency steroid use suture failure forceful coughing vomiting or straining
98
what are some clinical manifestations your pt may present when they are dealing with a evisceration
fever, tachycardia, pain, gush of serosanguinous fluid
99
what is a fistula
abnormal opening between two or more organs
100
what are factors that may cause a fistula to form?
improper suture technique inadequate blood supply tension on suture line obstruction. hematoma/ abscess formation malnutrition
101
how can you fix a fistula?
surgically repair, wound packing, install a drain
102
why may someone get a drain installed?
decompresses/drains fluid/air helps removal of blood/pus
103
what are some types of drains
hemovac penrose drain jackson pratt (JP) -bulb drain
104
who should do the first dressing change to evaluate the wound in wound care?
surgeon
105
what directions do you clean wounds?
top to bottom (incision) outward laterally in a pressure ulcer (Clean to Dirty)
106
if a patient has a drain, what do you clean first, the incision or the drain?
incision first then drain
107
what do dry dressings do?
protects and absorbs moisture prevents contamination promotes epithelial movement
108
what does synthetic dressing promote?
semipermeable which promotes O2 exchange bacterial barrier promotes epithelialization
109
how often should you change synthetic dressing
change Q3 days
110
how often should you typically change wet to dry dressing
1-2x a day
111
what are examples of heated moist therapy
hot packs, compress, Kpad, Sitz bath
112
what are examples of dry heat therapy
heating pad, hyperthermia blanket
113
what are examples of cold moist therapy
compress, cold water sponge bath
114
what are examples of dry cold therapy
ice bag, ice collar, hypothermia blanket
115
what should you watch out for with heat and cold therapy?
rebound phenomenon
116
what is rebound phenomenon
when you leave hot/cold therapeutic devices on for too long and it can cause tissue congestion/ vasoconstriction
117
what are high risk patients for rebound phenomenon
very young/elderly present of open/infected wounds impaired circulation impaired sensation
118
what are indications of when to use heat therapy
muscle spasms, joint stiffness, contractures, pain
119
what are cold indications?
trauma, control bleeding, inflammation, muscle spasms, pain
120
what are contraindications of heat therapy
first 24 hr after trauma, active bleed, edema areas, blisters
121
what are contraindications for cold therapy
open wound, hypersensitivity to cold, asthma
122
what does approximated mean
the act of bringing together wound edges with skin layers lined up so they can be held together with sutures
123
what is contraction
the closure of a wound as new collagen replaces the damaged
124
what is pruritus
itching
125
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N193 (8 decks)

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