WOUND CARE ASSESSMENT

Question 1

What should be inspected?

Answer 1

Color, Turgor, Edema, Lesion, Associated injuries

Question 2

What will be assessed in wounds?

Answer 2

Location, Width/Length/Depth, Last Tetanus Shot, Appearance

Question 3

Wound appearance are?

Answer 3

Size, Draining, swelling, pain

Question 4

Types of tissues?

Answer 4

Necrotic, Eschar, Slough, Granulation

Question 5

Necrotic tissue is?

Answer 5

Inviable

Question 6

Eschar tissue is?

Answer 6

Color black or brown with leathery texture

Question 7

Slough tissue is?

Answer 7

Stringy, cheesy, loose, yellow, tan

Question 8

Granulation tissue is?

Answer 8

Viable pink pale to beefy red

Question 9

What is epithelialization?

Answer 9

Occurs along wound edges with pale pink appearance of the wound

Question 10

Periwound areas checked?

Answer 10

Erythema, Maceration, Rash

Question 11

What is Erythema?

Answer 11

Infection redness

Question 12

What is Rash?

Answer 12

Papular or macular shaped caused by fungal infection

Question 13

Undermining/Tunneling materials inspection: Descriptor and for measurement

Answer 13

Hand of clock and cotton tipped applicator

Question 14

Acute care implementation support?

Answer 14

Fluid intake 2,500mL a day

Question 15

Acute care implementation prevention?

Answer 15

Transmission and contamination

Question 16

Acute care implementation positioning?

Answer 16

Offload pressure

Question 17

How to prevent MASD and pressure injuries?

Answer 17

Wrinkle free, semi fowler position, change pos feq, don’t use baby powder/cornstarch

Question 18

How to treat wounds? 5 steps

Answer 18

Surgical asepsis
Never use alcohol or hydrogen perox
Obtain c and s
Teach pt
Teach pt of ROM

Question 19

How to treat pressure injuries using the RYB CODE?

Answer 19

Red: protect, Yellow: Cleanse, Black: Debride

Question 20

Transparent film dressing

Answer 20

Ulcerated, Burned area

Question 21

Hydrocolloid dressing

Answer 21

Pressure injuries

Question 22

Dressing wounds? 2

Answer 22

Secure and suture/staples

Question 23

Cleaning wounds? 4 steps

Answer 23

Remove debris, Saline solu, not all need to be changed, penrose drain (surgical)

Question 24

Pressure should be between psi?

Answer 24

4-15 psi

Question 25

Pack using what technique?

Answer 25

Damp to damp

Question 26

What is Bandage?

Answer 26

Strip of cloth

Question 27

What is Gauze?

Answer 27

Retain dressing

Question 28

What is elasticized?

Answer 28

Puts pressure to improve venous circulation

Question 29

What is binders?

Answer 29

Bandages for specific body parts (armsling)

Question 30

Basic turns for bandaging? 5

Answer 30

Circular, spiral, spiral reverse, figure 8, recurrent

Question 31

Loc effects of heat?

Answer 31

High capillary permeability, high cellular metabolism, vasodilation, sedative effect, inflammation

Question 32

Materials for applying heat/cold?

Answer 32

Ice packs, Aquathermia pads, hot water bag, cold packs, hot packs

Question 33

How to apply heat and cold?

Answer 33

Compress, soak, sitz bath, sponge