Wound Care / Dressing Change

Question 1

Purpose of wound care

Answer 1

Enhance healing
Remove MOs
Protection
Control bleeding and edema
Comfort

Question 2

Types of wound dressings

Answer 2

Gauze dressings
Telfa
Self-adhesive
Hydrocolloid (HCA)

Question 3

Types of gauze dressings

Answer 3

Wet-dry
Dry-dry
Sterile vs clean

Question 4

Telfa

Answer 4

Non-adherent gauze

Question 5

Self-adhesive dressings

Answer 5

Acuderm
Opsite
Tegraderm

Question 6

Hydrocolloid dressings

Answer 6

Biofilm
Duoderm
Restore
Tegrasor

Question 7

Securing methods

Answer 7

Tape
Ties
Binders

Question 8

Types of binders

Answer 8

Ace

Elastic

Question 9

Montgomery straps

Answer 9

Type of ties

Question 10

Types of tape

Answer 10

Paper
Silk
Transpore

Question 11

Wound closure

Answer 11

Staples
Sutures
Steristrips

Question 12

Dressing complications

Answer 12

Pathogen growth
Skin breakdown (tape, drainage)
Decreased circulation
Trauma

Question 13

RN role in wound care

Answer 13

Nurse may reinforce first dressing and change after per order, or more frequent if necessary with notifying provider

Question 14

Types and functions of drains

Answer 14

Mechanical suction (Wound vac, chest tube)
Self suction (Jackson Pratt, Hemovac)
Gravity (penrose)

Question 15

Drains nursing care

Answer 15

Ensure patency
Monitor, empty, and document
Prevent complications

Question 16

Sterile technique rules

Answer 16

Above waist and within site
No talking
Do not cross over
Sterile touches sterile only
Check expiration dates
Do not use if wet or open

Question 17

Heat effects

Answer 17

Vasodilation
Increased capillary permeability
Increased tissue metabolism
Reduced muscle tension
Decreased blood viscosity

Question 18

Cold effects

Answer 18

Vasoconstriction
Pain relief
Reduced tissue metabolism
Reduced muscle tension
Increased blood viscosity

Question 19

Types of heat and cold therapy

Answer 19

Compresses
Water-flow blankets
Soaks/Sitz baths

Question 20

Risks of heat/cold therapy

Answer 20

Tissue damage

Question 21

Guidelines for heat/cold therapy

Answer 21

Provider order
Assess risks
Monitor time and temperature

Question 22

Aseptic/Clean technique

Answer 22

Clean gloves
Dressings sterile
No talking
Do not use if we or open
Keep in sight above waist
Used for low infection risk wounds

Question 23

Principles of wound cleansing

Answer 23

Maintain sterility
Clean from least contaminated to most contaminated from wound/incision toward surrounding skin
Gentle friction
Linear wounds-work straight along incision
Irregular wounds-circular motion from wound/drain site to surrounding skin
Increasingly larger concentric circles

Question 24

Equipment for wound care

Answer 24

Clean gloves
Saline
Sterile gloves
Paper tape
Trash can
Tape measure
1 pkg dressing sponge
4 pkgs gauze

Question 25

Dressing removal

Answer 25

Don clean gloves
Remove old dressing
Assess wound
Remove gloves correctly

Question 26

Cleaning the wound

Answer 26

Wash hands
Open equipment
Pour normal saline
Don sterile gloves
Cleanse using wet gauze
Dispose of gauze correctly
Do not allow hands to drop below waist

Question 27

When cleaning a drain

Answer 27

Move from incision area to drain site

Question 28

Wound ABCDE

Answer 28

Approximate size
Body location
Color
Drainage
Edges