Wound Care II Flashcards

Question

What are wound care principles?

Answer 1

- Practice universal precautions! - Be aware of allergies to adhesives and latex in order to avoid development of secondary rash, burn, or severe allergic reaction

Answer 2

- The dressing that goes directly on top or inside of the wound. - May have specific chemical properties to provide or absorb moisture, prevent infection through anti-microbial intervention (silver, honey) or prevent the secondary dressing from sticking to the wound or sutures

Answer 3

- Usually used to secure the primary dressing | - Gauze, Tegaderm, coban, etc.

Answer 4

- Adaptic or petroleum impregnated gauze - Xeroform - Silver dressings - 4x4 and 2x2 dressings - Semi-occlusive dressings - Gloves - Cotton tipped applicators - 1 or 2" gauze dressing wrap - Coban, digisleeve, or compression garment - Tweezers - Suture removal kits - Debriding agents

Answer 5

- Pressure ulcers, pressure sores, bed sores - Injuries to skin and underlying tissue resulting from prolonged pressure on skin. Bed sores most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips, and tailbone

Answer 6

- Medical conditions that limit ability to change positions, requires them to use a wheelchair, confines them to a bed for a long period of time, or who have impaired sensation - People who do not perceive normal sensory cues from the body to shift weight - Bed sores develop quickly and are difficult to treat

Answer 7

- Nursing, homes, hospitals, assisted living, home health

Answer 8

- Can be issued by governing agencies if a pressure sore was developed in-house - Extensive documentation is required

Answer 9

- Anyone who provide care for the patient and the patient themselves - Physician/surgeon: prescribe care and medication - Nursing: usually perform the dressing changes and call the shots with wound care - Physical Therapy: perform modalities such as e-stim, ultrasound, diathermy, as well as wound care. In some settings, PTs irrigate the wound. Assist with positioning and improving mobility - Occupational Therapy: patient and family education regarding prevention, skin care, pressure prevention positioning, safety when performing ADLs, encourage more participation in occupation. In some settings, wound care - Dietician: ensures proper nutrition - Psychologist or social worker might be involved: depending on cause, for proper discharge planning, and to determine if there is any depression - Family members and caregivers: for follow through in prevention and healing

Answer 10

- National Pressure Ulcer Advisory Panel (NPUAP) - Minimum Data Set 3 (MDS is used in nursing homes and skilled nursing units) - The Agency for Health Care Policy and Research Guidelines (AHCPR) - The Omnibus Budget Reconciliation Act (OBRA)

Answer 11

- Stage 1: an area of localized redness that does not blanch when pressed. Skin is intact - Stage 2: a shallow ulcer affecting only the epidermis. May be blistered or fluid filled. There is no slough present. Skin tears do not fall in this category - Stage 3: deeper wound that extends into the subcutaneous tissue but does not go all the way through. May include tunneling and undermining - Stage 4: full thickness tissue loss affecting the epidermis, dermis, and subcutaneous tissue. May include muscle and bone. Tunneling and undermining are common at this stage - Unstageable: the extent of the wound cannot be measured or visualized. Usually blocked by eschar, necrosis, or blister. DTI (deep tissue injury)

Answer 12

It is used to identify risk of pressure sores. The scale looks at sensory perception, moisture, activity, mobility, nutrition, and friction and shear

Answer 13

It is used by nurses to help further define Extent of Pressure Sore

Answer 14

When the depth of the wound extends past the original opening. You can lift the lip of the wound off the wound border

Answer 15

Caused by destruction of the fascial planes which results in a narrow passageway. Tunneling results in dead space that has the potential for abscess formation

Answer 16

There is no reverse back staging of wounds. A stage 4 pressure ulcer is always stage 4, even when fully healed

Answer 17

- Computer software programs - Photographs - Zip-lock baggy tracing technique

Answer 18

- Moist wound healing - Interactive dressings - Alginate wound dressings (processed seaweed) - Hydrocolloid dressings - Composite dressings - Foam wound dressings - Gauze dressing (sterile and non-sterile, 2x2, 4x4, wrap dressings) - Hydrogel dressings

Answer 19

- Application of controlled levels of negative pressure to accelerate debridement and promote healing - Decreases bacterial level

Answer 20

Oxygen significantly increases the oxygen saturation of plasma available to the tissues

Answer 21

- Turning schedules (times vary: every hour, every 30 minutes, etc.) - Proper pressure reducing wheelchair cushions - Hill-Rom or similar air bed - Other pressure reducing devices for bed - Patient and family education: skin inspection, pressure reduction, use of pressure relieving devices. Monitoring tubes, cords, dressings, shoes, clothing, etc. that can produce pressure and limit blood flow to and area - Good nutrition - Monitor and control sugars if diabetic - Dressing changes if at home

Answer 22

- Typically use of foam, gel, air, or a negative space to relieve pressure - Memory foam was developed by NASA

Answer 23

- Wires and tubes | - IVs, vents, catheters, bedding tucked in too tightly