Wound Care Lab

Question 1

What is antiseptic technique

Answer 1

Elimination of many germs off of a living surface

Question 2

Can you disinfect a person

Answer 2

No you disinfect an object

Question 3

Can you disinfect a person

Answer 3

No you disinfect an object

Question 4

When is a person considered leukocytotic and neutropenic

Answer 4

More than 11,000
Less than 4,500

Question 5

How do you measure a wound

Answer 5

Length will be head to toe
Width will be right to left

Question 6

How do you measure a wound

Answer 6

Length will be head to toe
Width will be right to left

Question 7

When you do not have an order what do you use to clean a wound and how

Answer 7

Normal saline, clean from least contaminated to most contaminated
-incisions: down the incision and then around
-open: from center outward

Question 8

Describe isotonic, chlorhexidine, and hydrogen peroxide

Answer 8

I= normal saline or lactated ringers, does not have antibacterial action
C=antiseptic, toxic to granulation, traditionally used before procedures USE ONLY WHEN ORDERED
H= mechanical debridement, no sustained antiseptic action, will damage granulation and blood clots, can’t be used on tunneling wounds

Question 9

Key points of wound irrigation

Answer 9

STERILE
Spray from superior to inferior
Will change gloves 2 times

Question 10

When is a pressure dressing used

Answer 10

Temporary control of bleeding caused by trauma, surgery, or puncture
-can be used with sandbags
-used for heart caths through femoral

Question 11

What are the three main types of drains and their function

Answer 11

Hemovac: spring activated, emptied every 4-8 hrs
Jackson Pratt: bulb activated
Penrose: passive, hard to measure output

Question 12

What is sanguineous drainage

Answer 12

Bloody, thick drainage, non transparent

Question 13

What is sero sanguineous drainage

Answer 13

Blood and serum, red-pink color, thickness is in between sanguineous and serous

Question 14

What is serous drainage

Answer 14

Serum from the body, pale yellow, watery, fluid is blister like

Question 15

What is purulent drainage

Answer 15

Pus, pale yellow to green color, WBC, infection

Question 16

Treatment for stage 1 pressure injuries

Answer 16

Dressing, turning, barrier cream, nutrition, careful full body assessment

Question 17

Treatment for stage 2 pressure injury

Answer 17

Hydro collide dressing, turning, off loading devices, nutrition, careful assessment of body

Question 18

Treatment for stage 3 wounds

Answer 18

Will need wound care nurse
Therapeutic bed
Nutrition
Packing/dressing often

Question 19

Treatment for stage 4 wounds

Answer 19

Will need wound care nurse
May need surgery/grafting
Extensive dressing changes
Intensive pressure relief

Question 20

Describe 1-2 degree burns

Answer 20

1: reddened area AKA sunburn
2: blisters, moderate to deep partial thickness, effects epidermis and part of dermis

Question 21

Describe 3-4 degree burns

Answer 21

Both often require surgery
3: skin is charred or non existent, no pain, severe fluid loss, nerve damage, full thickness wound of epidermis and dermis, debridement and grafting needed
4: deep burn necrosis, damage to fascia, muscle and or bone

Question 22

Important nutritional needs for wound healing

Answer 22

Vitamin A/c and minerals
Protein
Calories
Hydration

Question 23

When is a wrap needed

Answer 23

Need for pressure
Need for immobilization
To support a wound
To reduce or prevent edema
To secure a splint or dressing

Typically rolled gauze or ace wrap

Question 24

What are the five p’s of applying a bandage

Answer 24

Pallor
Paresthesia — numbness/tingling/nerve damage
Pain — nerve function effected
Pulselessness — impaired circulatory function
Paralysis — damaged motor/nerve function

Question 25

Which way do you wrap

Answer 25

Towards the heart

Question 26

When is cold therapy used and what does it do

Answer 26

Trauma (early stages) and arthritis -reduces hemorrhage -reduces edema Reduces muscle spasms Reduces pain Alternate 1/2 hour on and off with heat

Question 27

When is heat therapy used and what does it do

Answer 27

Arthritis, cramps, spasms Back pain, surgical wounds Hemorrhoids, phlebitis, IV inflitration Episiotomies Causes vasodilation, increasing oxygen, nutrients and leukocytes to tissue Increased metabolism Elimination of waste

Question 28

Key points in ear irrigation

Answer 28

Clean procedure -warm solution -position sitting or laying down -Adult=pull pinna up, Peds=opposite -aim at top of ear canal

Question 29

Key points of eye irrigation

Answer 29

Sterile -position pt supine or head turned with effected eye down -retract lower eyelid -inject at inner canthus