Wound Care Lab Flashcards
What is antiseptic technique
Elimination of many germs off of a living surface
Can you disinfect a person
No you disinfect an object
Can you disinfect a person
No you disinfect an object
When is a person considered leukocytotic and neutropenic
More than 11,000
Less than 4,500
How do you measure a wound
Length will be head to toe
Width will be right to left
How do you measure a wound
Length will be head to toe
Width will be right to left
When you do not have an order what do you use to clean a wound and how
Normal saline, clean from least contaminated to most contaminated
-incisions: down the incision and then around
-open: from center outward
Describe isotonic, chlorhexidine, and hydrogen peroxide
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
Key points of wound irrigation
STERILE
Spray from superior to inferior
Will change gloves 2 times
When is a pressure dressing used
Temporary control of bleeding caused by trauma, surgery, or puncture
-can be used with sandbags
-used for heart caths through femoral
What are the three main types of drains and their function
Hemovac: spring activated, emptied every 4-8 hrs
Jackson Pratt: bulb activated
Penrose: passive, hard to measure output
What is sanguineous drainage
Bloody, thick drainage, non transparent
What is sero sanguineous drainage
Blood and serum, red-pink color, thickness is in between sanguineous and serous
What is serous drainage
Serum from the body, pale yellow, watery, fluid is blister like
What is purulent drainage
Pus, pale yellow to green color, WBC, infection
Treatment for stage 1 pressure injuries
Dressing, turning, barrier cream, nutrition, careful full body assessment
Treatment for stage 2 pressure injury
Hydro collide dressing, turning, off loading devices, nutrition, careful assessment of body
Treatment for stage 3 wounds
Will need wound care nurse
Therapeutic bed
Nutrition
Packing/dressing often
Treatment for stage 4 wounds
Will need wound care nurse
May need surgery/grafting
Extensive dressing changes
Intensive pressure relief
Describe 1-2 degree burns
1: reddened area AKA sunburn
2: blisters, moderate to deep partial thickness, effects epidermis and part of dermis
Describe 3-4 degree burns
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
Important nutritional needs for wound healing
Vitamin A/c and minerals
Protein
Calories
Hydration
When is a wrap needed
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
What are the five p’s of applying a bandage
Pallor
Paresthesia — numbness/tingling/nerve damage
Pain — nerve function effected
Pulselessness — impaired circulatory function
Paralysis — damaged motor/nerve function
Which way do you wrap
Towards the heart
When is cold therapy used and what does it do
Trauma (early stages) and arthritis
-reduces hemorrhage
-reduces edema
Reduces muscle spasms
Reduces pain
Alternate 1/2 hour on and off with heat
When is heat therapy used and what does it do
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
Key points in ear irrigation
Clean procedure
-warm solution
-position sitting or laying down
-Adult=pull pinna up, Peds=opposite
-aim at top of ear canal
Key points of eye irrigation
Sterile
-position pt supine or head turned with effected eye down
-retract lower eyelid
-inject at inner canthus
