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S4- Acute Care > Wound Care Module 1 > Flashcards

Wound Care Module 1 Flashcards

1
Q

PART 1: REDUCE OF ELIMINATION CAUSE

A

PART 1: REDUCE OF ELIMINATION CAUSE

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2
Q

What are the 5 parts of a wound care assessment?

A
  • Assess patient risk using the Braden Scale
  • Make adjustments for correct bed and chair positions
  • Determine appropriate surfaces for pressure reduction
  • Reduce the effects of gravity
  • Understand the importance of oxygenation and blood flow
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3
Q

What is used to assess risk for pressure ulcer risk?

A

Braden Scale

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4
Q

What 6 factors are scored with the Braden Scale?

A
  • Sensory Perception
  • Moisture
  • Activity
  • Mobility
  • Nutrition
  • Friction and Shear
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5
Q
  • What is the highest Braden Scale score?

- A score lower than ____ puts patients at risk for pressure ulcers.

A
  • 28

- 18

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6
Q

What is the correct bed positioning?

A

knees and hips slightly flexed

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7
Q

Pressure Reduction Surfaces are categorized as _________ Pressure or _________ Pressure.

A

localized or distributed

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8
Q
  • If the patient is in bed, change position at least every ___ hours.
  • If the patient is in a chair, change position at least every ____. Instruct your patient to shift their weight every ___ minutes if they are able.
A
  • 2 hours

- hour, 15 minutes

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9
Q

What causes a diabetic foot ulcer?

A
  • Neuropathy leading to decrease/loss of sensation.
  • Difficulty discovering an ulcer.
  • Cant feel pressure being exerted on foot.
  • May go unnoticed until ulcer already present.
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10
Q
  • What is off-loading?

- Why is it important?

A
  • Off-loading is the act of relieving pressure from plantar tissues. It is the key to pressure ulcer treatment and prevention.
  • The goal of off-loading is to control, limit, or remove all intrinsic and extrinsic factors that increase plantar pressures.
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11
Q

What non-surgical methods can be used for treatment of ulcers?

A
  • Contact Casting
  • Orthotics
  • Cast Walkers
  • Therapeutic Footwear
  • Dressings
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12
Q

What is the most effective method of reducing edema?

A

Elevate the leg and allow gravity to drain fluid from the limb.

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13
Q
  • ___________ bandages are useful when a patient can’t elevate their affected limbs. They’re also helpful for times when a patient is on his feet.
  • What must be taken before application of this?
A
  • Compression

- ABI Index

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14
Q

What are the benefits of compression therapy?

A
  • Improves rate of ulcer healing
  • Reduces the incidences of recurrence
  • Prolongs the time to the first recurrence
  • Improves lymphatic drainage
  • Reduces superficial venous pressure
  • Improves blood flow velocity through unoccludeddeep and superficial veins
  • Reduces reflux in the deep veins
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15
Q

What 2 things are used for compression therapy?

A

Rigid and Elastic Compression

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16
Q

What is the first goal in the treatment of an ulcer?

A

Reestablish arterial flow (revascularization)

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17
Q

What are 3 surgical methods for revascularization?

A
  • Arterial bypass
  • Angioplasty
  • Stents
18
Q

What are the causes of poor blood flow?

A
  • Pressure
  • Arterial occlusion
  • Vasoconstriction
  • Peripheral vascular disease
  • Atherosclerosis
19
Q

What causes lower oxygenation levels?

A
  • Inadequate oxygen intake
  • Hypothermia or hyperthermia
  • Anemia
  • Alkalemia
  • Chronic obstructive pulmonary disease
20
Q

PART 2: NUTRITION AND PATIENT SUPPORT

A

PART 2: NUTRITION AND PATIENT SUPPORT

21
Q

Thorough nutrition therapy should include what 3 things?

A
  • A nutritional assessment
  • Design of an individualized treatment plan
  • Periodic monitoring to evaluate the plan’s effectiveness
22
Q

A treatment plan should always begin with the least _______/_______ approach and should incorporate what 2 things?

A

-invasive/costly

  • Adequate calories and proteins to promote anabolism and the growth of new tissue.
  • A diet that fits the individual patient needs.
23
Q

A complete nutritional assessment includes what 5 things?

A
  • body measurements
  • evaluation of lab results
  • physical examination
  • dietary interview
24
Q

The outcome of a nutritional assessment provides the ability to do what?

A
  • Determine pt nutrient needs.
  • Evaluate adequacy/appropriateness of current diet.
  • Recommend changes.
25
Q
  • Malnutrition occurs in ___% of non-surgical patients.
  • Malnutrition occurs in ___-___% of surgical patients.
  • Malnutrition occurs in ___-___% of older patients.
A
  • 30%
  • 45%-57%
  • 53%-74%
26
Q

What are the physical signs of dehydration?

A
  • Dry skin
  • Cracked lips
  • Thirst
  • Poor skin turgor
  • Fever
  • Appetite loss
  • Nausea
  • Dizziness
  • Increased confusion
27
Q

What are the clinical signs of dehydration?

A
  • Increased laboratory values for the following: serum creatinine, hematocrit, blood urea nitrogen, potassium, chloride, osmolarity, sodium
  • Decreased blood pressure
  • Increased pulse rate
  • Constipation
  • Concentrated urine
28
Q

What are 3 ways to prevent dehydration?

A
  • Keep water or other beverages at the bedside so that they are easily accessible.
  • Offer water at least every two hours if the patient doesn’t consume fluids on his or her own.
  • Intravenous therapy when necessary.
29
Q

PART 3: PREPARE FOR WOUND HEALING

A

PART 3: PREPARE FOR WOUND HEALING

30
Q

________ = A group of organisms living together in or on the body prior to tissue invasion not causing infection.

A

Colonization

31
Q

_________ = Invasion of tissues by microorganisms resulting in systemic reaction
(fever, edema, erythema, etc.).

A

Infection

32
Q

What are the 3 things used in the detection of infection?

A
  • Local and systemic symptoms
  • Contamination and bacterial balance
  • Clinical abnormalities
33
Q

What are the local symptoms of infection?

A
  • Erythema
  • Edema
  • Drainage
  • Tissue around wound with induration
  • Tenderness
  • Warmth
  • Crepitus
34
Q

What are the systemic symptoms of infection?

A
  • Fever
  • Leukocytosis
  • Confusion
  • Tachycardia
  • Hypotension
  • Malaise
35
Q

Wounds with bacterial counts of ___k organisms per gram of tissue or less are considered contaminated.

A

100k

36
Q

What are 3 culturing methods?

A
  • Surface Swab Culturing
  • Needle Aspiration
  • Tissue Biopsy
37
Q

What is debridement?

A

Debridement is the removal of necrotic tissue from the wound area.

38
Q

What are some types of debridement?

A
  • Sharp Debridement
  • Chemical/Enzymatic
  • Autolytic
  • Mechanical
39
Q

What are the goals of wound cleansing?

A
  • To remove debris that support bacterial growth and delay healing.
  • To use as little chemical or mechanical force as possible.
  • To protect healthy granulation tissue.
  • To balance pH and moisture.
  • To minimize odor and pain.
  • To separate necrotic tissue from healthy tissue.
40
Q

What 3 types of solutions are used for wound cleaning?

A
  • Saline Solution
  • Commercial Wound Cleaners
  • Antiseptic Solution
41
Q

You must limit the use of antiseptic solutions to between __-__ days.

A

3-7

S4- Acute Care (15 decks)

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