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Wound Care/ Nursing Process Flashcards

0
Q

Contusion

A

BRUISE Tissue injury without breaking of the skin PURPLE COLOR

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1
Q

What are TED hose ?

A

Elastic hose to prevent blood clott ! Legs clean and dry , no wrinkle in hose , check for redness and swelling , take off once a day for hygiene purpose

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2
Q

Keloid

A

A overgrowth of collagen scar tissue. Form during maturation phase COLOR RANGE FROM RED TO PINK OR WHITE …. African American , dark complexion whites … Young woman have the highest formation of keloids

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3
Q

Granulation

A

SOFT PINK , GROWTH OF NEW HEALTHY TISSUE , Fills the incision during the process Of healing … Fills wound depending on size

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4
Q

Abscess

A

COLLECTION OF PUS ! –Contains pus , surrounding by inflamed tissue , localized infection …WHITE , YELLOW , PINK ,GREEN depending on the infected microorganism

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5
Q

Exudate

A

DRAINAGE ! Fluid cell , slowly exuded or discharged body cell or blood vessel through small pores or break in the membrane

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6
Q

How does the nurse cleanse a wound ?

A

, from the wound outward to prevent contaminating the wound . Away from the incision from cleanest to dryest , swipe once per swab

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7
Q

How is irrigation done ?

A

Flushing out of and area with liquid …. Tip of syringe 1INCH away from wound surface . Pat dry around the wound so the tape can stick …. Use normal saline sterile salt water , 0.9% , sodium chloride

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8
Q

What is evisceration ? What is the nurse response ?

A

Wound separation with protrusion of organs ……. Place the patient in supine position , cover organs with sterile saline soaked towels , notify surgeon immediately

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9
Q

Describe how to stage pressure ulcers ?

A

STAGE 1 - erythema (redness) non blanching or not getting white … may be BROWN /BLACK on dark pigmented people .. NO BREAKS IN SKIN ……STAGE 2 - superficial skin breaks or CLEAR BLUSTERS …..STAGE 3- full thickness skin break does not go into deeper tissue such as muscle or bone …may have underlying tunneling or slough

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10
Q

Arterial ulcers

A
  • found on toes or ankles , skin tight , hard , shiny , cold to touch , may or may not have swelling , pain when walking , faint to absent pedal pulse , OFTEN ROUND SMOOTH EDGES , minimal drainage , , do not elevate legs , , walking is good for circulation , caused by arterial peripheral disease
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11
Q

venous stasis ulcer

A

Shallow beefy red , typically on the back of the lower leg , not like pressure ulcer , almost always edema of the leg , caused by high pressure in the veins or previous clot , elevate the legs it drains blood back into the heart , cause dysfunction of you veins

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12
Q

Diabetic ulcer

A

Diabetic prone to getting ulcers on their feet ,, due to neuropathy and poor circulation , diabetics have chronic wounds / slow wound healing

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13
Q

Moisture associated dermatitis

A

Fungus can cause a ras or skin irritation , common in vasodialated and incontinent persons …. Repeated expose of moisture to urinary , fecal , can cause dermatitis , itching , burning tenderness , shallow skin breakdown …. Easily confused with pressure ulcer

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14
Q

What is eschar ? What color is it ?

A

Scab, dead tissue that is cast off the surface of the skin …. A BLACK LATHERY CRUST OR THICK DRY BLACK NEROTIC TISSUE

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15
Q

What are the most common sites for pressure ulcers ?

A

Bony prominences eg: secrum , occipital bone , shoulder , elbow , scapula ,lower legs , heel , thigh , knee

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16
Q

What are signs of wound infection ?

A

Purulent drainage , fever , heat , pain , redness , loss of function , change in V/S , odor , swelling , WBC count

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17
Q

Unstageable wound

A

Has eschar

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18
Q

Maceration

A

Soft wrinkles eg: shower for too long or wearing of a Bandaid the skin gets wrinkle

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19
Q

Purulent

A

Pus/drainage - Thick , yellow , green , tan , brown

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20
Q

Evisceration

A

Purtrusion of an internal organ throught a wound or surgical incision

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21
Q

What are the phases of healing ?

A

INFLAMMATION -immediately after tissue injury 2-5 days , PROLIFERATION - period where new cell fill and heal wound 2- weeks , REMODLEING -period where wound undergoes change during maceration wound contracts and SCAR SHRINKS 16months to 3 years

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22
Q

Who would be more at risk for skin breakdown ?

A

Elderly , recent surgery , immobility , incontinence

23
Q

How is a sterile pack open ?

A

Distal , lateral , lateral , proximal

24
What are the types of drainage ?
Serous , sanguinous , serosanguineous , purulent
25
What are the steps of nursing process ?
ADPIE - ASSESSMENT - objective and subjective info put together , DIAGNOSIS - Nanada + problem +etiology + symptoms , PLAN - goal and intervention , IMPLEMENT - carry out the plan , EVALUATION - to see of plan worked out
26
t-tube
After gallbladder surgery a tube is inserted in the duct to maintain flow of the bile
27
Who is primarily responsible for initiating the care plan and selecting nursing diagnosis ? Who else should be responsible for initiating the care plan ?
RN, LVN , and patient
28
When is assessment done ?
It's ongoing ! Everytime you see the patient
29
What is the subjective and objective information ?
Subjective - what the patient says ....objective - what is measured by the nurse
30
Dehiscence
Separating of a surgical incision or rapture of a wound closure
31
Serosanguineous
Pale , red , watery - a mixture of serous and sanguineous ...... Blood and serum discharge from the wound
32
Sanguineous drainage
Bright red - indicates active bleeding ......bloody discharge from the wound .
33
Serous
Clear watery plasma
34
Wound vac
Negative pressure , remove debris and drainage , protective barrier , , provides moist healing enviorment , negative wound pressure therapy , change 3x a week for clean wound and 12-24hrs for infected
35
Penrose drainage
Soft rubber tube , placed in the wound arer to prevent build up of fluid
36
Describe different types of surgical drains
Hemovac and Jackson Pratt , tube- tube , Penrose , wound vacuum
37
What factors affect healing ?
Age , nutrition , medication , infection , lifestyles , chronic illness , smoking
38
What factors a affect healing ? Describe ?
AGE - elderly skin fragile ... NUTRITION- diet rich in protein , carbohydrate ...has less supply obese patient to infection & slower healing , EXCERSIZE - regular excersize helps healing , MEDICATION - steroids decrease immunity , thins blood INFECTION - infected wound slows the healing process CHRONIC ILLNESS - diabetes , resp ! SMOKING
39
How is An outcome statement (goal) properly written ?
Patient centered , shorterm or long term , at a certain time frame , realistic , measurable an specific , no vague words eg: want to patient to have less shortness of breath
40
How does the nurse assess the wound prior to the doctor ordering a wound change ?
Palpating , inspection , outline of drainage .... Doctor changes the first dressing .
41
What would signs of internal hemorrhage be ?
Increase heart rate , increase resp rate , decrease , blood pressure , decrease urinary out put , , skin cool and clamp , bruising , swelling , pain , restlessness , , dry skin , skin/blood drainage ... Check for destention -could be pooling
42
Describe healing by primary , secondary , tertiary intentions ?
Primary - clean incision .... secondary - open wound heals by granulation upward ....tertiary - delayed infected closure , due to infection drainage , granulation and the closure
43
Hemovac and Jackson Pratt drainage
A closed drainage system , drains by creating a vaccume , empty when it's half way ,COMPRESS BEFORE CLOSING THE GAP , THE GAP IS WHAT COMMUTE THE VACUME clip to gown , drain sponge dressing before draina
44
How does the nurse prioritize ?
ABC- airway , breathing , circulation & Maslow hierarchy - physical needs before psychosocial needs , safety
45
What is a nursing order ?
Specific instruction on who doing what to the patient , something the nurse can prescribe . Eg: who is taking the patient for a walk , WHO , WHAT , WHEN ,WHERE , WHY
46
What can be done to prevent stress on the incision and dehiscence ?
Avoid straining , no coughing - give cough suppressant , vomit , sneezing GIVE SUPPORT - use pillows to lessen strength , abdominal binder/bindings - to stop the wound called dihescence
47
What factors affect healing ?
Age , nutrition , medication , infection , lifestyles , chronic illness , smoking
48
What factors a affect healing ? Describe ?
AGE - elderly skin fragile ... NUTRITION- diet rich in protein , carbohydrate ...has less supply obese patient to infection & slower healing , EXCERSIZE - regular excersize helps healing , MEDICATION - steroids decrease immunity , thins blood INFECTION - infected wound slows the healing process CHRONIC ILLNESS - diabetes , resp ! SMOKING
49
How is An outcome statement (goal) properly written ?
Patient centered , shorterm or long term , at a certain time frame , realistic , measurable an specific , no vague words eg: want to patient to have less shortness of breath
50
How does the nurse assess the wound prior to the doctor ordering a wound change ?
Palpating , inspection , outline of drainage .... Doctor changes the first dressing .
51
What would signs of internal hemorrhage be ?
Increase heart rate , increase resp rate , decrease , blood pressure , decrease urinary out put , , skin cool and clamp , bruising , swelling , pain , restlessness , , dry skin , skin/blood drainage ... Check for destention -could be pooling
52
Describe healing by primary , secondary , tertiary intentions ?
Primary - clean incision .... secondary - open wound heals by granulation upward ....tertiary - delayed infected closure , due to infection drainage , granulation and the closure
53
Hemovac and Jackson Pratt drainage
A closed drainage system , drains by creating a vaccume , empty when it's half way ,COMPRESS BEFORE CLOSING THE GAP , THE GAP IS WHAT COMMUTE THE VACUME clip to gown , drain sponge dressing before draina
54
How does the nurse prioritize ?
ABC- airway , breathing , circulation & Maslow hierarchy - physical needs before psychosocial needs , safety
55
What is a nursing order ?
Specific instruction on who doing what to the patient , something the nurse can prescribe . Eg: who is taking the patient for a walk , WHO , WHAT , WHEN ,WHERE , WHY
56
What can be done to prevent stress on the incision and dehiscence ?
Avoid straining , no coughing - give cough suppressant , vomit , sneezing GIVE SUPPORT - use pillows to lessen strength , abdominal binder/bindings - to stop the wound called dihescence

Wound Care / Nursing Process (1 decks)

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