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EPCC Nursing Foundations > Wound Collection Retain > Flashcards

Wound Collection Retain Flashcards

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1
Q

What are they two types of testing for wounds?

A

Culture and sensitivity

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2
Q

What does a sensitivity wound culture determine?

A

Proper antibiotic therapy

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3
Q

What does a wound culture determine?

A

organisms that grow in the presence oxygen (aerobic) or without oxygen (anaerobic)
administer analgesic 30 min before procedure

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4
Q

Where should the nurse collect the specimen from ?

A

The center of the wound - NOT from the edges because it could contain skin flora and the procedure has to be repeated

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5
Q

Two things to never do when collecting a wound specimen are

A
  1. never collect from pus or pooled exudates
  2. never touch the swab to the outside of the test tube
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6
Q

Do you use the same swab in the drainage?

A

no
you rotate sterile swabs in the drainage

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7
Q

What makes a sputum specimen contaminated?

A

saliva

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8
Q

How much sputum is needed for a specimen collection?

A

1-2 tsp of sputum

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9
Q

What time of the day should sputum specimens be collected? and what is the rationale?

A

Collect sputum first thing in the morning before eating or drinking - the results are more accurate

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10
Q

What are ways to reduce contamination of sputum specimen?

A

clearing the nose and throat
rinsing the mouth

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11
Q

Which method is used to help a pt who is only producing saliva in specimen cup?

A

chest physiotherapy (postural drainage to help mobilize mucus and facilitate expectoration)

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12
Q

To collect a specimen of sputum, what is the method so that it is performed correctly?

A

Early in the morning 3 days in a row

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13
Q

Where are throat specimens collected?

A

Oropharynx or tonsillar region using a sterile swab.

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14
Q

A throat specimen can be contaminated if the sterile swab touches which parts of the mouth?

A

gums
tongue
teeth

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15
Q

Which is more accurate point of care (in the medical facility) or the lab?

A

Lab testing is more accurate

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16
Q

What are the risks of collecting specimens that can lead to a false positive or false negative?

A

storage conditions
poor method of specimen collecting
not rotating sterile swabs

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17
Q

Which solutions are used to irrigate or clean wounds

A

Isotonic saline
wound cleansers

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18
Q

If an antimicrobial solution is used to irrigate or clean a wound the nurse needs to ensure the solution is

A

diluted

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19
Q

Why is it contraindicated to microwave liquids or used cold liquids on a wound

A

lowering the wound temperature slows down the healing process
microwaving the solution could make it too hot

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20
Q

Solutions that are going on a wound should be this temperature

A

warm the solution to body temperature

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21
Q

Why should the nurse avoid drying the wound after cleaning it

A

helps retain wound moisture

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22
Q

If a wound is clean, has little exudate, and reveals healthy granulation (lumpy pink tissue containing new connective tissue and capillaries form around the edges of the wound), the nurse should avoid doing this and why

A

the nurse should avoid repeated cleaning because unnecessary cleaning can delay wound healing by traumatizing the newly produced tissues

if the wound appears clean, consider not cleaning it at all

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23
Q

What factors affect wound healing?

A

mental illness (they are not thinking of staying clean)
medications (antibiotics - tetracyclines, corticosteroids)
suppressed immune system
anti-neoplasm (drugs that are used to treat cancer)
cyclo-therapeutics
poor nutrition

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24
Q

What are tetracyclines and corticosteroids and how do they affect wound healing?

A

o corticosteroids - anti-inflammatory
-reduces swelling in mucous membranes
- increases risk of infection
o tetracycline - protein synthesis inhibitor antibacterial
- slows protein synthesis preventing bacterial from forming bacteria uses protein to stay alive and multiply

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25
Q

How does tetracycline affect wounds

A

fights infection caused by bacteria

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26
Q

Hoe does corticosteroids affect wound healing

A

they increase risk for infection and they delay wound healing
skin thinning

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27
Q

How does a suppressed immune system affect wound healing

A

it causes a delay in wound healing because it effects fibroblast proliferation (migration toward wound) and angiogenesis (formation of new blood vessels)

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28
Q

Define reactive hyperemia

A

when the pressure is relieved the skin will turn a bright red flush color (erythema)
the red face you get when sleeping on the desk

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29
Q

if reactive hyperemia does not go away, what does this indicated

A

tissue damage has occurred

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30
Q

Is reactive hyperemia a pressure ulcer

A

NO

31
Q

What is a stage 1 pressure ulcers

A

unbroken skin and red but does NOT blanch

32
Q

what is a stage 2 pressure ulcer

A

partial thickness skin loss (2 layers - epidermis and dermis affected)

33
Q

Abrasions and blisters are examples of white stage of pressure ulcer or partial thickness loss

A

stage 2

34
Q

describe stage 3 pressure ulcers

A

full thickness loss
damage to the subQ layer
could reach as deep as the fascia and adipose tissue
CANNOT SEE BONE YET

35
Q

describe stage 4 pressure ulcers

A

full thickness loss and damage to muscle and bone

36
Q

muscle and bone damage to the sacral and greater trochanter is considered what stage of pressure ulcer

A

stage 4

37
Q

How does a partial thickness wound heal

A

regeneration

38
Q

how does a full thickness wound heal

A

complete tissue repair

39
Q

Describe maceration

A

moisture from fecal or urinary matter
the tissue is softened by prolonged wetting making the epidermis more easily eroded and at risk for injury

40
Q

If the skin is wrinkled and damaged by moisture from a swimming pool this is called

A

maceration

41
Q

this object contributes to shearing and friction

A

linen (the raised sewn part)

42
Q

The Braden scale is used to assess pts at high risk for a pressure injury, this scale has the max point of

A

23 points

43
Q

An adult who scores between this range on the Braden scale is at risk for developing a pressure injury

A

18-19

44
Q

Describe the primary intention healing of the wound healing process

A

closed or approximated
edges are closed by sutures or tissue adhesive

45
Q

How does the primary intention healing of wound healing process look

A

closed surgical incision

46
Q

Describe how a secondary intention healing of wound healing is different from the primary phase

A

longer repair time
scaring time is greater
risk for infection is greater

47
Q

What does the secondary phase of wound healing look like

A

bigger tissue loss
edges around wound are big
heals through granulation and regeneration from the inside out

48
Q

How does the secondary intention healing of wound healing heal

A

heals through granulation and regeneration from the inside out

49
Q

If the first layer of a dressing becomes soiled, what does the nurse do

A

apply a second layer because blood clots might be disturbed if the first layer of dressing is taken off

50
Q

If the nurse suspects internal bleeding or severe bleeding she will asses for signs of shock which are

A

rapid thready pulse
cold clammy
pallor
low BP

51
Q

Describe the tertiary intention healing

A

the wound is left open
edema
infection
exudate

52
Q

If a pt falls, which type of therapy will the nurse get ready for the pt

A

cold therapy

53
Q

What is occurring during regeneration

A

granulated tissues grow like collagen and protein synthesis occurs

54
Q

The phases of healing are

A

inflammation phase
proliferative phase
maturation phase

55
Q

Which type of medication impairs the inflammatory phase

A

steroids
corticosteroids

56
Q

When does the inflammation phase begin

A

immediately after injury and last for 3-6 days

57
Q

What is occurring in the inflammatory phase

A

homeostasis
phagocytosis
fibrin - migration of the epithelial cells

58
Q

When does the proliferative phase begin

A

from day 3 or 4 - 21 days postinjury

59
Q

What is occurring in the proliferative phase

A

o collagen
o granulation tissue (connective tissue + new capillaries)
o eschar (necrotic tissue if the wound does not heal by epithelialization)
o serosanguinous (blood - red) [healing by secondary intention - healing by the inside out {granulation + regeneration}}

60
Q

When does the maturation phase begin

A

~day 21 and can last 1-2 years post injury

61
Q

What is occurring in the maturation phase

A

fibroblasts are synthesizing collagen and the scar becomes stronger

62
Q

Keloids are formed during which phase

A

maturation

63
Q

How do you get rid of keloids

A

abd

64
Q

How can the nurse teach a pt how to take care of a wound at home

A

determine their current level of knowledge taking care of a wound (understanding the risk of pressure injuries or the cause of the wound)
self- care abilities for mobility and wound care - can they ambulate and change positions, can they see the wound or have the hand coordination to change it out
teach that nutrition plays a key role in wound healing

65
Q

Which nutrients are important for wound healing

A

iron
vitamin B and C (water soluble)
fluid
protein
calories

66
Q

Why does the blood for reactive hyperemia rush to the area

A

compensative

67
Q

bright sanguineous bleeding indicates

A

fresh bleeding

68
Q

dark sanguineous bleeding indicated

A

older bleeding

69
Q

Define evisceration

A

the protrusion of the internal oragans through an incision

70
Q

A viscera rupture in surgery is called

A

evisceration

71
Q

If evisceration happens to a pt, what does the nurse do

A

get a dressing with sterile saline

72
Q

Describe debridement

A

removing damaged tissue or foreign objects from a wound removal of necrotic material

73
Q

list the kinds of exudate

A

purulent
serous
sanguineous

EPCC Nursing Foundations (43 decks)

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