Wound management Flashcards
Name the absorbent dressing types
- calcium alginates
- hydrofibers (aquacel), silver impregnated hydrofiber
- silicone foam
- hydrocolloids
- antimicrobial dressing
- crystalline sodium chloride impregnated nonwoven gauze
- hydrogel

What dressing is this?

non-adherent gauze with bizmuth
What are the side effects of Dakin’s?
- Redness
- irritation
- swelling
- pain
What stage of injury is this?

Unstageable pressure injury
What are the side effects of nystatin?
burning, itching, redness, stinging
What are non-modifiable risk factors for pressure injury?
older than 65
history of pressure injury
What are the interventions for candidiasis?
- keep skin dry
- treat with nystatin
- treat Fluconazole PO or IV for widespread rash
What are the dressings used for stage 2 pressure injury?
- silicone foam to absorb moisture and reduce friction
- hydrocolloid for moderate drainage, change every 3 to 5 days
- non-adherent dressing covered with dry gauze and tape (cloth or silicone tape on fragile skin)
- hydrogel with gauze and tape to add moisture to the wound
What are the guidelines for administering Flagyl?
- PO = empty stomach preferred
- IV = infuse over 30 to 60 minutes
topical = cleanse area first, apply in thin layer
What are the contraindication for compression wrap therapy?
- poor result on ankle-brachial index study
- presence of arterial disease
- decompensated heart failure
- actue SOB
What are personal risk factors for arterial ulcers?
- smoking
- advanced age
- diabetes
- HTN
- hyperlipidemia
- family history
- ethnicity
What is important patient teaching for Flagyl?
- do not drink alcohol for 3 days after treatment ends (risk for disulfram-like reaction)
- avoid driving if feeling drowsy
- possible metallic taste
- may have a dry mouth
- urine may turn dark
What interventions for dry, flaky skin?
- petrolatum ointment (avoid between the toes)
- eucerin emollient after bathing
- lacHydrin
- triamcinolone
What stage injury is this?

Stage 3 pressure injury
Name the pressure points on the body
- back of head
- back of shoulders
- elbows
- lower back and buttocks
- hips
- inner knees
- heels

What are the pharmacokinetics of mupirocin?
metabolized in skin, minimal systemic absorption
What steps can be taken to prevent skin tears?
- do not drag patient, use a lift device
- do not use tape or adhesives on sensitive skin
- maximize nutrition and hydration
- do not pull skin when giving care
- moisturize skin with a low pH product
What are the signs a wound is infected?
- pus
- foul odor
- pain
- swelling
- redness
- heat
- fever
- chills
What is the nursing assessment for Flagyl?
- assess for infection (vitals, wound, sputum, urine, stool, WBCs)
- get cultures before starting therapy
- monitor neuro status with IV admin
- monitor liver function tests
What type of wound is this?

Arterial ulcer
What therapeutic class is fluconazole?
systemic antifungal
What are the nursing interventions for peristomal MASD?
- assess for proper stomal appliance placement
- correct and educate on stoma appliance
- crust skin with pectin based powder and then no sting protectant
- use zinc oxide if paste won’t adhere
What is a stage 2 pressure injury?
- partial thickness loss of skin with exposed dermis or
- serum filled blister
- wound bed pink or red and moist
- no slough or eschar present, no granulation tissue

What are some cardiovascular diseases that increase risk for pressure injury?
impaired circulation
peripheral vascular disease, either venous or arterial
edema
MI
GI bleed





















