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FUN 1
Wound Care Skills
| Question | Answer |
|---|---|
| What does nonpathogenic mean? | Harmless, do not produce disease |
| What does pathogenic mean? | Cause specific diseases or infections |
| What does asepsis mean? | Absence of pathogenic microorganisms |
| What does medical asepsis mean? | Techniques that inhibit growth and transmission of pathogenic microorganisms, clean technique |
| What does surgical asepsis mean? | Techniques that destroy all microorganisms and their spores, sterile technique |
| What is a nosocomial infection? | Infection acquired while in the hospital or other health care agency |
| What does the CDC define as "Standard precautions"? | To interrupt the chain of infection & transmission of blood-borne pathogens and other potentially infectious materials |
| What is the best way to prevent infections in patients in the health care system? | Hand hygiene |
| What is proper hand hygiene? | Wash hands before & after pt. care, touching body fluids, secretions, excretions, and contaminated equipment; between pt. contact; and immediately after removing gloves |
| What is important to remember when gloving? | Wear the correct size |
| What are the "standard precautions"? | Hand hygiene, gloving, gowning, mask & protective eyewear |
| What is the first tier of CDC's isolation guidelines? | Standard precautions |
| What is the second tier of CDC's isolation guidelines? | Disease specific isolation; transmissions categories: airborne, droplet, & contact precautions |
| Which way does the label face when pouring sterile solutions? | Towards palm |
| What is important to remember when teaching patients for infections prevention & control | Both patient & families have to learn to use infection prevention & control practices at home. Need to be aware of how infection is spread & ways to prevent transmission. Educate about techniques used to control spread of infection |
| What physical changes in the skin do you look for when assessing patient? | Color, texture, thickness, turgor, temperature, and hydration |
| What is impaired skin integrity? | Pressure ulcers |
| When do pressure ulcers occur? | Sufficient pressure on the skin to cause the blood vessels in an area to collapse |
| What are the factors that play a role in pressure ulcers? | Unrelieved pressure, friction & shearing force |
| What is the definition of pressure ulcer? | Localized injury to the skin or underlying tissue, usually over a bony prominence cause by pressure with shear or friction |
| How many stages are there to pressure ulcers? | Four |
| What is Stage I of pressure ulcer? | Localized area of skin intact with nonblanchable redness |
| What is Stage II of pressure ulcer? | Partial-thickness loss of dermis |
| What is Stage III of pressure ulcer? | Full-thickness tissue loss in which subcutaneous fat is sometimes visible, but bone, tendon, and muscle are not exposed |
| What is Stage IV of pressure ulcer? | Involves full-thickness tissue loss with exposed bone, tendon, or muscle |
| What is an Unstageable/unclassified pressure ulcer? | Involves full-thickness tissue loss, a wound base covered by slough (yellow, tan, gray, green, or brown) and eschar in the wound bed that usually is tan, brown, or black |
| What is a "suspected deep tissue injury"? | Wound appears as a localized purple or maroon area of discolored intact skin or a blood-filled blister |
| What are nurse interventions to skin care? | Assess for improvement, document size and depth of ulcer, amount and color of exudate, presence of pain, appearance of exposed tissue (press gently to check for blanching) |
| How many phases are there to wound healing? | Four |
| What is the 1st stage of wound healing? | Homeostasis - Termination of bleeding, begins when injury occurs |
| What is the 2nd stage of wound healing? | Inflammatory - Initial increase in flow of blood elements and water out of the blood vessels into vascular space. Causes cardinal signs & symptoms of inflammation (redness & swelling is normal during inflammatory) |
| What is the 3rd stage of wound healing? | Reconstruction - Collagen formation, appears as irregular, raised, purplish, immature scar. Dehiscence most frequently occurs during reconstruction |
| What is the 4th stage of wound healing? | Maturation - Fibroblast exit the wound, wound gains strength, healed wounds rarely return to strength tissue had prior to surgery, keloids may form |
| What is a keloid? | Overgrowth of collagenous scar tissue at the site of a wound |
| What holds a clot together? | Fibrin |
| How many processes are there to wound healing? | Three |
| What is the 1st process to wound healing? | Primary intention - Wound is made surgically, skin edges are close together, minimal scarring results, process begins during the inflammatory phase of healing |
| What is the 2nd process to wound healing? | Secondary intention - Healing occurs when skin edges are not close together or when pus has formed, wound may have purulent exudate |
| What is the 3rd process to wound healing? | Tertiary intention-Occurs with delayed suturing of a wound in which two layers of granulation tissue are sutured together. Occurs when a contaminated would is left open & sutured closed after the infection is controlled or a primary wound becomes infected |
| What are the affecting factors in healing? | Nutritional needs, fluids, rest & activity, |
| What nutrients are key to healing process? | Vitamin A & C, protein & zinc |
| What is purulent fluid? | Producing or containing pus |
| Do surgical wounds that are aseptically created heal slow or quick? | Quick |
| What is a wet-to-dry dressing primary purpose? | Mechanically debride a wound, the moistened contact layer of the dressing increases the absorptive ability of the dressing to collect exudate and wound debris. As the dressing dries, it adheres to the wound & debrides it when removed |
| What commonly used wetting agents in a wet-to-dry- dressing? | Normal saline & lactated ringers solution, acetic acid, sodium hypochlorite solution, povidone-iodine, & antibiotic solutions |
| Would a wet-to-dry dressing be appropriate for a pressure ulcer? | Yes |
| What are transparent dressings? | Self-adhesive film that is synthetic permeable membrane that acts a temporary secondary skin |
| What is the best way to avoid fluid retention when irrigating a wound? | Position patient on his/her side to encourage flow of the irrigant away from the wound |
| What is the purpose of irrigation? | Promote wound healing through the removal of debris from a wound surface decreasing bacterial counts, and loosening & removing eschar |
| What is the proper way to irrigate a wound? | Least contaminated to most contaminated |
| Why do you irrigate wound least contaminated to most contaminated? | Prevent cross contamination |
| What may bleeding in a wound indicate? | Slipped suture, dislodged clot, coagulation problem, or trauma to blood vessels or tissue |
| What is an indication of internal bleeding? | Dressing may be dry while abdominal cavity collects blood. HR will be increased, BP will be decreased & urinary output will be decreased |
| Define Dehiscence (Dehiss)? | Wound layer separate, pt. may say "something has given way", it may result after periods of coughing, sneezing, or vomiting, may be preceded by serosanguineous drainage |
| What are nursing interventions for Dehiss? | Pt. should remain in bed & be NPO, be told not to cough, and be reassured. Place warm, moist sterile dressing over the area until provider evaluates the site |
| Define Evisceration? | Abdominal organs protrude through an opened incision |
| What are nursing interventions for evisceration? | Pt. is to remain in bed, and the wound & contents should be covered w/warm, sterile, saline dressings. Surgeon should be notified immediately (this is medical emergency, & wound requires surgical repair) |
| When does the CDC label a wound as "infected"? | It contains purulent drainage |
| What will a patient with an infected wound present with? | Fever, tenderness, and pain @ the wound site; edema and an elevated WBC |
| Describe purulent drainage? | Odor, brown, yellow or green, depending on the pathogen |
| Define exudate | Fluid, cells or others substances that have slowly exuded from cells or blood vessels through small pores or breaks in the cell membrane |
| Define drainage | Removal of fluids from a body cavity, wound or other source of discharge through one or more methods |
| Define serous | Clear, watery plasma |
| Define sanguineous | Bright red; indicates active bleeding |
| Define serosanguineous | Pale, red, watery; mixture of serous & sanguineous |
| What do you assess when checking drainage? | Color, amount, consistency & odor |
| What is a T-Tube? | Drainage tube frequently inserted into the duct to maintain a free flow of bile, it exits through the abdominal incision or a separate surgical wound, it drains via gravity into a closed drainage system (bag is emptied & measured every shift) |
| What does wound vac mean? | Vacuum - assisted closure device |
| What is a wound vac? | Negative-pressure wound therapy |
| What is the Jackson-Pratt drain? | Closed drainage system that uses a bulb to provide the needed vacuum |
| What is an open drainage system? | Rubber/plastic used to remove exudate from the wound and deposit it out through the skin onto a dressing |
| What is the Penrose drain? | Sterile safety pin placed through the drain to keep it from sliding into the wound |
| What is a Hemovac? | Table vacuum container that is an expandable unit connected by tubes to the drainage site |
| What are the nursing interventions after a bandage is applied? | Assess, document & immediately report changes in circulation, skin integrity comfort level, and body function such as ventilation or movement |
| What is a closed wound? | Underlying tissue of the body is involved; top layer of skin is not broken |
| What are nursing interventions for closed wound? | Small - ice packs & elastic bandage; Large - treat for shock, cold compresses & pressure bandage |
| What is a open wound? | Openings or breaks in the mucous membrane or skin; they are always in danger of bleeding or infection |
| What are types of open wounds? | Abrasions, punctures, incisions, lacerations, avulsions & chest injuries |
| What is ablative surgery? | Excision or removal of diseased body part (amputation, removal of appendix, cholecystectomy |
| What are influencing factors for the older patient in surgery? | Recovers more slowly, increased risk of aspiration, atelectasis, pneumonia, thrombus formation, infection, & altered tissue perfusion (pressure ulcer), increased risk for disorientation & toxic reactions, teaching time may be prolonged |
| What are the 6 steps to controlled coughing? | Take several deep breaths, Inhale through nose, Exhale though mouth w/ pursed lips, Inhale deeply again & hold breath for count of three, Cough two or three consecutive times w/out inhaling, caution against clearing throat |
| What do leg exercises prevent? | Venostasis |
| What is a pneumatic compression device? | SCD - Sequential Compression Device |
| What are antiembolism stockings called? | Ted hose |
| What is the best is the best way to prevent venostasis & sluggish bowels? | Ambulation |
| How long do you need to listen for bowel sounds before you can notate that bowel sounds are absent? | 3 mins/quadrant |
| What is the role of the circulating nurse? | Prepares necessary equipment, arranges sterile & non-sterile supplies, performs appropriate assessments, counts sponges, needles, and equipment after surgery, observes for break in sterile technique |
| What is the order of thorough assessment when a patient goes to PACU? | Airway, Breathing, LOC, Circulation, System assessment |
| When can you give patient pain meds? | If they are PRN, when they ask for them |
| What are signs/symptoms for shock? | Tachycardia, restlessness, pale, moist skin, weak & thready pulse, cyanotic skin |
| What is a sign/symptom for pulmonary embolism? | SOB/Chest pain |
| What is the 1st sign of hemorrhage? | Restlessness |
| When do you do incision assessments? | Every 2-4 hours |
| What do you assess for incision assessments? | Bleeding, color, exudate, temperature, drainage, wound edges, monitor for evisceration |
| What is objective data when assessing for pain? | Increased pulse rate, restlessness, moaning, guarding |
| What is subjective data when assessing for pain? | Patient reports pain, pain scale assessment, OPQRST |
| Is addiction an issue for regular surgery? | No |
| What do you assess for venostasis? | Strength of pedal pulses, edema in legs, aching legs, redness in legs, skin color, skin temperature |
| What should discharge instructions include? | Wound care guidelines, medications, activities, when to call the doctor, when to follow up |
Created by:
tandkhopkins
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