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Skills Lab Quiz #3
Wounds, PPE, and Blood Glucose
Question | Answer |
---|---|
A force parallel to the skin surface. | Friction |
Combination of friction and pressure. | Shearing Force |
Due to localized ischemia. | Pressure ulcers |
Promotes skin maturation and skin excoriation. | Incontinence |
4 stages of pressure ulcer formation | Nonblanchable, partial-thickness, full-thickness skin loss, full-thickness skin loss with tissue necrosis. |
What signals potential ulceration? Doesn't turn white. | Nonblanchable erythema |
Stage of pressure ulcer formation that involves skin loss involving the epidermis. | Partial-thickness skin loss. |
Stage of pressure ulcer formation involving damage or necrosis of subcutaneous tissue that may that may extend down to, but not thru, underlying fascia. | Stage: III. Full-thickness skin loss involving damage or necrosis. |
Stage of pressure ulcer formation that involves skin loss with tissue necrosis or damage of muscle, bone, or supporting structures. | Stage IV .Full-thickness skin loss. Involves tissue necrosis. |
Impaired skin integrity | Stage I and II |
Impaired tissue integrity | Stage III and IV |
Risk assessment tools/ Use of Braden Scale consists of 6 subscales: | Sensory perception, moisture, activity, mobility, nutrition, and friction & shear. 23 points possible. |
Epidermis affected only. Partial thickness Nursing Diagnoses: impaired skin integrity | Stages I and II Pressure Ulcer Formation |
Full-thickness In dermis Nursing diagnoses: impaired tissue integrity | Stages III and IV Pressure Ulcer Formation |
Bright red flush. If pushing on it, it doesn't turn white. | Reactive Hyperemia |
Etiology of pressure ulcers | Reactive hyperemia |
When using the Braden Scale, what point total is the client at risk for a pressure ulcer? | 18 points |
Three types of healing influenced by amount of tissue loss. | Primary, Secondary, and Teritary |
Repair time is longer, scaring is greater, susceptibility to infection is greater. | Secondary intention |
Occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss. | Primary intention |
Example of primary intention | Closed surgical incision |
A wound that is extensive and involves considerable tissue loss, and in which the edges cannot or should not be approximated. | Secondary intention |
Delayed primary intention | Teritary intention |
Wound left open to allow edema/infection to resolve. | Teritary intention |
Phases of wound healing | Inflammatory phase, proliferative phase, and maturation phase. |
Phase of wound healing immediately after injury. Lasts how long? | Inflammatory phase Lasts 3 to 6 days |
2 major processes occurring in inflammatory phase: | Hemostasis and phagocytosis |
Cessation of bleeding | Hemostasis |
Macrophages engulf microorganisms and cellular debris. | Phagocytosis |
Phase of wound healing: post injury. Last how long? | Proliferative phase. Extends from day 3 or 4 to about 21. |
Phase that occurs 24 hrs. after injury fibroblasts migrate and begin to synthesized collagen. As amount of collagen increases so does wound strength. | Proliferative phase |
Phase of wound healing that begins about day 21 to 1 or 2 years after injury. | Maturation phase |
Phase where in order for healing to take place, oshcar needs to be surgically removed. | Proliferative phase |
Phase where fibroblasts continue to synthesize collagen. Collagen fibers reorganize into a more orderly structure. | Maturation phase |
Wound is remodeled and contracted. | Maturation phase |
Material, such as fluid and cell, that has escaped from blood vessel during inflammatory process and is deposited in tissue or on tissue surfaces. | Exudate |
Chiefly of serum | Serous |
Clear (watery) | Serous |
Pus | Purulent (exudate/drainage) |
Yellow, green, brown blue, depends on bacteria. | Purulent (exudate/drainage) |
Large amounts of RBC indicating damage to capillary that is severe enough to allow escape of RBC from plasma. | Sanguineous (hemorrhagic) (exudate/drainage) |
Watery red (exudate/drainage) | Serous/Sanguineous (exudate/drainage) |
Clear/pus infected (like a scrape) | Poroserous (exudate/drainage) |
3 major types of wound exudates/drainage | Serous, purulent, sanguineous |
Massive bleeding. | Hemorrhage |
Greatest risk during first 48 hours after surgery. | Hemorrhage |
Partial or total rupture of a sutured wound. | Dehisence |
Factors increasing the risk of dehisence: | Obesity, poor nutrition, multiple trauma, failure of suturing, excess coughing, vomiting, and dehydration. |
Protrusion of the internal viscera thru an incision. (internal stuff pops out) | Evisceration |
4 complications of wound healing | Hemorrhage, infection, dehisence, and evisceration |
When excessive bleeding (hemorrhage) is occurring after surgery what is the necessary steps? | Reinforce bandage and contact doctor immediately. |
4 factors affecting wound healing | Development, nutrition, lifestyle, and medications |
Malnourished patients require what in regards to wound healing? | Require time to improve their status before surgery, such as obesity. |
What type of lifestyle affects wound healing | Smoking decreases function of hemoglobin. |
What types of medications affect wound healing? | Anti-neoplastic (chemo) and anti-inflammatory agents interfere. Prolonged = resistant organisms due to infection. |
Seen right after an injury. Important to assess what? | Untreated wounds; assess for signs of shock. |
Sutured wounds are an example of what? | Treated wounds |
Assessed to determine progress of healing. | Treated wounds. Always assess with each wound change. Assess drainage on dressing. |
Examples of wound drainage saturation on dressings | Minimal, moderate, heavy |
When treating wounds the nurse should observe what? | Appearance, size, drainage, and any swelling, pain, or status/draining of tubes (are they intact?) |
Localized signs and symptoms of infection | Localized: Swelling, redness, pain or tenderness w/palpation or movement Palpable heat at infected area Loss of function of body part affected, depending on the sight, extent of involvement, or movement |
Systemic signs and symptoms of infection | Fever Increase pulse or respiratory rate Malase (feeling blah) and loss of energy Anorexia (loss of appetite) Enlarge tenderness of lymph nodes that drain the area. |
Risk for impaired skin integrity | Nursing diagnoses |
4 ways to support wound healing | Moist wound beds, fluids/nutrition, infection prevention, and positioning. |
Beds that are too dry or disturbed too often fail to heal. How would you support this wound to heal? | Moist wound beds |
When supporting wound healing, how much fluid should the patient be given? | 2500 ml/day |
When supporting wound healing, why is it essential to receive sufficient nutrition? | To receive sufficient protein, which helps promote healing. |
What vitamins should be included when getting sufficient nutrition for wound healing? | Vitamins: C, A, B12, and B5 and zinc. |
Prevents micros from entering the wound. | Infection |
Prevent bloodborne pathogens to/from client to others. | Contamination |
What is another name for contamination? | Transmission |
What id off-loading? | Positioning |
What is the purpose of positioning? | To keep pressure off the wound. And assisting to be as mobile as possible to enhance circulation. To promote wound healing. |
4 ways to prevent pressure ulcers | Providing nutrition, maintaining skin hygiene, avoiding skin trauma, and providing supportive devices. |
Adequate intake of calories, protein, vitamins, and iron. | Providing nutrition to prevent pressure ulcers |
Why does monitoring weight regularly help in preventing pressure ulcers? | Helps to assess nutritional status. |
When preventing pressure ulcers, lab work is done looking for what? | Albumin, lympho count, protein, and hemoglobin. |
When preventing pressure ulcers, what should you be doing to maintain skin hygiene? | Assess daily, minimize force and friction, mild cleansing agents, avoid hot water, avoid exposure to cold and low humidity. Put lotion on skin will help to maintain skin hygiene. |
How do we avoid skin trauma when preventing pressure ulcers? | Smooth, firm, and wrinkle free foundation (to sit/lay). Positioning and turning correctly as indicated (max 2 hrs) are important for client. |
Based on color of open wound rather than depth and size. | The RYB color code. |
Protect (cover). Ready to heal. Late regeneration phase of tissue repair. | Red (RYB color code) |
Slough - liquid to semi-liquid. Accompanied by purulent drainage or prevent infection. | Yellow (RYB color code) |
Remove nonviable tissue (Debridement wet to damp dressing) | Yellow (RYB color code) |
Debride eschar | Black (RYB color code) |
Thick necrotic tissue | Eschar |
Must be done before wound can heal | Debridement |
4 ways of debridement | Sharp, mechanical, chemical, autolytic |
Scalpel or scissors are used | Sharp debridement |
Scrubbing force or moist to moist dressings. | Mechanical debridement |
Spraying | Mechanical debridement |
More selective than sharper mechanical | Chemical debridement |
Dressings contain wound moisture and trap eschar. Body's own enzymes in drainage break down necrotic tissue. | Autolytic debridement |
Type of debridement that takes longer. | Autolytic |
Most selective debridement | Autolytic |
Type of debridement that causes the least amount of damage. | Autolytic |
If deep | you fill it |
If wet | absorb it |
If dry | moisten it |
If shallow | cover it |
Soft, gray, yellow | Slough |
7 types of dressings | Transparent film, impregnated nonadherent, hydrocolloids, clear absorbent acrylic, hydrogels, polyurethane foams, alignates (exudate absorbers) |
Stage 1 only. Will keep from going to a stage 2. | Transparent film |
Post operative (give example also) | Impregnated nonadherent (Telfa) |
Protect wound from drying. Stage 2 and 3. | Hydrocolloids |
Minimal to moderate drainage. Stage 2 and 3. | Hydrocolloids |
Thin for skin tears or friction | Hydrocolloids |
Can be used fir stage 4 only if not draining. | Hydrocolloids |
Always used for excessive drainage. | Alignates |
What is alignates? | Exudate absorbers |
Used for stage 4 or non-stageable. (example) | Alignates (seaweed) |
Glycerin or water-based nonadhesive jellylike sheets. Oxygen permeable. | Hydrogels |
To liquefy necrotic tissue or slough, rehydrate the wound bed, and fill in dead space. | Hydrogels |
Used with IV dressing, central line dressing, superficial wounds, and pressure ulcers stage 1. | Transparent film |
Used to prevent skin irritation. | Montgomery straps (tie straps) |
Used for wounds that require frequent dressing changes. | Montgomery straps (tie straps) |
When taping a wound what do you always do first? | Always do middle first. Taping 2/3 to 1 inch of skin. |
When taping over a joint what should you do? | Place tape in the opposite direction from the body action. Example = across a body joint or crease, not lengthwise. |
What type of pressure does a vacuum-assisted closure (VAC) use? | Applies negative pressure |
What is the purpose of using a VAC? | To stimulate (speed up) formation of granulation tissue. |
When removing a VAC what should you do to decrease pain? | Squirt 1% lidocaine before removing. |
What should you never use VAC for? | Never give to: Fistula to organs or cavities, necrotic tissue, malignancy in wound margines, untreated osteomalitice. Patients with a heparin drip |
Another form of VAC? (2) | Hyperbaric oxygen chamber Growth factors |
What does the hyperbaric oxygen chamber do? | Promotes angiogenesis, stimulates collagen synthesis. |
When using hyperbaric chamber you should never do what? | Never give 100% oxygen |
Approximate cost of hyperbaric chamber? | Approx. $1200 per hour |
Cream used to put in wound. Very expensive. | Growth factor (costs about $200 for 2gm). |
Strips used for blood glucose monitors. | Reagent strips |
Capillary blood specimen is often taken to measure what? | Blood glucose. (Capillary blood) |
What part of finger is the capillary blood specimens commonly obtained from? | The lateral aspect or side of finger in adults. |
What part of body can be used when patient is in shock or the fingers are edematous. | Earlobe |
What can cause an inaccurate reading when doing blood glucose monitoring? | Smearing of the blood. |
Purpose of PPE? | To protect health care workers and clients from transmission of potentially infective materials. |
Can be either local or systemic and may take the form of dermatitis, urticaria (hives), asthma, or anaphylaxis. | Latex allergies |
When putting on a gown what should you do? | Overlap the the gown at the back as much as possible, and fasten the waist ties or belt. |
Why should you overlap the gown in back as much as possible? | Securely covers the uniform at the back. |
Why should you use waist ties? | Keeps the gown from falling away at from the body which can cause inadvertent soiling of the uniform. |
How do you avoid clouding of the glasses with PPE? | Place the edge of the mask under the glasses. |
When removing a mask with strings what should you do first? | Untie the lower strings first to prevent the top part of the mask from falling onto chest. |
When removing a mask, why shouldn't you touch the front of the mask? | The front of the mask through which the nurse has been breathing is contaminated. |
Factors that inhibit wound healing in the elderly: | Vascular changes, collagen tissue is less flexible, scar tissue is less elastic, cell renewal is slower, impaired oxygen to tissues can delay healing. |
What is an example of delayed healing due to impaired oxygen delivery to these tissues? | Diabetes or cardiovascular disease |