Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Nursing Skills
Test 2 - LP 4
| Question | Answer |
|---|---|
| What are the five goals of wound care? | to keep the wound moist , clean, protect from trauma or invasion, manage pain and support healing |
| What are the three reasons that pain management is important? | Pain stresses the body and slows healing, decreases appetite and decreases mobility |
| What are some examples of causes of wound pain? (8) | wet to dry dressing, adhesives, whirlpool, acetic acid, tight compression, edema, infection, pressure |
| What two types of methods should be used instead of wet/dry or whirlpool? | enzymatic or autolytic |
| What is the best product to use when cleaning a wound? | normal saline ( warm) |
| To reduce pain, dressings should be | non adherent |
| To properly address exudate management you need to choose the correct | dressing |
| What product should be used on the healthy skin surrounding the wound? | skin prep |
| Deaden the nerve endings in the skin, applied directly to skin | topical local anesthetic |
| Ibuprofen is an example of a | non opioid medications |
| Percocet,Vicodin are examples of | opioids |
| drugs whose initial use was not for pain but rather for other conditions. They are a diverse group of drugs that includes antidepressants, anticonvulsants (ant seizure drugs), and others. | adjuvant medications |
| How soon should you medicate before treatment if using parenteral route? | 15- 30 min |
| How soon should you medicate before treatment if using the oral route? | 30-60 min |
| After giving a pain medication and before treating the wound you should | always assess effectiveness of drug |
| What non pharmacologic techniques can be used for pain relief? (4) | distraction, relaxation, imagery, deep breathing |
| Moist wound healing promotes the production of ____ in the wound bed. | collagen |
| Moist wound healing prevents the production of | crust or scab formation |
| Moist wound healing aids in the _____ cell migration | epidermal |
| Moist wound healing reduces infection. True/ False | TRUE |
| Moist wound healing traps ____ enzymes which enhance ____/ | lytic, autolytic debridement |
| What needs to be documented about the wound? (11) | location, extent of tissue loss/stage, granulation, measurements, odor, wound edges, drainage, undermining, tunneling, surrounding skin, pain |
| The appearance in color(s) of the wound is measured in | percent |
| Beefy red, healthy pink | granulation |
| Light pink, usually around the edges | epithelialization |
| Black eschar, yellow slough | necrotic |
| Term used to describe when healthy skin turns white from too much moisture | maceration |
| What are the four characteristics of healthy wound | bright red, moist, shiny, does not bleed easily |
| What are the four characteristics of an unhealthy wound | dark red/blue/pale, dehydrated, dull, bleeds easily/fragile |
| Clear portion of the blood, watery | Serous |
| Portion of the fluid that contains a large number of RBCs, looks like blood, thin and watery | Sanguineous |
| Portion of fluid that is made up of WBC, liquefied tissue debris, dead and live bacteria, thick, musty foul odor, color dependent on causative organism | Purulent |
| Combination fluid from blood is called | serosanguineous |
| Cleaning away devitalzed tissue and foriegn matter from a wound. | Debridement |
| Body's own cells breakdown tissue | Autolytic |
| In the autolytic method, what two things work to liquefy the necrotic tissue? | WBC's and enzymes |
| Does the autolytic method keep the necrotic tissue and eschar together? | no it separates them |
| Resectioning skin by removing necrotic tissue with a sharp instrument is called | surgical/sharp debridement |
| Applying enzymes to wound surface such as Panafil, Papain, UPS to assist with debridement is called | enzymatic debridement |
| What are three forms of mechanical debridement? | wet/dry, maggots, pressurized irrigation |
| From what direction should a dressing be removed? | the center |
| After removing the dressing, what two things should be assessed? | drainage and odor |
| When providing wound care are clean or sterile gloves to be used? | clean |
| What are two examples of when we would use sterile gloves for wound care? | new surgical wounds, fresh acute trauma |
| When cleaning a wound we always move from ___ to ____, even when irrigating. | clean, dirty |
| When choosing dressing, consider one that absorbs ____ while keeping wound_____. | exudate, moist |
| Moist dressing should placed only on the________. | wound surface |
| Explain procedure for using a moist saline dressing | moisten gauze, wring out moisture, open and fluff and fill wound spaces without excessive pressure, cover with dry dressing, REMOISTEN TO REMOVE |
| What is the downside to using a wet/dry dressing? (2) | dries over time and debrides wound, can be very painful |
| What are transparent dressings made out of | adherent polyurethane |
| Are transparent dressings waterproof? | yes |
| What are three examples of when a transparent dressing could be used? | abrasions, skin tears, stage 1 pressure ulcer |
| What is the wear time for a transparent dressing? | up to seven days |
| Water impermeable polyurethane with gelatinous outer covering | hydrocolloid |
| What type of ulcer and for what type of drainage the hydrocolloid be suited for? | State II pressure ulcers, small to moderate drainage |
| What type of debridement does a hydrocolloid provide? | Autolytic |
| Is a hydrocolloid a primary or secondary dressing? | secondary |
| What is the wear time for a hydrocolloid? | three to seven days |
| Polymers with water content 90-95% semitransparent, non adherent | hydrogels, gels |
| In what three forms are hydrogels available? | gels, sheets, impregnated gauze |
| What are the three benefits of using a hydrogel? | comfortable, permeable, absorptive |
| In what case would a hydrogel be used? | partial to full thickness wound with no exudate |
| What type of debridement is achieved when using a hydrogel? | Autolytic |
| How often is a hydrogel changed? | daily |
| Dressing derived from seaweed that forms thick gel as it mixes with wound drainage | calcium alginates or hydrofibrils |
| In what two forms are alginates available? | sheet or rope |
| How absorbent are alginates? | very absorbent, hemostatic |
| When would we use an alginate? | partial to full thickness wound with moderate to heavy exudate |
| How often is an alginate dressing changed? | every 1-2 days |
| What is a dressing that is best suited for heavily draining wounds? | foams |
| What are foams made out of? | polyurethane |
| What are the benefits of using a foam? (4) | highly comfortable, permeable, non adherent, easy to apply |
| How often should a foam dressing be changed? | as needed |
| What type of dressing as a non stick absorbent layer with an adhesive border? | combination/island |
| What are three examples of when we would use a combination/island dressing? | superficial wound, skin tear, secondary dressing for heavily draining wounds |
| How often do you change a combination/island dressing? | as needed |
| What is an example of a dressing containing metal? | a silver dressing |
| If using a broad spectrum antimicrobial, use only until_____. | infection is under control |
| What four agents are cytoxic and should be avoided unless in acute phase of infection? | hydrogen peroxide, povidone iodine (Betadine), acetic acid, Dakin solution (sodium hypochlorite) |
| Facilitate quick dressing changes. Montgomery straps eliminate the need to remove and reapply tape during a dressing change. | Montgomery straps |
| Aside from saline, what three wound cleaning agents are recommended? | CaraKlenz, SafClens, Biolex |
| Form a protective barrier between skin and bodily wastes, fluids, adhesive products, friction and shear | Skin protectants/barrier products |
| What are the uses for a skin protectant/barrier product? (5) | incontinence, general skin care, fragile skin, peristomal care, periwound protection |
| If skin is irritated, be sure to use a product that does not contain_____. | alcohol |
| Involves placing a foam dressing, cut to shape, into the wound. A tube is attached to the foam with a suction device, at the other end the tube is attached to a canister. The whole area is then sealed with a sticky film | Negative Pressure Wound Therapy |
| Breathing 100% oxygen while under increased atmospheric pressure. | Hyperbaric oxygen |
| Regranex is an example of | Platelet derived growth factor (PSGF) |
| Example of how radiation is used to treat wounds | Ultraviolet C radiation treatments |
| What type of therapy is an example of a skin substitute? | biologic dressing ( xenofrafts) |
| What are the five benefits of VAC therapy? | pressure is controlled and uniform, helps promote granulation tissue, removes interstitial fluid, removes infectious materials, provides moist wound healing environment |
| Pressure Ulcer | |
| Wounds that occur as a result of insufficient arterial perfusion to an extremity or location | Arterial Leg Ulcer |
| Wounds that usually occur on the lower leg in people who have chronic venous insufficiency disease | Venous statis ulcer |
| Usually occur on the feet of diabetics who have lost sensation in their feet due to uncontrolled blood sugars causing diabetic neuropathy | Diabetic food ulcer |
| a surgical device placed in a wound to drain fluid. It consists of a soft rubber tube placed in a wound area, to prevent the build up of fluid. Not used that much | Penrose |
| Small, compact and allows for patient complete ambulation, delivers a vacuum to the wound, then reverts to gravity for drainage | Closed suction drainage |
| How should a drain be removed | remove dressing, remove suture, hold pressure over site and grasp tube near body and pull out with quick steady motion |
| How soon should site close up after drain is removed? | 24-48 hours |
| Before removing a stitches or staples always make sure of what? | that the wound edges have uniform closure |
| When removing stitches, where do you snip and where do you pull? | opposite sides |
| Before applying steristrips, what should be applied to skin? | tincture of benzoin to either side of the incision |
| What type of wrap is used for initial turns? | circular |
| What type of wrap is "preferred"? | spiral |
| What type of wrap is used on joints? | figure 8 |
| What type of wrap is used for stumps, head and fingers? | recurrent |
| Designed for a specific body part and may such as slings also used for abdomen and chest. Often made of fabric. | Binder |
Created by:
anastasia158
Popular Nursing sets