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Wound Care - Study guide questions/ Open Book & Moodle Questions

What is surgical asepsis or sterile technique? Designed to destroy all microorganisms and their spores
How does the nurse use sterile techniques when performing a dressing change? Verify physician orders, assemble all equipment necessary for a sterile procedure before you begin, this way you avoid having to leave sterile area to locate missing supplies
What is the 1st principle of sterile technique? Sterile object remains sterile only when touched exclusively by other sterile objects
What is the 2nd principle of sterile technique? Place only sterile objects on sterile field
What is the 3rd principle of sterile technique? Sterile field out of ranges of vision or an object held below a persons waist is contaminated
What is the 4th principle of sterile technique? Sterile object or field becomes contaminated by prolonged exposure to air
What is the 5th principle of sterile technique? When a sterile surface comes in to contact with a wet, contaminated surface, sterile object/field is contaminated
What is the 6th principle of sterile technique? Fluid flows in direction of gravity
What is the 7th principle of sterile technique? Consider the edges of a sterile field or container to be contaminated
What is a sterile field? Area that is free of microorganisms and has been prepared to receive sterile items
Why do pressure ulcers occur? Sufficient pressure on the skin to cause the blood vessels in an area to collapse
What are some ways to prevent, and/or care for, pressure ulcers? On going assessment & evaluation, observe for signs of hydration, turn patients who are on complete bed rest or unable to reposition themselves.
Define clean Not infected or inflamed wound is free
Define clean-contaminated Was the respiratory, alimentary, or genitourinary tract entered under controlled conditions
Define contaminated Fresh, open and has pus
Define infected Old wound, more than 4-6hrs old, may have green color
What are two modifiable factors that may interfere with wound healing? Nutritional needs/fluids, rest & activity
What are two non-modifiable factors that may interfere with wound healing? Pre-existing conditions, chronic diseases
What foods should the nurse offer the patient to assist with wound repair? Vitamin A, C, foods rich in protein, and zinc
What can be done to prevent separation of a wound while coughing? Splinting - apply a pillow, rolled blanker, or the palms of the hands to the incisional area to lessen intra-abdominal pressure
What are the basic principles of wound irrigation? Cleansing wound & medicating wound
What is an abrasion? Process of scraping or wearing away
What is a elective surgery? Alteration of personal appearance; rhinoplasty, breast augmentation)
How does age affect the individual's response to a procedure or surgery? Young and old patients don't tolerate major surgical procedures because of their metabolism & slower response to physiologic changes and also risk of aspiration, atelectasis, & pneumonia
What is appropriate for a LPN to delegate to unlicensed assistive personnel in the perioperative nursing period? May obtain V/S, weight, and height measurements. Make sure to have instructed proper precautions as well
What should the nurse include to ask during the assessment of the pre-op patient? Use of chemicals, alcohol, recreational substances, allergies, past surgeries, history of disease and/or infection
What pre-operative teaching is important for the patient? Include patient and family & remember to use basic terminology & information that is easier for them to understand rather than complex explanations
When are serum electrolytes assessed? Prior to surgery
What happens when your K level is elevated? Increased HR
What happens when your K level is decreased? Decreased BP and urine output
What is the role of the nurse in the informed consent? Make sure patient understands what physician explained and act as a witness to consent form
What is the role of the nurse in emergency contact? Attempt to locate family & document the attempts / Act as witness
What is the role of the nurse for telephone consent? Ensure family can repeat what physician has explained to them / Act as witness x 2
How would you explain the use of IS to your patient? Spirometer is used to help prevent any type of respiratory issues such as pneumonia after surgery. It promotes deep breathing
What is ICP and why would coughing be contraindicated? Intracranial Pressure - coughing increases ICP, leading to leakage of cerebrospinal fluid
What medical devices are routinely ordered to reduce the risk of thrombus formation? Antiembolism stockings (Ted Hose) and/or sequential compression device's (SCD's) with an intermittent external pneumonic compression system
What is a pre-op checklist? Required list used to ensure all required care has been preformed & the patient is properly prepared for surgery
What should the nurse monitor the incision for following surgery? Assess for bleeding or excessive drainage
What should the nurse monitor ventilation for following surgery? Arterial oxygen saturation (SaO2) monitored by arterial gas measurements or by pulse oximetry
What should the nurse monitor pain for following surgery? Effective pain management allows for early ambulation, promotion of adequate rest & fewer postoperative complications
What should the nurse monitor urinary function for following surgery? Bladder area for distension & changes in renal function (usually takes 6-8hrs for voiding to occur post-op)
What should the nurse monitor Venous stasis for following surgery? Assessment of feet/legs including pedal pulses, notating skin color and temperature
What activity should the nurse monitor for following surgery? Early ambulation is a significant factor in hastening postoperative recovery & preventing postoperative complications; should watch for thrombophlebitis
What gastrointestinal status should the nurse monitor for following surgery? Ausculate for bowel sounds in the abdomen to assess for the return of peristalsis
What is the description for pneumonia/atelectasis complication? Dyspnea & increase respiratory rate, increase in temp, productive cough, chest pains, crackles over involved lung area, delirium in older pt./hyperglycemia in diabetic pt.
What is the description for pulmonary embolism complication? Dyspnea, sudden sharp chest pain or upper abd pain, increase HR, decrease in BP, cyanosis
What is the description for hemorrhage complication? Escape of blood from ruptured blood vessel
What is the description for shock complication? Abnormal condition of inadequate blood flow to the body's peripheral tissues
What is the description for urinary retention complication? Restlessness & diaphoresis, lower abd. pain, inability to void, distended abd. drum like sounds on percussion of bladder, increase in BP
What interventions does a nurse perform for complication of pneumonia/atelectasis? Encourage early ambulation, monitor temp, reposition pt. every two hours, encourage IS, cough & deep breaths, check lung sounds & suction to clear secretions if the pt. is unable to cough, encourage fluid intake
What interventions does a nurse perform for complication of pulmonary embolism? Notify RN and/physician immediately, establish IV access & monitor V/S
What interventions does a nurse perform for complication of hemorrhage? Direct pressure/indirect pressure, apply tourniquet, monitor V/S, notify RN/physician immediately
What interventions does a nurse perform for complication of shock? Elevate legs (unless pt. has spinal anesthesia) Notify RN/physician immediately, establish IV access
What interventions does a nurse perform for complication of urinary retention? Monitor for voiding & check for distended bladder with bladder scanner (ultrasound), encourage fluid intake, provide privacy, pour warm water over perineum
What interventions does a nurse perform for complication of wound evisceration? Notify RN/physician immediately, plate pt. in low fowler's position with knees bent to prevent abd. tension, prevent wound infection by placing warm, moist gauze over exposed tissue and administer antiemetic's
What interventions does a nurse perform for complication of wound dehiscence? Notify RN/physician immediately, place pt. in low fowler's position with knees bent to prevent abdominal tension
What interventions does a nurse perform for complication of wound infection? Monitor temp. incision site for approximate suture line, edema, bleeding, sings of infection, maintain the patency of any drains
What is the difference between medical & surgical asepsis? Medical asepsis is techniques that inhibit growth & transmission of pathogenic microorganisms, while surgical asepsis is techniques destroys all microorganisms & their spores
When an inflammation is systemic, what signs besides edema turgor, heat, and pain develop? Tenderness and loss of function in affected body part
What factors affect a person's immunologic defense mechanisms? Increasing age, extreme young, stress, fatigue, nutritional status, hereditary factors, disease processes, environmental factors, medical therapy, chemo, radiation, lifestyle, occupation, diagnostic procedures, travel history, trauma
Describe the goals of the CDC guidelines for transmission-based precautions in hospitals? To interrupt the chain of infection and reduce transmission of blood-borne pathogens and other potentially infectious materials
What determines the method of sterilization or disinfection? Disinfection is used to destroy microorganisms and sterilization is used to destroy microorganisms and spores. Methods of sterilization depends on the type of microorganism present & type of item that need to be disinfected or sterilized
Name possible nursing diagnoses for patients susceptible to or affected by an infection? Impaired tissue integrity, risk for infection, social isolation
How are wounds classified? Determined based on a series of factors that include cause, the severity of injury, amount of contamination, and size
Name the phases of wound healing Hemostasis, Inflammatory, Reconstruction, and Maturation
The extent of the inflammatory response depends of what factors? Level of injury inflicted, size of the area involved, and the physical condition of the patient
Explain the use of gauze, semi-occlusive, and occlusive dressings in the care of surgical wounds Gauze dressings permit air to reach the wound, semi-occlusive dressings permit O2 but not air impurities to pass, occlusive dressings permit neither air nor O2 to pass
What are the advantages of transparent dressings? Adheres to undamaged skin to contain exudate and minimize wound contamination, serves as a barrier to external fluids and bacteria, yet still allows the wound to breathe, promotes a moist environment that speeds epithelial cell growth
What are the two principles of basic wound irrigation? Cleanse in direction from least contaminated area to most contaminated; When irrigating, be sure all the solution flows from the lease contaminated to most contaminated
Wound bleeding may indicate what conditions? Slipped suture, dislodged clot, coagulation problem, or trauma to blood vessels or tissue
Describe the factors that would dictate the use of staples or sutures Patients history of wound healing, the site of the wound, the tissue involved, and purpose of the sutures
List the three drainage systems Closed drainage, Open drainage, and Suction drainage
Describe the closed drainage system System of tubing and other apparatus attached to the body to remove fluid in an air tight circuit that prevents environmental contaminates from entering wound cavity
Describe the open drainage system System passes through an open-ended tube into a receptacle or out into the dressing
Describe the suction drainage system System uses a pump or other mechanical device to help extract fluid
What is elective surgery? Not necessary to preserve life and may be performed at a time the patient chooses
What is urgent surgery? Required to keep additional health problems from occurring
What is emergent surgery? Performed immediately to save the individuals life or to preserve the function of a body part or system
What are the common variations of surgery? Inpatient, One-day, Outpatient, Short-stay surgical center, Short-stay unit, and mobile surgery unit
Describe inpatient surgery Patient hospitalized for surgery
Describe One-day surgery (Same day surgery) Patient is admitted the day of surgery is scheduled and discharged the same day
Describe Outpatient surgery (Not hospitalized) Patient is admitted to a short stay unit or directly to surgical suite
Describe Short stay surgical center Independently owned agency; Surgery is performed when overnight hospitalization is not required (aka - ambulatory/one-day surgery center)
Describe Mobile surgery unit Moves from place to place it goes to the patient instead of patient traveling to the unit
What are the common fears associated with surgery? Fear of loss of control, unknown, anesthesia, pain or inadequate post-operative analgesia, death, separation disruption, change in body image, detection of cancer
What are factors that affect the individual's ability to tolerate surgery? Age, physical condition, nutritional factors, psychosocial needs, socioeconomic & cultural needs, medications, education & experience
Which test are commonly reviewed prior to surgery? U/A, CBC, Chem profile, serum electrolytes, chest x-ray's, and EKG
When diagnosing risk for latex allergy response, what factors influence this diagnosis? Multiple surgical procedures, food allergies (bananas, avocado's, kiwi, chestnuts), job with daily exposure to latex, history or reactions to latex (balloons, condoms, gloves) children w/spina bifida, history of allergies & asthma
Name the four primary purposes for the use of the incentive spirometer (IS) Prevents atelectasis, improves lung expansion, improves oxygenation & prevents post-operative pneumonia
What is the first phase of anesthesia? Induction - patient is awake and the anesthetic is often given intravenously (IV)
What is the second phase of anesthesia? Maintenance - patient is kept anesthetized at appropriate levels throughout the surgical procedure
What is the final phase of anesthesia? Emergence - when surgery is complete, reversal agents are given
What is the difference between spinal & epidural anesthesia? Spinal is injected into the cerebrospinal fluid in the subarachnoid space, while the epidural is injected into the epidural space outside the dura mater & depth of anesthesia is lighter than spinal
How is deep vein thrombosis (DVT) prevented after surgery? Early and frequent ambulation and leg exercises; antiembolism stockings & pneumatic compression devices (external intermittent compression system, SCD)
Patient comes into ER with open wound to R leg with large piece of tissue missing, leaving tendons & muscle exposed. What type of wound is it? Avulsion
Nurse is caring for patient with wound on R arm with bandage, what is 1st priority assessment when inspecting skin that is distal to bandage? Circulatory impairment
Patient with pressure ulcer on sacrum, full thickness skin loss with necrosis tissue; what is the wound classification? Stage III
Physician orders sterile wound change, what is the most appropriate way to cleanse wound & surrounding area? Use antiseptic swab, start from incision outward, 1 stroke/swab, then allow to dry
Patient is admitted to post-anesthetic care unit (PACU), which nursing action is most important during stay in this unit? Suctioning mucous from respiratory passages
Nurse assesses patient for electrolyte imbalance, which clinical manifestation indicates K deficiency? Muscle weakness
Nurse caring for patient who had abdominal hysterectomy, which intervention prevents post-op thrombophlebitis? Leg exercises 10x/hr.
Which of the following is true regarding preoperative medication? The preoperative phase is the optimal time to introduce the concept of patient controlled analgesia (PCA) to patient
What should the nurse do to help prevent respiratory complications in a post-op patient? Assist patient to ambulate within a few hours of surgery, unless contraindicated
When preparing to remove a dressing, the nurse should don _______ gloves? Clean
Abdominal binders can be used to hold dressings in place & they are also used with obese patients for additional support, True or False True
What are the phases of wound healing? Hemostasis, Inflammation, Reconstruction, Maturation
Nurse writes the problem "impaired skin integrity" for a client with stage IV pressure ulcer, which intervention should be included in plan of care? Obtain order for dietitian, obtain order for an air flow bed
What is the nurses first priority when caring for a patient needing wound care? Check medical record for physicians orders
What is the most important assessment made by the nurse after assessing a post-op patient for a patent airway? Stability of V/S
What are true statements regarding medications and surgery? Seriously ill pt. may receive as many as 20 meds peri-operative setting at one time; Review of pt's current medication regimen is essential to promote safe surg. outcome; Pt chart should be "flagged" for allergy status to alert all health care workers
Created by: tandkhopkins