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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 |
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