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Chapter 31
Wound Care
| Question | Answer |
|---|---|
| What is a break in the skin or mucous membrane? | Wound |
| What is an accident or violent act that injures the skin, mucous membranes, bones, and organs? | Trauma |
| When a person has a _____________, infection is a major threat. | Infection |
| Wound care involves ________________ infection and further injury to the wound and nearby tissues. | Preventing |
| What is a partial-thickness wound caused by the scraping away or rubbing of the skin? | Abrasion |
| What is a closed wound caused by a blow to the body (a bruise), Also called a deep tissue injury? | Contusion |
| What is a cut produced surgically by a sharp instrument that creates an opening into an organ or body space? | Incision |
| What is an open wound with torn tissues and jagged edges? | Laceration |
| What type of wound is created for therapy? | Intentional |
| What do you call a wound in which the skin and mucous membrane is broken? | Open |
| What do you call a wound in which tissues are injured but the skin is not broken? | Closed |
| Bruises, twists, and sprains are examples of which type of wound? | Closed |
| What type of wound is not infected? | Clean |
| Which type of wound occurs from the surgical entry of the reproductive, urinary, respiratory, or GI system? | Clean-contaminated |
| Which type of wound has a high risk of infection? | Contaminated |
| Which type of wound contains large amounts of microbes and shows signs of infection; also called a dirty wound? | Infected |
| Which type of wound does not heal easily; for example pressure ulcers and circulatory ulcers? | Chronic |
| What type of wound involves the dermis and epidermis being broken? | Partial-thickness |
| What type of wound involves the dermis, epidermis, and subcutaneous tissue are penetrated; may involve bone or muscle? | Full-thickness |
| What is an open wound that breaks the skin and enters a body area, organ, or cavity? | Penetrating |
| What is an open wound made by a sharp object? | Puncture |
| With a puncture wound, entry of the skin and underlying tissues may be intentional or __________________. | Unintentional |
| What is a break or rip in the outer layers of the skin? | Skin tear |
| Measures to prevent skin tears include keeping your _______________ short and smoothly filed. | Fingernails |
| Measures to prevent skin tears include following safety rules to handle, move, turn, position, or ______________ a person. | Transfer |
| Measures to prevent skin tears include taking measures to prevent __________ and shearing. | Friction |
| Measures to prevent skin tears include using an ___________ device to move and turn the person in bed. | Assist |
| Measures to prevent skin tears include using ______________ to support arms and legs. | Pillows |
| Measures to prevent skin tears include ______________ bed rails and wheelchair arms, footplates, and leg supports. | Padding |
| Measures to prevent skin tears include dressing the person in __________ clothes with long sleeves and long pants. | Soft |
| Skin tears are caused by friction, ____________, pulling, or pressure on the skin. | Shearing |
| Skin tears are painful and are a portal of entry for microbes making _____________ a risk. | Infection |
| What is swelling caused by fluid collecting in tissues? | Edema |
| What is a condition in which there is death of tissue? | Gangrene |
| Measures to prevent vascular ulcers include reminding the person not to sit with the legs _____________. | Crossed |
| Measures to prevent vascular ulcers include repositioning the person at least every ________ hours. | Two |
| Measures to prevent vascular ulcers include not using ____________ or rubber band-type garters to hold socks or hose in place. | Elastic |
| Measures to prevent vascular ulcers include not dressing the person in _____________ clothing. | Tight |
| Measures to prevent vascular ulcers include not ______________ or rubbing the skin to bathe or dry. | Scrubbing |
| Measures to prevent vascular ulcers include keeping linens clean, dry, and _____________-___________. | Wrinkle-free |
| Measures to prevent vascular ulcers include keeping ____________ off the heels and other bony areas. | Pressure |
| Measures to prevent vascular ulcers include using _______________ and other devices for support. | Pillows |
| Measures to prevent vascular ulcers include not _____________ over pressure points. | Massaging |
| What are open sores on the lower legs or feet? | Vascular ulcers |
| Vascular ulcers are caused by decreased ____________ _____________ through the arteries or veins. | Blood flow |
| What are open sores on the lower legs or feet, also called stasis ulcers? | Venous ulcers |
| Venous ulcers are caused by poor ____________ blood flow. | Venous |
| When a person has a venous ulcer the skin on their legs is dry, leathery, ____________, and hard. | Flaky |
| When a person has a venous ulcer ____________ is a common symptom. | Itching |
| Venous ulcers are painful and ______________ is difficult. | Walking |
| What is an inflammation of a vein? | Phlebitis |
| The doctor may order _________________ stockings or elastic bandages for a person with venous ulcers. | Compression |
| Compression stockings or elastic bandages ________________ comfort. | Promote |
| Compression stockings or elastic bandages promote _______________ by providing support and pressure to the veins. | Circulation |
| Compression stockings or elastic bandages prevent ____________ and promote healing. | Injury |
| What do you call a blood clot? | Thrombus |
| What is a blood clot that travels through the vascular system and becomes lodged in a vessel? | Embolus |
| Anti-embolism stockings, TED hose, or elastic stockings are other terms for ______________ ________________. | Compression stockings |
| When delegated to apply compression stockings you need to know what ______________ to use. | Size |
| When delegated to apply compression stockings you need to know when to _____________ them and for how long. | Remove |
| Generally compression stockings are removed every __________ hours for 30 minutes. | Eight |
| For safety, when a person is wearing compression stockings, it is important that you never __________ over the top of the stocking. | Fold |
| Compression stockings are applied ______________ the person gets out of bed. | Before |
| Generally the person _______ in bed when their compression stockings are off. | Lies |
| Elastic bandages are applied to the ____________ and legs. | Arms |
| When applying elastic bandages: ___________ the person during the procedure. | Face |
| When applying elastic bandages: Start at the ___________ (distal) part of the extremity. | Lower |
| When applying elastic bandages: Work upwards towards to __________ (proximal) part of the extremity. | Top |
| When applying elastic bandages: Expose fingers or ___________ if possible. | Toes |
| When applying elastic bandages: Apply the bandage with a firm, ___________ pressure and a 50% overlay. | Even |
| When applying elastic bandages: Check the color and temperature of the extremity every __________. | Hour |
| When applying elastic bandages: __________ a loose or wrinkled bandage. | Re-apply |
| Elastic bandages must be firm and ________ but not tight. | Snug |
| What are open wounds on the lower legs or feet caused by poor arterial blood flow? | Arterial ulcers |
| During which phase of wound healing does bleeding stop and a scab form over the wound? | Inflammatory |
| ________________ foot ulcers are open wounds on the foot caused by complications of diabetes. | Diabetic |
| Wound edges are brought together to close the wound in ___________ intention wound healing. | Primary |
| Sutures (stitches), staples, clips, special glue, or adhesive strips hold the ____________ edges together. | Wound |
| _______________ intention wound healing is used for contaminated and infected wounds. | Secondary |
| Wounds are cleaned and ___________ _____________ is removed in secondary intention wound healing. | Dead tissue |
| Wound ___________ are not brought together in secondary intention wound healing | Edges |
| Infection is a great risk during ___________ intention wound healing. | Secondary |
| During secondary wound healing and takes longer and leaves a larger ______________. | Scar |
| The wound is left open and closed later during __________ intention wound healing. | Tertiary |
| Infection and poor _______________ are common reasons for tertiary intention. | Circulation |
| What nutrient is needed for tissue growth and repair? | Protein |
| What is the separation of wound layers that may involve the skin layer and underlying tissues? | Dehiscence |
| What is the separation of the wound with the protrusion of abdominal organs? | Evisceration |
| What type of wound drainage is clear and watery? | Serous |
| What type of wound drainage is bloody? | Sanguineous |
| Serosanguineous drainage is thin, watery drainage that is tinged with _____________. | Blood |
| What type of wound drainage is thick, green, yellow, or brown drainage? | Purulent |
| What does the doctor insert when large amounts of drainage are expected? | Drain |
| Drainage is measured by noting the number and ____________ of dressings with drainage. | Size |
| Dressings are ___________ to calculate the amount of drainage. | Weighed |
| Drainage can be measured by measuring the amount of drainage in the ______________ container. | Collection |
| You can observe the surrounding skin of a wound by noting if it is _____________. | Intact |
| When making wound observations you should note the ___________ of surrounding skin. | Color |
| When making wound observations you should note if the surrounding ________ are swollen. | Tissues |
| Wound dressings have many functions including protecting the wounds from injury and ______________. | Microbes |
| Wound dressings have many functions including _______________ drainage. | Absorbing |
| Wound dressings have many functions including removing _____________ tissue. | Dead |
| Wound dressings have many functions including ______________ comfort. | Promoting |
| Wound dressings have many functions including ____________ unsightly wounds. | Covering |
| Wound dressings have many functions including providing a ______________ environment for wound healing. | Moist |
| Wound dressings have many functions including to apply _____________ to help control bleeding. | Pressure |
| What type of dressings absorb moisture and drainage? | Gauze |
| Dressings must be ______________ over wounds. | Secured |
| If a dressing is dislodged then _______________ can enter the wound and drainage can escape. | Microbes |
| Adhesive, paper, plastic, cloth and elastic __________ are commonly used to secure dressings. | Tapes |
| What occurs if skin is removed with tape? | Abrasion |
| Elastic tape allows _______________ of body parts. | Movement |
| Tape is applied to the top, _____________, and bottom parts of the dressing. | Middle |
| Rules for applying dressings include waiting about 30 minutes for _______ ___________ to take effect. | Pain medications |
| Dressing _____________may cause discomfort. | Changes |
| Wound odors, appearance, and _______________ may be unpleasant. | Drainage |
| Rules for dressing changes include controlling your ____________ communication. | Nonverbal |
| Rules for dressing changes include removing soiled dressing so the person cannot ____________ the soiled side. | See |
| When removing tape, you should pull it ______________ the wound. | Toward |
| What are wide bands of elastic fabric applied to the abdomen, chest, or perineal areas? | Binders |
| You should re-apply the binder if it is _______________ or wrinkled. | Loose |
| When applying a binder you need to secure safety pins so the point _________ from the wound. | Away |
| Change binders that are _____________ or soiled. | Moist |
| Warm and cold applications promote healing and reduce __________ swelling. | Tissue |
| Warm applications are often used for _____________ - _______________ injuries or problems. | Musculo-skeletal |
| Warm applications relieve ____________. | Pain |
| Warm applications relax _____________. | Muscles |
| Warm applications decreases ____________ stiffness. | Joint |
| Warm applications promote _________________. | Healing |
| Warm applications reduces _________ swelling. | Tissue |
| When heat is applied to the skin, ______________ __________ in the area dilate. | Blood vessels |
| What word means to expand or open wider? | Dilate |
| When blood vessels dilate, blood ___________ increases. | Flow |
| When heat is applied to the skin, the area becomes ___________ and warm. | Red |
| Heat can cause burns so you should report pain, excessive redness or ____________ at once. | Blisters |
| What happens to blood vessels when heat is applied for too long? | Constrict |
| What word means to become more narrow? | Constrict |
| When blood vessels constrict, blood flow ______________. | Decreases |
| Older and fair-skinned persons have fragile skin that is ___________ easily. | Burned |
| Do not apply heat over an area with a metal or ceramic ___________. | Implant |
| When applying a moist heat application, ____________ is in contact with the skin. | Water |
| Heat penetrates _____________ and quicker with a moist heat application. | Deeper |
| What is a soft pad applied over a body area? | Compress |
| To maintain the temperature of the compress, sometimes an ________________ pad is applied over the compress. | Aquathermia |
| During a ________ ___________ the perineal and rectal areas are immersed in warm water. | Sitz bath |
| Sitz baths are common for _____________ and after rectal or pelvic surgeries. | Hemorrhoids |
| What involves wrapping a body part with a wet or dry application? | Pack |
| Some warm packs and aquathermia pads are __________ heat. | Dry |
| The aquathermia pad is an _____________ device in which the tubes are filled with distilled water. | Electrical |
| When cold is applied to the skin, blood vessels ____________ and blood flow decreases. | Constrict |
| Cold has a ______________ effect on the skin. | Numbing |
| Burns and _____________ occur from intense cold. | Blisters |
| When cold is applied for a long time, blood vessels ___________ and blood flow increase. | Dilate |
| When applying warm and cold applications how often should you check the person and the application site? | 5 minutes |
| A cold compress is a ____________ cold application. | Moist |
| Ice bags, ice collars, and ice gloves are all _________ cold applications. | Dry |
| Rules for applying warm and cold applications include measuring the ______________ of a moist applications. | Temperature |
| Rules for applying warm and cold applications include not applying very hot (106F +) temperature applications because ______________ damage can occur. | Tissue |
| Rules for applying warm and cold applications include ____________ dry warm or cold applications before applying them. | Covering |
| Rules for applying warm and cold applications include covering dry warm or cold applications with a flannel cover or _____________ as directed. | Towel |
| Rules for applying warm and cold applications include keeping the application on for no more that ________ to 20 minutes. | 15 |
| Rules for applying warm and cold applications include following the rules of _______________ safety when using electrical appliances to apply heat. | Electrical |
| Rules for applying warm and cold applications include placing the _________ ___________ withing the person's reach. | Call light |
| To promote safety and comfort when applying warm and cold you should __________ on the person every 5 minutes. | Check |
| The person may become weak or feel faint from a ____________ bath. | Sitz |
| When giving a sitz bath you must understand that ______________ may occur from the bath's relaxing effect. | Drowsiness |
| To promote safety and comfort when applying warm and cold you should always read _____________ labels and follow manufacturer instructions. | Warning |
| To promote safety and comfort when applying warm and cold you should place the aquathermia pad heating unit on an _________, uncluttered surface. | Even |
| To promote safety and comfort when applying warm and cold you should make sure the _____________ on the aquathermia pad do not have kinks or bubbles. | Hoses |
| When using an aquathermia pad you should ____________ it in place with ties, tape, or rolled gauze - not pins. | Secure |
| When using an aquathermia pad you should not place the pad __________ the person or under a body part. | Under |
| Placing an aquathermia pad under a body part or person prevents the _______________ of heat. | Escape |
| When using an aquathermia pad you should give the __________ used to set the temperature to the nurse to prevent anyone from changing the temperature. | Key |
| What do you call a body temperature that is much higher than the person's normal range? | Hyperthermia |
| What is placed over the cooling blanker used to treat a person with hyperthermia? | Sheet |
| What do you call a very low body temperature? | Hypothermia |
| What kind of blanket is used to treat hypothermia? | Warming |
| When using warming and cooling blankets, _________ ________ are measured often. | Vital signs |
| Wounds cause pain and discomfort and often affect breathing and _______________. | Movement |
Created by:
na3
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