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Chapter 30

Wound Care

QuestionAnswer
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