Dr. Turner Wound Care flash cards.
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| Names for Pressure Ulcers | Pressure sore, decubitus ulcer, bedsore.
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| What is a pressure ulcer? | Localized injury to the skin and other underlying tissue, usually over a body prominence as a result of pressure or a combination of pressure & shear & friction.
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| What is a primary wound? | The wound is created and closed in surgery. Edges are apporomated (close together)or closed and risk for infection is low. Heals quickly and little scaring as long as infection and breakdown does not occur.
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| What is a secondary wound? | A wound involving a loss of tissue such as a burn, pressure ulcer, or laceration. The wound is left open to become filled with scar tissue. Increased chance of infection. If scaring is severe,loss of tissue is often permanent.
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| What is a tertiary wound? | A wound is created, left open to heal but then closed at a later date.
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| What colors can wounds be? | Red, yellow, black. mixed colors.
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| What is a venous stasis ulcer? | Blood pools in the veins, this causes a problem in blood flow.
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| What is a diabetic foot ulcer? | decreased sensation to the lower extremities, a diabetic doesn't feel if they have a wound.
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| Arterial Ulcers are caused by? | impairment of arterial blood flow. (seen in men without hair on their legs.)
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| What is a wound? | A disruption of the integrity and function of tissues in the body.
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| What is a partial thickness wound? | involves loss of the epidermis layer of skin.
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| what is a full thickness wound? | involving all layers of skin and heal by scar formation because deep structures do not regenerate.
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| How does serous drainage appear? | Clear, pink, watery plasma
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| How does Purulent drainage appear? | edges of the wound appear inflamed, is is odorous and purulent, which causes a yellow, green, or brown color. (pus)
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| How does serosanguineous drainage appear? | pale, pink, watery, a mixture of clear and red fluid. Some red blood cells.
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| How does sanguineous drainage appear? | bright red, indicated active bleeding.
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| Do you obtain a wound culture before or after cleaning? | obtain after cleaning.
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| What is wound dehiscence? | When layers of wound tissue separate. Typically abdominal wounds after sudden strain such as coughing. Pts describe it as if something has "given way"
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| How can you protect a wound from dehiscence? | place a pillow over the wound when straining.
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| What is evisceration? | protrusion of visceral organs through a wound opening. (emergency)
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| What to do for evisceration? | place sterile towel soaked is sterile saline over the organs.
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| Do you have to have a doctors orders to culture a wound? | Do not culture a wound without doctors orders.
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| What is the purpose of a wound drain? | To promote healing
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| What is a freestanding (pen-rose) drain? | A hollow tube inserted into a wound. Use a safety pin through the tubing so it does not slide into the body. Use drain sponges around the drain. No gauze.
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| What is a self-contained suction drain? | Also know as a Jackson-Pratt, or a hemovac. It holds about 3oz of fluid. Report any bleeding.
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| What is a Woundvac? | Vacuum assisted closure. Can cause breakdown to intact skin. Don't over extend dressings.
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| What is granulation tissue? | What a wound starts to heal, it is seen in secondary intention not in primary.
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| What is undermining? | Soft, mushy tissue around the wound.
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| Dry Dressing | Using a telfa pad, used when a wound is closed soon after surgery. Wound heals by primary intention.
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| Wet-to-Dry dressing | used in pressure ulcers, when slough, debris, eschar is present. Provides mechanical debriment. Soak gauze, ring out, lay into skin.
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| Moist dressing | When you don't want a wound to dry (burns) healing by secondary intention with no eschar-slough. using saline, orvaseline keep healthy tissue moist.
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| Transparent Dressing | IV site, pressure site.
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| Pressure dressing | when bleeding is likely, (cardiac cautherization, wound in the leg- use elastic bandages.
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| Describe a bandage | Goes over a dressing, such as an ace wrap.
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| Describe a binder | Provides support for a wound, two people put a binder on. It can cover a dressing. Uses often after peg tube insertion.
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| What is the purpose of wound irrigation? | to create enough pressure to clean a wound, provide debridement.
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| What is the technique for wound irrigation? | Use a 35ml syringe with short IV tubing attached to an 18 gauge angiocath without a needle. Push the fluid through giving enough pressure.
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| What precautions do you take during wound irrigation? | Don't get too close.
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| How to Wound vacs work? | use negative pressure (atmospheric) and porous sponge to heal.
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| What is an antiseptic? | Used to clean skin/tissue. Ex: 70% alcohol, iodine compounds, chlorine compounds, chlorhexidine. Be aware of allergy to iodine.
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| What is a disinfectant? | Used to clean objects. Ex: aldehydes, hydrogen peroxide, Dakins solution. A aware the Hydrogen Peroxide eats live flesh.
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