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NUR 336 final
| Question | Answer |
|---|---|
| Stage 1 Pressure Ulcer: | nonblanchable redness, skin is still intact, typically over a bony prominence |
| Stage 2 Pressure Ulcer: | partial thickness skin loss, epidermis and dermis, tissue injury or fluid filled blister, |
| Stage 3 Pressure Ulcer: | full thickness tissue loss(subcutaneous can be seen)no muscle or bone showing yet, possible granulation, could have tunneling, could have eschar or slough (rare) |
| granulation is | red dead skin |
| eschar is | black/dark colored scab like appearance, dead tissue |
| slough is | white, yellow dead tissue, generally can be wiped off |
| stage 4 Pressure Ulcer: | full tissue thicknesss loss with muscle/bone exposed. exposed tunneling, eschar or slough common |
| dehiscence is | partial/ total rupture of sutured wound |
| evisceration is | organ coming out of a wound |
| serous drainage | mostly clear or slightly yellow, thin, normal wound drainage appearing 48-72 hrs |
| sanguineous drainage | bright red, somewhat thick, seen when the skin is freshly breached like post injury or surgery |
| serosanguinous drainage | think like water with light pink or red tinge, watery discharge secreted by open wound, an indication of active healing |
| purulent drainage | not a characteristic of healthy wound healing, milky green, brown yellow, pus |
| open wound drains: | example penrose drain. open drains involve applying absorbent dressings to the area to collect drainage as well as using small plastic tubes |
| negatives to using open wound drains: | -difficult to keep skin and site clean from infection -hard to accurately measure amount of drainage out |
| closed drainage systems: | example:hemovac closed drainage systems use compression and suction to remove drainage, collecting it in a reservoir |
| self-contained drainage systems: | small bulb on the end of a plastic tube with a plug that allows removal of drainage, compress the bulb after emptying it |
| portable wound suction: | incorporates a larger disc shaped reservoir for collecting drainage, this system has a pouring spout |
| what type of drainage would you expect to see from a blister? | serous |
| if the wound is wet, would you apply a wet or dry dressing change? | dry |
| a JP drain is (open or closed system) | closed |
| a Hemovac is (open or closed system) | closed |
| a Penrose drain is (open or closed system) | open |
| It is okay to clean an ostomy with ? | warm water, can use mild pH soap |
| When assessing a stoma what do you want to look at? | size, shape, color, appearance, location, construction, leaking? |
| when cutting the wafer for an ostomy the nurse will cut the wafer how much larger than the stoma? | 1/8 |
| closed end ostomy pouches can be used how many times? | one time use |
| a drainable ostomy pouch can be used how many times? | multiple times |
| The nurse should change a pouch for a colostomy every ____ days? | 3-7 days |
| The nurse should change a pouch for a ileostomy pouch every ___ days? | 3-5 days |
| The nurse should empty the pouch when it becomes ____ full? | 1/3 to 1/2 full |
| a double barrel indicates | two separate stomas |
| the stool from the small intestine will be? | liquid |
| the stool from the large intestine will be? | soft to formed |
| Primary intention of wound healing: | occurs when tissue surfaces are closed by stitches, staples, skin glue, or steri-strips, |
| a surgical incision that is closed by stitches is a example of what wound healing intention? | primary intention |
| secondary intention of wound healing: | occurs when wound has a great deal of tissue lost and the edges cannot be brought together. |
| a pressure ulcer would be what type of wound healing? | secondary |
| secondary intention differs from primary intention in what three ways? | -longer repair and healing time -greater chance for scarring -increased chance of infections |
| tertiary intention: | occurs when there is a need to delay closing a wound, like if there is poor circulation to the wound area |
| a abdominal wound that is kept open in order to allow drainage is an example of what type of wound healing? | tertiary |
| What medication would you avoid giving a patient with chronic wounds? | corticosteroids(suppress immune system) and NSAIDS (inhibit platelet action) |
| complications of wound healing? | -repeated trauma, inadequate nutrition, age, poor perfusion to wound area |
| When removing the bio-patch a nurse would remove it in what direction? | remove towards the insertion site, without touching any part that was covered |
| What do you use to clean the site for a central line dressing change?how long do you clean for? | 30 seconds with chloraprep |
| you should provide perineal care every? | once every 12 hours |
| needle length and size for ID | 25-27 gauge, 3/8-5/8 in length |
| needle length and size for IM | 20-25 gauge, 1-1&1/2 in length |
| needle length and size for subQ | 25-27 gauge, 3/8-5/8th in length |
| if giving insulin what should the nurse do after drawing up the medication? | have another nurse verify |
| landmark for deltoid | 1. palpate lower edge of acromion process, form the base of a triangle 2. palpate 4 fingers across the deltoid muscle with the top finger along the acromion to mark the triangle 3. inject in the center of the triangle |
| landmark for ventrogluteal | 1. palm of opposite hand from hip being used on greater trochanter of femur 2. index finger on anterior superior iliac spine(hip bone) 3. middle finger extends toward iliac crest 4. thumb points to groin |
| landmark for vastus lateralis | 1. place on hand above the knee and one hand below greater trochanter 2. locate the midline of anterior thigh and midline of lateral thigh 3. inject within the rectangle formed |
| where is the dorsogluteal site used as a last result? | dangerous due to potential piercing of sciatic nerve and major blood vessels |
| In the deltoid what is the volume of drug administered that can be tolerated for an adult? | 0.5-1ml |
| when a nurse is preparing to give a injection what is the highest priority of the nurse? | verifying client allergies |
| which type of dressing would the nurse select to help promote hemostasis? | alginate dressing-help establish hemostatsis while providing a moist environment for healing |
| if a client has a dry wound with minimal exudate the nurse should apply what type of dressing? | hydrogel |
| a pulsating lavage is a form of? | mechanical debridement, this dislodges exudate and necrotic tissue in wound bed |
| why would a nurse apply oxygen to someone following an acute injury who has multiple wounds? | if a client has lack of oxygen or poor perfusion this will delay the wound healing process, giving oxygen helps aid the healing process. |
| if a client has a stage 1 pressure injury what would the nurse include during plan of care? | applying a barrier cream to prevent further skin breakdown |
| type of ostomy created when a part of the descending colon is removed and the remaining section is used to create a stoma | descending colostomy |
| a loop colostomy involves | a large and usually temporary stoma that is created by pulling a loop of the intestine onto the abdominal wall and creating two openings in the loop |
| aa nurse is reinforcing teaching with a client who has colon cancer and is scheduled for a procedure to remove their entire large intestine and rectum, The nurse should reinforce with the client that they are having what type of procure? | ileostomy |
| a nurse is replacing the ostomy appliance for a client whose newly created colostomy is functioning. After removing the pouch, what action should the nurse take first? | cleanse the stoma and peristomal skin, this removes any effluent and assists with skin assessment. |
Created by:
Savschlag
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