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MT sterile wound
MT NHCC Sterile tech, wound irrigation
| Question | Answer |
|---|---|
| Decribe Serous wound exudate? | Clear, watery plasma |
| Decribe Sanguinous wound exudate? | Bright red, active bleeding |
| Decribe Serosanguinous wound exudate? | Pale red & water mixture (RBC + plasma) |
| Decribe Purulent wound exudate? | Thick, yellow, green, tan or brown & possible odor (cells & debris, usually an infection) |
| A Contusion (bruise) is an example of what type of wound? | closed |
| Describe a Contusion (bruise)? | Injury by blunt object; blood vessels rupture, and blood seeps into tissue; edema from trauma to injured cells |
| What is the treatment for a Contusion? | Apply cold compresses for 24 to 48 hours; analgesics for pain; rest injured partRICE : Rest, Ice, Compression, Elevation |
| What are the 5 Open wounds? | Abrasion, Laceration, Incision, Puncture, Stab |
| What is an Abrasion? | Scraping of skin surface (brush burn) |
| What is the treatment for an Abrasion? | Wash well with soap and water; keep clean; no covering necessary |
| What is a Laceration? | Jagged cut through skin and underlying tissue |
| What is an Incision? | Straight cut through skin and underlying tissue by sharp knife |
| What is a Puncture? | Penetration of skin and underlying tissue by sharp-pointed object; skin quickly seals over when object is removed |
| What is a Stab? | Form of puncture wound by large object such as a knife, stick, or piece of glass |
| What is the treatment for a Laceration? | Wash well with soap and water; edges approximated by “butterfly” adhesive or by suturing |
| What is the treatment for an Incision? | Wash well with soap and water; edges approximated by “butterfly” adhesive or by suturing |
| What is the treatment for a Puncture? | Soak wound; encourage bleeding in small wound to wash out bacteria; monitor for signs of infection; tetanus prophylaxis |
| What is the treatment for a Stab? | Do not remove object; stabilize object to prevent further damage; control bleeding; seek immediate medical attention |
| What is Primary intention? | Wound edges remain close together, tissue loss minimal, healing ridge, wound edges “approximated” (without hematoma), clean incision, risk for dehiscence |
| What is Secondary intention? | Wound edges left open, heal by scar formation, tissue loss, open, jagged wound, slow healing process, increased risk for infection. Keloids = excessive amount of connective tissue (scar) |
| What is Tertiary intention? | Delayed primary closure, left open 3-5 days to drain infection/exudates, later closed with staples, sutures or tape, minimal scarring, heals from bottom up |
| What is included in Assessment of wounds? | Source or etiology of trauma, When did it occur? Previous treatment? Associated symptoms? Fever, itching, draining |
| What are the wound indication(s) for wearing clean gloves? | Chronic wounds |
| When is Sterile technique used? | when there is a break in the first line of defense (i.e. the skin and mucous membranes) and may be indicated for selected procedures performed by the nurse or other health care personnel at the bedside, or during surgical procedures |
| What are the wound indication(s) for wearing sterile gloves? | Surgical wound |
| what is meant by “reinforcing” a dressing? | apply over existing dressing. Don’t need order for reinforcement. Put date & time on piece of tape on dressing. Can also draw on dressing & trace drainage. Chart: “dressing reinforced X 1, 2, 3, etc.” Put time, check vitals. |
| the advantages of reinforcing dressings.? | Keep initial dressing intact. Dressing may be used as a pressure over incision |
| the disadvantages of reinforcing dressings.? | Lack of assessment of wound (can’t see); Would need to chart “dressings appear…. (dry & intact)”; Environment is warm, dry, moist = perfect environment for bacteria to grow |
| What are the steps of a sterile dressing change? | MD ORDER, OBSERVE, ASSESS CLIENT, PREPARE, GATHER, DETERMINE, ASSESS WOUND, PALPATE, CLEANSE, AND APPLY |
| How do you assses a patient for a dressing change? | identify, explain, may need pre-medication; possibly pain meds/nausea meds – give ½ hour before |
| What does the accronym COAT stand for? | color, odor, approximation & temp |
| What do you assess on the wound before a dressing change? | COAT, If drainage, include amount. Open wound bed – RYB: Red (granulated tissue), Yellow (pus), Black (necrotic) |
| What are the three purposes for wound irrigation.? | Debridement, remove bacteria and exudates to promote healthy granulation tissue, cultures |
| Type of wound cleansing solution? | Normal saline, sterile water, plain water |
| What type of a catheter would you use to irrigate a deep wound? | a soft catheter tip. Replace catheter tip each time |
| If using a shower to irrigate a wound how far do you hold head ? | 12 inches from wound and use a gentle flow |
| How far do you Keep tip of syringe above the wound? | 1 inch |
| What size syringe barrel should you use when irrigating a wound? | larger volume barrel syringe (60cc) |
| How should you Position client when irrigating a wound? | so fluid flows away from wound |
| When irrigating a wound, when should you Get cultures? | after irrigation (if yellow, brown or greenish drainage – must have MD order) |
| What type of gloves do you use to remove the old dressing? | clean gloves |
| What type of gloves do you use to Irrigate the wound? | What type of gloves do you use to |
| How long is the The open bottle of normal saline is good for ? | 24 hours. |
| what are three different purposes that a variety of dressings are designed for? | 1.To provide barrier protection from contamination 2. Impregnate dressing with antibiotics 3. Aid in liquefying necrotic tissue with moisture |
| What is a Hydrocolloid dressing? | Dressings composed of gelatin, pectin, and carboxymethylcellulose. Available in wafers, pastes, and powders. Forms a gel as it absorbs exudates. |
| What are some examples of a Hydrocolloid dressing? | Tegasorb, Duoderm, Comfeel, Restore |
| What are the indications for using a Hydrocolloid dressing? | Wounds that have light to moderate exudates/drainage |
| Hydrocolloid dressings are Not recommended for use with wounds that? | is exposed tendon or bone, tunneling cavities, third-degree burns or friable periwound skin |
| Because Hydrocolloid dressings are almost totally occlusive they should not be used with what type of wounds? | the presence of bacterial, fungal, or viral infection and active cellulites or vasculitis. |
| What is the Change frequency of Hydrocolloid dressings? | Every three to seven days |
| What are Transparent Film dressings? | Adhesive membrane dressing that’s waterproof. Allows oxygen and water vapor to cross through the film while keeping out contaminants |
| What are some examples of Transparent Film dressings? | Bioclusive, Tegaderm, OP-site |
| What are the Indications for Transparent Film dressings? | Wounds with minimal to no exudates. Also as secondary dressing to secure nonadhesive alginates, gauzes, and foams |
| What are the Nursing considerations Transparent Film dressings? | Not recommended for wounds that have friable skin around wound edges |
| What is the Change frequency for Transparent Film dressings? | Every three to seven days when used as a primary dressing, or when fluid extends beyond the dressing’s edge. |
| What are Hydrogel dressings? | Gel that’s composed primarily of water. Available in tubes, foil packets, and spray bottles. Can also come impregnated in gauze or a non-woven sponge or in a hydrogel matrix sheet |
| What are the indications for Hydrogel dressings? | Wounds that have minimal or no exudates/drainage |
| What are nursing considerations when using Hydrogel dressings? | Viscosity decreses as gel warms to body surface temperature, so use a thin layer to prevent it from spreading to the periwound, where it can cause maceration. Avoid overpacking wounds, which can damage tissue. |
| What is the Change frequency for Hydrogel dressings? | One or two times a day |
| What is the purpose of Vacuum assisted wound closure? | 1. Uses negative pressure, Accelerates wound healing, Removes fluid from surrounding wound, Decreases peripheral edema, increases circulation, Helps promote cell division by uniform mechanical force on wound |
| What are the three levels of Levels of latex reactions? | Contact dermatitis, Type IV hypersensitivity, Type I hypersensitivity |
Created by:
2007Nurse
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