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Nursing Skills

Test 2 - LP 4

QuestionAnswer
What are the five goals of wound care? to keep the wound moist , clean, protect from trauma or invasion, manage pain and support healing
What are the three reasons that pain management is important? Pain stresses the body and slows healing, decreases appetite and decreases mobility
What are some examples of causes of wound pain? (8) wet to dry dressing, adhesives, whirlpool, acetic acid, tight compression, edema, infection, pressure
What two types of methods should be used instead of wet/dry or whirlpool? enzymatic or autolytic
What is the best product to use when cleaning a wound? normal saline ( warm)
To reduce pain, dressings should be non adherent
To properly address exudate management you need to choose the correct dressing
What product should be used on the healthy skin surrounding the wound? skin prep
Deaden the nerve endings in the skin, applied directly to skin topical local anesthetic
Ibuprofen is an example of a non opioid medications
Percocet,Vicodin are examples of opioids
drugs whose initial use was not for pain but rather for other conditions. They are a diverse group of drugs that includes antidepressants, anticonvulsants (ant seizure drugs), and others. adjuvant medications
How soon should you medicate before treatment if using parenteral route? 15- 30 min
How soon should you medicate before treatment if using the oral route? 30-60 min
After giving a pain medication and before treating the wound you should always assess effectiveness of drug
What non pharmacologic techniques can be used for pain relief? (4) distraction, relaxation, imagery, deep breathing
Moist wound healing promotes the production of ____ in the wound bed. collagen
Moist wound healing prevents the production of crust or scab formation
Moist wound healing aids in the _____ cell migration epidermal
Moist wound healing reduces infection. True/ False TRUE
Moist wound healing traps ____ enzymes which enhance ____/ lytic, autolytic debridement
What needs to be documented about the wound? (11) location, extent of tissue loss/stage, granulation, measurements, odor, wound edges, drainage, undermining, tunneling, surrounding skin, pain
The appearance in color(s) of the wound is measured in percent
Beefy red, healthy pink granulation
Light pink, usually around the edges epithelialization
Black eschar, yellow slough necrotic
Term used to describe when healthy skin turns white from too much moisture maceration
What are the four characteristics of healthy wound bright red, moist, shiny, does not bleed easily
What are the four characteristics of an unhealthy wound dark red/blue/pale, dehydrated, dull, bleeds easily/fragile
Clear portion of the blood, watery Serous
Portion of the fluid that contains a large number of RBCs, looks like blood, thin and watery Sanguineous
Portion of fluid that is made up of WBC, liquefied tissue debris, dead and live bacteria, thick, musty foul odor, color dependent on causative organism Purulent
Combination fluid from blood is called serosanguineous
Cleaning away devitalzed tissue and foriegn matter from a wound. Debridement
Body's own cells breakdown tissue Autolytic
In the autolytic method, what two things work to liquefy the necrotic tissue? WBC's and enzymes
Does the autolytic method keep the necrotic tissue and eschar together? no it separates them
Resectioning skin by removing necrotic tissue with a sharp instrument is called surgical/sharp debridement
Applying enzymes to wound surface such as Panafil, Papain, UPS to assist with debridement is called enzymatic debridement
What are three forms of mechanical debridement? wet/dry, maggots, pressurized irrigation
From what direction should a dressing be removed? the center
After removing the dressing, what two things should be assessed? drainage and odor
When providing wound care are clean or sterile gloves to be used? clean
What are two examples of when we would use sterile gloves for wound care? new surgical wounds, fresh acute trauma
When cleaning a wound we always move from ___ to ____, even when irrigating. clean, dirty
When choosing dressing, consider one that absorbs ____ while keeping wound_____. exudate, moist
Moist dressing should placed only on the________. wound surface
Explain procedure for using a moist saline dressing moisten gauze, wring out moisture, open and fluff and fill wound spaces without excessive pressure, cover with dry dressing, REMOISTEN TO REMOVE
What is the downside to using a wet/dry dressing? (2) dries over time and debrides wound, can be very painful
What are transparent dressings made out of adherent polyurethane
Are transparent dressings waterproof? yes
What are three examples of when a transparent dressing could be used? abrasions, skin tears, stage 1 pressure ulcer
What is the wear time for a transparent dressing? up to seven days
Water impermeable polyurethane with gelatinous outer covering hydrocolloid
What type of ulcer and for what type of drainage the hydrocolloid be suited for? State II pressure ulcers, small to moderate drainage
What type of debridement does a hydrocolloid provide? Autolytic
Is a hydrocolloid a primary or secondary dressing? secondary
What is the wear time for a hydrocolloid? three to seven days
Polymers with water content 90-95% semitransparent, non adherent hydrogels, gels
In what three forms are hydrogels available? gels, sheets, impregnated gauze
What are the three benefits of using a hydrogel? comfortable, permeable, absorptive
In what case would a hydrogel be used? partial to full thickness wound with no exudate
What type of debridement is achieved when using a hydrogel? Autolytic
How often is a hydrogel changed? daily
Dressing derived from seaweed that forms thick gel as it mixes with wound drainage calcium alginates or hydrofibrils
In what two forms are alginates available? sheet or rope
How absorbent are alginates? very absorbent, hemostatic
When would we use an alginate? partial to full thickness wound with moderate to heavy exudate
How often is an alginate dressing changed? every 1-2 days
What is a dressing that is best suited for heavily draining wounds? foams
What are foams made out of? polyurethane
What are the benefits of using a foam? (4) highly comfortable, permeable, non adherent, easy to apply
How often should a foam dressing be changed? as needed
What type of dressing as a non stick absorbent layer with an adhesive border? combination/island
What are three examples of when we would use a combination/island dressing? superficial wound, skin tear, secondary dressing for heavily draining wounds
How often do you change a combination/island dressing? as needed
What is an example of a dressing containing metal? a silver dressing
If using a broad spectrum antimicrobial, use only until_____. infection is under control
What four agents are cytoxic and should be avoided unless in acute phase of infection? hydrogen peroxide, povidone iodine (Betadine), acetic acid, Dakin solution (sodium hypochlorite)
Facilitate quick dressing changes. Montgomery straps eliminate the need to remove and reapply tape during a dressing change. Montgomery straps
Aside from saline, what three wound cleaning agents are recommended? CaraKlenz, SafClens, Biolex
Form a protective barrier between skin and bodily wastes, fluids, adhesive products, friction and shear Skin protectants/barrier products
What are the uses for a skin protectant/barrier product? (5) incontinence, general skin care, fragile skin, peristomal care, periwound protection
If skin is irritated, be sure to use a product that does not contain_____. alcohol
Involves placing a foam dressing, cut to shape, into the wound. A tube is attached to the foam with a suction device, at the other end the tube is attached to a canister. The whole area is then sealed with a sticky film Negative Pressure Wound Therapy
Breathing 100% oxygen while under increased atmospheric pressure. Hyperbaric oxygen
Regranex is an example of Platelet derived growth factor (PSGF)
Example of how radiation is used to treat wounds Ultraviolet C radiation treatments
What type of therapy is an example of a skin substitute? biologic dressing ( xenofrafts)
What are the five benefits of VAC therapy? pressure is controlled and uniform, helps promote granulation tissue, removes interstitial fluid, removes infectious materials, provides moist wound healing environment
Pressure Ulcer
Wounds that occur as a result of insufficient arterial perfusion to an extremity or location Arterial Leg Ulcer
Wounds that usually occur on the lower leg in people who have chronic venous insufficiency disease Venous statis ulcer
Usually occur on the feet of diabetics who have lost sensation in their feet due to uncontrolled blood sugars causing diabetic neuropathy Diabetic food ulcer
a surgical device placed in a wound to drain fluid. It consists of a soft rubber tube placed in a wound area, to prevent the build up of fluid. Not used that much Penrose
Small, compact and allows for patient complete ambulation, delivers a vacuum to the wound, then reverts to gravity for drainage Closed suction drainage
How should a drain be removed remove dressing, remove suture, hold pressure over site and grasp tube near body and pull out with quick steady motion
How soon should site close up after drain is removed? 24-48 hours
Before removing a stitches or staples always make sure of what? that the wound edges have uniform closure
When removing stitches, where do you snip and where do you pull? opposite sides
Before applying steristrips, what should be applied to skin? tincture of benzoin to either side of the incision
What type of wrap is used for initial turns? circular
What type of wrap is "preferred"? spiral
What type of wrap is used on joints? figure 8
What type of wrap is used for stumps, head and fingers? recurrent
Designed for a specific body part and may such as slings also used for abdomen and chest. Often made of fabric. Binder
Created by: anastasia158
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