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Nursing Skills
Test 2 - LP 4
Question | Answer |
---|---|
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 |