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Nursing Lecture D
Terms in this set (73)
Surgical asepsis is also known as what?
Can the setup of a sterile field prior to a procedure be delegated to a CNA?
What are the two main types of heat therapy?
Moist and dry
What is the term for when a wound (usually a surgical or abdominal wound) bursts open?
A shallow wound that occurs when leg veins do not return blood flow?
Venous Stasis Ulcer
What are the six main categories of types of wounds?
What type of dressing is used to prevent dehydration, is protective, and absorbs small amounts of drainage?
What are four types of heat therapy?
Electric heating pads
Commercial heat packs
Which hand do you glove first when applying sterile gloves?
Your dominant hand.
What type of wound is generally caused by scraping of the skins outer layer?
What type of wound is commonly caused by knives, metal edges, or broken glass?
What type of wound is jagged, with irregular cuts or tears of the skin and a raised chance of infection?
When can the original dressing on a surgical site be removed and/or changed?
When the doctor's order says it can be (only applies to the initial change)
What type of dressing allows the gauze to "wick" drainage and is covered with a secondary dressing?
Wet to dry dressing
What type of wound is due to an actual blockage in an artery causing decreased blood flow?
What type of wound is due to compression of soft tissue over a bony prominence leading to tissue destruction?
Pressure Ulcer/Decubitus Ulcer
What type of wound is caused by an object piercing the skin layers, creating a small hole of varying depth and often leading to infection?
What type of debridement uses the body's own ability to lyse and dissolve necrotic tissue using hydrogels or alginates and can generally be left in place for 5 days unless otherwise specified?
What are five risks associated with heat therapy?
What type of wound is caused by damage to the skin cells from heat sources and can vary in depth, size, and severity?
What type of dressing maintains a moist environment to facilitate wound healing?
What term is used to describe the skin around a wound being easily rejoinable for staples or sutures?
What are three risks associated with cold therapy?
What stage of a pressure ulcer is it when you find purple or maroon intact skin?
"Suspected deep tissue injury"
What type of burn is partial thickness, affects the epidermis and dermis and is painful?
What term is used for using something (ex. a pillow) to hold tight against a surgical site when coughing, standing, or straining, to prevent a wound from opening?
What type of dressing is applied DIRECTLY OVER THE WOUND, does not adhere to the wound, forms a gel over the wounded area, and the outer edge creates a seal?
What type of burn is partial thickness, is superficial on the epidermis, and is painful?
What do you do when a wound eviscerates or dehiscence occurs?
Treat it as an emergency, take care of it and immediately call the physician.
What type of dressing is used to control sudden or excessive bleeding to stop the bleeding and promote clot formation?
What stage of a pressure ulcer is partial thickness loss, an intact or open blister, a shallow crater involving loss of dermal skin?
What are three types of cold therapy?
What type of burn is full thickness, involves the epidermis, dermis, and hypodermis into muscle or bone, and causes no pain because of damage to the nerves?
Third degree burns
What type of debridement involves dissecting necrotic tissue from viable tissue with a scalpel or scissors and is considered the fastest and most effective method of debridement?
What type of dressing is NOT pre-moistened and is there to absorb moisture from exudate to maintain a moist environment. It is suited for wounds with a large amount of exudate.
What are the four stages of wound healing, in order?
Maturation (remodeling phase)
What stage of pressure ulcer is found when the depth of the wound is obscured by slough or eschar?
What are some conditions treated with heat therapy?
New surgical wounds
lower back pain
What stage of wound healing is occurring from 2 days to 3 weeks, wherein new blood vessels and collagen are laid down in the wound bed (key word, this process is called granulation)?
What are three things that cold therapy does to help?
Vasoconstriction reduces inflammation
Reduces muscle spasms for analgesia
Increases blood viscosity
What is the basic difference between an order for R.I.C.E and an order for R.E.C.I.P.E?
RICE is an order to rest, while RECIPE is an order to rest but also do physical therapy.
What stage of pressure ulcer is found when there is full thickness loss, and exposed bone, tendon, muscle, or fascia?
Compared to skin prior to injury, how strong is fully formed scar tissue after a wound heals completely?
80% as strong as it was, at best.
What type of drain should be used when more than 200 ml of exudate is expected within 24 hours?
What stage of pressure ulcer is found when the skin is intact with non-blanchable redness and pain, usually over a bony prominence?
What type of debridement uses a moist gauze over or in the wound that is allowed to dry and then is gently removed to pull the necrotic tissue off with it?
What stage of wound healing is occurring immediately, when blood vessels constrict and a clot forms?
Moist heat vs. Dry heat. Which type of heat will penetrate more quickly and therefore presents a higher risk for burns?
What are the three types of wound healing and their basic meaning?
Primary Intention - stitches, we close edges together, fast healing
Secondary Intention - Wound is left open to heal by scar formation
Tertiary Intention - Delayed closure. Like a little secondary followed by primary.
What are four actions resulting from heat therapy that are helpful?
Reduced blood viscosity
Increased capillary permeability
Reduced muscle tension
What stage of pressure ulcer is found with full thickness loss but no visible bone, tendon, muscle, or fascia?
What type of binder is wide straps of tape with laces, often used to secure dressings that require frequent changes to prevent skin breakdown?
What do you ALWAYS asses before applying a sterile dressing?
What type of wound drain is squeezed to create suction into a bulb?
What phase of wound healing is occurring from the beginning to 2-5 days wherein the wound is stimulating fibroblast cells to produce collagen?
What phase of the wound healing process occurs from 3 weeks to 2 years while new collagen forms, and results in scar formation?
What types of conditions are treated with cold therapy?
What type of debridement involves the use of enzymes to dissolve nonviable tissue, and therefore must be carefully applied ONLY to the wound and not put on the intact skin?
Biochemical debridement (aka Enzymatic)
In what order do you measure (and report) a wound?
Length > Width > Depth IN CENTIMETERS
What scale is used to predict skin breakdown aka to assess skin integrity?
Braden scale (Higher is better, life motto)
What type of wound drain is used when 100-200 ml of exudate is expected within 24 hours?
What types of rolled gauze are used for packing? Specific names we need to be familiar with.
Kling or Kerlix
What term is used to describe any and all types of wound drainage?
What type of wound drainage is clear or pale yellow?
What type of drainage is thick, yellow, green, brown, or tan, and means the wound is infected?
What type of wound drainage is bright red, possibly with clots, and indicates active bleeding?
What type of drainage is pale red, and watery?
Serosanguineous (serous and sanguineous mixed)
What is the term for tissue that is dead, devitalized, and adherent to viable tissue?
What terminology is used to refer to the skin around a wound?
What is a risk concern with abdominal binders?
That they can impair ventilation
In what three ways do we describe the periwound skin?
Color - red, pink, or pale
Ecchymosis - present or not present
Edema - present or not present
How are the settings for a wound vac decided?
The doctor orders them
What is the meaning of NPWT that we must get comfortable with because we will see it relatively often?
Negative pressure wound therapy (a wound drain)
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