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75 Cards in this Set
- Front
- Back
Wound
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Any injury to the bodys tissue involving a break in the skin.
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Nursing focus during postsurgical recovery phase
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Promote wound healing
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Wound classifications derive from
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Derive from their cause, the severity of injury, amount of contamination, skins integrity
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Incision
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Cut produced surgically creating an opening into an organ
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Puncture
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Stab wound for a drainage system
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Classifications of wounds
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Clean wound
Clean contaminated Contaminated Dirty or infected wounds |
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Four phases of wound healing
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Hemostasis
Inflammatory phase Reconstruction Maturation |
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Hemostasis
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Termination of bleeding
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What happens during the hemostasis phase
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Fibrin in the clot begins to hold the wound together, and bleeding subsides.
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What happens during the inflammatory phase
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Initial increase in the flow of blood elements. This process causes cardinal signs and symptoms of inflammation: erythema, heat, edema, pain, and tissue dysfunction
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During what phase do cells in the injured tissue migrate divide and form new cells
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Inflammatory phase
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Collagen formation occurs during what phase
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Reconstruction
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During the reconstruction phase, encourage patients to consume foods rich in
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Protein & vitamin A & C
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Wound dehiscence most frequently occurs during which phase?
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Reconstruction
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Keloid
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Overgrowth of collageneous scar tissue at the site of a wound
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Keloids form during which phase
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Maturation
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Keloids color range from
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Red to pink to white
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Primary intention
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Skin edges close together and little tissue is lost. Minimal scarring. Healing begins during inflammatory phase
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Granulation tissue
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Soft, pink, fleshy projections consisting of capillaries surrounded by fibrous collagen
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Tertiary intention
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Contaminated wound left open and surgeon closes it later after infection is controlled.
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Serous
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Clear, watery plasma
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Purulent
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Thick, yellow, green, tan or brown
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Serosanguineous
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Pale, red, watery. Mixture of serous and sanguineous
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Sanguineous
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Bright red: indicates active bleeding
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Phagocytosis
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Cells engulf and dispose of microorganisms
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Gauze dressings
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Permit air to reach the wound
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Semiocclusive dressings
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Permit oxygen but not air impurities to pass
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Occlusive dressing
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Permit neither air nor oxygen to pass
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Who does the initial dressing change?
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Physician or surgeon
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Dry dressing
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Choice for management of a wound with little exudate or drainage
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Does dry dressings debride the wound?
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No. Not the proper selection for wounds requiring debridement
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Because removal of a dressing can be painful, what should you do
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Give an analgesic at least 30 minutes before exposing the wound
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Primary purpose of wet to dry dressing
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Debride a wound
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Common wetting agents for wet to dry dressing
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Normal saline, lactated ringers solution, isotonic solutions
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Transparent dressings
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Thin, self-adhesive transparent film that belongs in semiocclusive or occlusive categories.
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Irrigation
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Gentle washing of an area with a stream of solution delivered through an irritating syringe
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Can irrigations introduce prescribed medications in solution form
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Yes
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What direction should irrigation fluid flow
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From least contaminated to most contaminated
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Eschar
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Black, leathery crust
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Solutions used for irrigation
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Warm water, saline, and mild detergent
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How far should the tip of the syringe be when irrigating
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1 inch (2.5cm) above the wound or area your cleansing
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With small wounds, what size syringe and gauge is best used
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35 mL syringe with a 19 gauge needle
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Wound bleeding usually indicates
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A slipped suture, dislodged clot, coagulation problem, trauma to blood vessels or tissue.
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Abscess
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Cavity containing pus and surrounded by inflamed tissue.
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Adhesion
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Band of scar tissue that binds together two anatomical surfaces normally separated
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Cellulitis
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Infection of the skin characterized by heat, pain, erythema, and edema
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Dehiscence
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Separation of a surgical incision or rupture of a wound closure
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Evisceration
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Protrusion of an internal organ through a wound or surgical incision
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Extravastation
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Passage or escape into the tissues
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Hematoma
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Collections of extravasated blood trapped in the tissue or in an organ
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Signs of hemorrhaging
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Rapid, thready pulse; decreased blood pressure; decreased urinary output; and cool, clammy skin
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When a skin suture breaks and dehiscence occurs, you will be able to close the wound effectively using
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Steri-strips or butterfly strip
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If evisceration occurs after dehiscence, what should the nurse do
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Pt must remain in bed in a low fowlers position, knees flexed. Keep patient on NPO status. Cover the wound and contents with warm, sterile dressing. Notify the surgeon immediately.
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The CDC labels a wound infected when it contains what?
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Purulent (pus) drainage
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A patient with an infected wound shows what type of signs
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Patient displays fever, tenderness, and pain at the wound site, edema, and an elevated WBC count
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Does purulent drainage have an odor
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Yes. Purulent drainage is brown, yellow, or green
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Normal wbc count
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4,500-10,000 white blood cells
per microliter (mcL) |
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How long are retention sutures left in place
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14 days or more
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Who removes wire sutures
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Physician
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Abnormal quantity of exudate or drainage is greater than how much the first 24 hour
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300 mL. Report it immediately.
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Normal bile drainage
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250 to 500 mL/ 24 hours
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Wound vac
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Device that assists in wound closure by applying negative pressure to draw edges of a wound together
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Acceptable negative pressure ranges
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5 mmHg and 200 mmHg. The average is 125 mmHg
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Maceration
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Damage to wound edges.
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Wound dessication
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To cause to dry up
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Bandage
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Strip or roll of cloth that can be wound around a part of the body
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Binder
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A bandage that is made of large pieces of material to fit a specific body part
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When applying a binder, patient should flex their arm approximate at what angle
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80 degree angle
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Basic bandage turns
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Spiral, figure of 8, recurrent, circular, spiral reverse
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Circular bandage used
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Cover small body regions (Digits or Wrist)
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Spiral bandage use
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Cover cylindrical body parts. Wrist or forearm
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Spiral- reverse bandage use
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Use to cover inverted cone shaped body parts. Calf or thigh
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Figure of 8 bandage use
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Used to cover joints and provide immobilization. Joints
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Recurrent bandage use
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Provides caplike coverage. Scalp
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Secondary intention
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Wound must granulate during healing. Skin edges not close together,or when pus has formed.
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