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65 Cards in this Set

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  • Back
What is clear watery drainage called?
Sangineous
What results when there is not enough blood supply to organs?
Shock
What is a violent act that injures the skin, mucous membranes, bones and internal organs?
Trauma
What's an open wound with torn ttissues and jagged edges?
Laceration
What is an open wound caused by poor blood return to the heart from the legs and feet? _____ ______
Stasis Ulcer
What is separation of the wound layers?
Dehiscence
What is a closed wound caused by a blow to the body?
Contusion
What is an open wound with clean straight edges?
Incision
What is a collection of blood under skin and tissues?
Hematoma
What is an insoluble protein essential to clotting?
Fibrin
What is a monocyte that is phagocytic?
macrophage
What are the cardinal signs of the inflammatory process?
a. erythema
b. Elevated temp
c. Swelling
d. pain
e. loss of function
What are the factors affecting wound healing?
a. age
b. nutrition
c. lifestyle (exercise)
d. medications
e. infection
f. chronic illness
Wound healing is slower in the elderly because?
a. metabolism is slower
b. skin is more fragile
c. peripheral vascular disease
d. reduced liver function
e reduced lung function
What are the S/S of hypovolemic shock?
a. fall in blood pressure
b. rapid, thready pulse
c. increased rate of respirations
d. restlessness
e. diaphoresis
f. cold clammy skin
What is the major purpose of a wound drain?
To provide an exit for blood and fluids that accumulate during the inflammatory process
Four signs and symptoms of a wound infection are:
1. purulent drainage
2. odor
3. increased redness
4. swelling
5. pain
6. temp greater than 101 degrees
7. WBC > 10,000
If wound dehiscence and evisceration occurs, what do you do?
a. supine patient
b. Place large sterile dressings or towels soaked in NSS over incision and viscera
c. notify physician
Local applications of heat are used to:
a. provide general comfort
Heat is applied to the skin to:
1. Provide comfort
2. speed the healing process
3. increases blood supply to area
4. reduce congestion
5. reduce inflammation and swelling
6. relieve muscle spasm
7. elevate body temperature
Heat works to reduce pain by:
Increasing the blood supply to the area, this helps remove waste products and excess fluid, this reduces pain by reducing pressure on the nerve endings
Cold reduces pain by:
a. decreased cellular activity leads to the numbing or anesthetic effect
b. reduces swelling
cold helps decrease swelling by:
a. decreasing fluid accumulation
b. vasoconstriction
Why does shivering occur during a cold treatment?
an attempt by the autonomic nervous system to conserve heat
What is a localized protective response caused by injury?
Inflammation
A wound with tissue loss heals by _____
Secondary intention
What is the microorganism most frequently present in wound infections?
staphlycoccus aureus
What is asepsis?
Destruction or containment of infectious agents
Where is the record of drainage made?
Patient's I&O record
Superficial wounds heal faster when kept _____.
Moist
What allows changing the dressing without removing and reapplying tape?
Montgomery straps
When removing a dressing, pull off the tape how?
Toward the wound
Surgical wounds are cleaned how?
From the center outward
In wet-to-dry technique, dressings are changed how often?
Every 4 to 6 hours
What kind of heat is better - Moist or Dry?
Moist
What temperature is too hot for the elderly?
115 degrees
Hot is how many degrees?
98-105
What do you put in a K-pad?
distilled water
How long do you use cold?
10 to 30 minutes (book says very cold applications can be used for 15-20 mins)
Cold treatments require what?
Drs order - they are usually on for 20 mins, off for an hour
Results of the inflammatory and repair process are:
Recovery, regeneration, replacement
Surgical wounds heal by ___ _____.
Primary intention
Wounds with tissue loss heal how?
Secondary intention
What drugs interfere with healing?
Steroids, heparin, antineoplastic agents
Complications of healing are:
a. hemorrhage
b. infection
c. dehiscence
d. evisceration
3 basic wound types:
Red, yellow, black
To activate a wound sukction device, what is done?
The body is compressed, and the outlet is closed.
When is the drainage device emptied?
At the end of the shift
Draining a wound helps prevent what?
Abscess or fistula
Binders are used for what?
To provide support and hold dressings in place
Wounds must be assessed for what?
appearance, drainage, swelling, odor, increased redness, pain, swelling
Always access for what before beginning wound care??
Allergies to medications, cleansing solutions, tape
What 2 nursing diagnosis are always present with wound care?
Impaired skin integrity, & risk for infection
Hydrocolloid dressings are applied when?
To non infected wounds. They keep wound moist and absorb drainage.
Moist packing and a damp dressing help _____ a wound
Debride
Sutures are usually in how long? (Longer for elderly)
7 to 10 days
What are possible systemic circulatory effects of applied heat?
faintness, faster pulse, dyspena (difficulty breathing)
What are various ways to apply heat?
compress, soak, hot pack, hot water bottle, aquathermia pad, heat lamp, heating pad, hot water bath
How is cold applied?
compresses, packs, ice bags, hypothermia blanket
The assessment of the wound indicates healing is occuring when:
Pink granulation tissue is visible
If the wound appears to be infected, you should:
Obtain an order for a C/S test
Hydrocolloid dressings are useful for open wound dressings because they:
Keep the wound moist while blocking entry of microorganisms
When caring for a pressure ulcer you know that:
Eschar must be removed before healing can occur
Proper technique for removal of sutures:
Never pull the suture through the wound
Cold packs applied during the first 24 hours after injury decrease swelling by:
Causing vasocinstriction and decreasing bleeding from damaged blood vessels