Funds Ch 36 - 2 S

Front 1

What is clear watery drainage called?

Back 1

Sangineous

Front 2

What results when there is not enough blood supply to organs?

Back 2

Shock

Front 3

What is a violent act that injures the skin, mucous membranes, bones and internal organs?

Back 3

Trauma

Front 4

What's an open wound with torn ttissues and jagged edges?

Back 4

Laceration

Front 5

What is an open wound caused by poor blood return to the heart from the legs and feet? _____ ______

Back 5

Stasis Ulcer

Front 6

What is separation of the wound layers?

Back 6

Dehiscence

Front 7

What is a closed wound caused by a blow to the body?

Back 7

Contusion

Front 8

What is an open wound with clean straight edges?

Back 8

Incision

Front 9

What is a collection of blood under skin and tissues?

Back 9

Hematoma

Front 10

What is an insoluble protein essential to clotting?

Back 10

Fibrin

Front 11

What is a monocyte that is phagocytic?

Back 11

macrophage

Front 12

What are the cardinal signs of the inflammatory process?

Back 12

a. erythema
b. Elevated temp
c. Swelling
d. pain
e. loss of function

Front 13

What are the factors affecting wound healing?

Back 13

a. age
b. nutrition
c. lifestyle (exercise)
d. medications
e. infection
f. chronic illness

Front 14

Wound healing is slower in the elderly because?

Back 14

a. metabolism is slower
b. skin is more fragile
c. peripheral vascular disease
d. reduced liver function
e reduced lung function

Front 15

What are the S/S of hypovolemic shock?

Back 15

a. fall in blood pressure
b. rapid, thready pulse
c. increased rate of respirations
d. restlessness
e. diaphoresis
f. cold clammy skin

Front 16

What is the major purpose of a wound drain?

Back 16

To provide an exit for blood and fluids that accumulate during the inflammatory process

Front 17

Four signs and symptoms of a wound infection are:

Back 17

1. purulent drainage
2. odor
3. increased redness
4. swelling
5. pain
6. temp greater than 101 degrees
7. WBC > 10,000

Front 18

If wound dehiscence and evisceration occurs, what do you do?

Back 18

a. supine patient
b. Place large sterile dressings or towels soaked in NSS over incision and viscera
c. notify physician

Front 19

Local applications of heat are used to:

Back 19

a. provide general comfort

Front 20

Heat is applied to the skin to:

Back 20

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

Front 21

Heat works to reduce pain by:

Back 21

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

Front 22

Cold reduces pain by:

Back 22

a. decreased cellular activity leads to the numbing or anesthetic effect
b. reduces swelling

Front 23

cold helps decrease swelling by:

Back 23

a. decreasing fluid accumulation
b. vasoconstriction

Front 24

Why does shivering occur during a cold treatment?

Back 24

an attempt by the autonomic nervous system to conserve heat

Front 25

What is a localized protective response caused by injury?

Back 25

Inflammation

Front 26

A wound with tissue loss heals by _____

Back 26

Secondary intention

Front 27

What is the microorganism most frequently present in wound infections?

Back 27

staphlycoccus aureus

Front 28

What is asepsis?

Back 28

Destruction or containment of infectious agents

Front 29

Where is the record of drainage made?

Back 29

Patient's I&O record

Front 30

Superficial wounds heal faster when kept _____.

Back 30

Moist

Front 31

What allows changing the dressing without removing and reapplying tape?

Back 31

Montgomery straps

Front 32

When removing a dressing, pull off the tape how?

Back 32

Toward the wound

Front 33

Surgical wounds are cleaned how?

Back 33

From the center outward

Front 34

In wet-to-dry technique, dressings are changed how often?

Back 34

Every 4 to 6 hours

Front 35

What kind of heat is better - Moist or Dry?

Back 35

Moist

Front 36

What temperature is too hot for the elderly?

Back 36

115 degrees

Front 37

Hot is how many degrees?

Back 37

98-105

Front 38

What do you put in a K-pad?

Back 38

distilled water

Front 39

How long do you use cold?

Back 39

10 to 30 minutes (book says very cold applications can be used for 15-20 mins)

Front 40

Cold treatments require what?

Back 40

Drs order - they are usually on for 20 mins, off for an hour

Front 41

Results of the inflammatory and repair process are:

Back 41

Recovery, regeneration, replacement

Front 42

Surgical wounds heal by ___ _____.

Back 42

Primary intention

Front 43

Wounds with tissue loss heal how?

Back 43

Secondary intention

Front 44

What drugs interfere with healing?

Back 44

Steroids, heparin, antineoplastic agents

Front 45

Complications of healing are:

Back 45

a. hemorrhage
b. infection
c. dehiscence
d. evisceration

Front 46

3 basic wound types:

Back 46

Red, yellow, black

Front 47

To activate a wound sukction device, what is done?

Back 47

The body is compressed, and the outlet is closed.

Front 48

When is the drainage device emptied?

Back 48

At the end of the shift

Front 49

Draining a wound helps prevent what?

Back 49

Abscess or fistula

Front 50

Binders are used for what?

Back 50

To provide support and hold dressings in place

Front 51

Wounds must be assessed for what?

Back 51

appearance, drainage, swelling, odor, increased redness, pain, swelling

Front 52

Always access for what before beginning wound care??

Back 52

Allergies to medications, cleansing solutions, tape

Front 53

What 2 nursing diagnosis are always present with wound care?

Back 53

Impaired skin integrity, & risk for infection

Front 54

Hydrocolloid dressings are applied when?

Back 54

To non infected wounds. They keep wound moist and absorb drainage.

Front 55

Moist packing and a damp dressing help _____ a wound

Back 55

Debride

Front 56

Sutures are usually in how long? (Longer for elderly)

Back 56

7 to 10 days

Front 57

What are possible systemic circulatory effects of applied heat?

Back 57

faintness, faster pulse, dyspena (difficulty breathing)

Front 58

What are various ways to apply heat?

Back 58

compress, soak, hot pack, hot water bottle, aquathermia pad, heat lamp, heating pad, hot water bath

Front 59

How is cold applied?

Back 59

compresses, packs, ice bags, hypothermia blanket

Front 60

The assessment of the wound indicates healing is occuring when:

Back 60

Pink granulation tissue is visible

Front 61

If the wound appears to be infected, you should:

Back 61

Obtain an order for a C/S test

Front 62

Hydrocolloid dressings are useful for open wound dressings because they:

Back 62

Keep the wound moist while blocking entry of microorganisms

Front 63

When caring for a pressure ulcer you know that:

Back 63

Eschar must be removed before healing can occur

Front 64

Proper technique for removal of sutures:

Back 64

Never pull the suture through the wound

Front 65

Cold packs applied during the first 24 hours after injury decrease swelling by:

Back 65

Causing vasocinstriction and decreasing bleeding from damaged blood vessels