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91 Cards in this Set
- Front
- Back
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Intentional wounds
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Wounds that are caused intentionally. Intentional trauma occurs during therapy. Examples: operations, venipunctures
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Unintentional wounds
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Wounds that are accidental. Examples: a person may fracture an arm in an automobile collision.
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Closed wound
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When the tissues are traumatized without a break in the skin.
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Open wound
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When the skin or mucous membrane surface is broken.
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Clean wound
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Uninfected wounds in which minimal inflammation is encountered and the respiratory, alimentary, genital, and urinary tracts are not entered. Clean wounds are primarily closed wounds.
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Clean-contaminated wounds
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Surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered. Such wounds show no evidence of infection.
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Contaminated wounds
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Open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique or a large amount of spillage from the gastrointestinal tract. Contaminated wounds show evidence of inflammation.
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Dirty or infected wounds
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Wounds containing dead tissue and wounds with evidence of a clinical infection, such as purulent drainage.
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How are wounds classified?
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Wounds, except for pressure ulcers and burns, are classified by depth (the tissue layer involved in the wound).
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Incision
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Open wound: can be deep or shallow.
Cause: sharp instrument |
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Contusion
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Closed wound, skin appears ecchymotic (bruised) because of damaged blood vessels.
Cause: blow from a blunt instrument. |
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Abrasion
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Open wound involving the skin.
Cause: surface scrape, either unintentional (fall) or intentional (dermal abrasion to remove pockmarks) |
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Puncture
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Open wound.
Cause: penetration of the skin and often the underlying tissues by a sharp instrument, either unintentional or intentional. |
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Laceration
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Open wound; edges are often jagged.
Cause: tissues torn apart, often from accidents (with machinery). |
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Penetrating wound
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Open wound.
Cause: penetration of the skin and the underlying tissues, usually unintentional. Examples: from a bullet or metal fragment. |
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Partial thickness wound
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Used to classify depth of pressure ulcers. Confined to the skin. The dermis and epidermis. Heals by regeneration
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Full thickness wound
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Used to classify depth of pressure ulcers. Involving the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone. These wounds require connective tissue repair.
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Pressure ulcer or decubitus ulcer
(bedsore) |
Any lesion caused by unrelieved pressure (a compressing downward force on a body area) that results in damage to underlying tissue, as defined by the U.S. Public Health Service's Panel for the Prediction and Prevention of Pressure Ulcers in Adults (PPPPUA, 1992)
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Ischemia
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A deficiency in the blood supply to the tissue. Pressure ulcers are due to localized ischemia.
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How are pressure ulcers formed?
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The tissue is compressed b/w 2 surfaces (bed and bone) with > than 32 mm Hg pressure. When blood cannot reach the tissue, the cells are deprived of O2 and nutrients, the waste products of metabolism accumulate in the cells, and the tissue consequently dies. Prolonged unrelieved pressure also damages the blood vessels.
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What is reactive hyperemia?
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When the skin has been compressed, it appears pale. When pressure is relieved, the skin takes on a bright red flush, called reactive hyperemia.
This flush is due to vasodilation. It usually lasts 1/2 to 3/4 as long as the duration of impeded blood flow. If the redness disappears in that time, no tissue damage can be anticipated. If not, then tissue damage has occured. |
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What is vasodilation?
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A process in which extra blood floods to the area to compensate for the preceding period of impeded blood flow.
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What are some factors that contribute to the formation of pressure ulcers?
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-Immobility and inactivity
-Inadequate nutrition -Fecal and urinary incontinence -Decreased mental status -Diminished sensation -Excessive body heat -Advanced age -The presence of certain chronic conditions |
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Friction
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A force acting parallel to the skin surface. Examples: sheets rubbing against skin can create friction. Friction can abrade the skin (remove superficial layers) making it more prone to breakdown.
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Shearing force
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A combination of friction and pressure.
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Immobility
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A reduction in the amount and control of movement a person has.
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Hypoproteinemia
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Abnormally low protein content in the blood.
Causes: inadequate intake and abnormal loss |
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Edema
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The presence of excess interstitial fluid. Edema makes skin more prone to injury by decreasing its elasticity, resilience and vitality. Edema increases the distance b/w the capillaries and the cells, thereby slowing the diffusion of O2 to the tissue cells and of metabolites away from the cell.
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Skin maceration
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Tissue softened by prolonged wetting or soaking. Maceration is caused by moisture from incontinence and makes the epidermis more easily eroded and susceptible to injury.
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Skin excoriation
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Area of loss of the superficial layers of the skin also know as denuded area. Digestive enzymes in feces, gastric tube drainage, and urea in urine all contribute to skin excoriation.
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What are the 6 subscales of the Braden scale?
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1. Sensory perception
2. Moisture 3. Activity 4. Mobility 5. Nutrition 6. Friction and shear |
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1. How many total points are possible using the Braden scale?
2. An adult who scores below _ points is considered at risk for skin breakdown? |
1. 23 total points are possible.
2. 18 |
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What is stage I of pressure ulcers?
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Stage I- nonblanchable erythema signaling potential ulceration.
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What is stage II of pressure ulcers?
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Stage II- partial thickness skin loss (abrasion, blister, shallow crater) involving the epidermis and possibly the dermis.
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What is stage III of pressure ulcers?
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Stage III- full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
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What is stage IV of pressure ulcers?
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Stage IV- full thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures, such as a tendon or joint capsule. Undermining and sinus tracts may also be present.
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Regeneration
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Renewal of tissues.
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Primary intention healing
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Occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss; it is characterized by the formation of minimal granulation tissue and scarring. Example: a closed surgical incision.
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Secondary intention healing
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A wound that is extensive and involves considerable tissue loss, and in which the edges cannot or should not be approximated.
Example: pressure ulcer |
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How does secondary intention differ from primary intention?
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Secondary intention healing differs from primary intention healing in 3 ways:
1. the repair time is longer. 2. the scarring is greater. 3. the susceptibility to infection is greater. |
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What is the inflammatory phase of wound healing?
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The inflammatory phase is initiated immediately after injury and lasts 3-6 days. Hemostasis (cessation of bleeding) occurs. Blood clots (framework for cell repair) are formed. A scab forms on the surface of the wound. Below the scab epithelial cell migrate into the wound from the edges. The cells serve as a barrier b/w the body and the environment. Phagocytosis occurs.
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Phagocytosis
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Occurs when phagocytes ingest microorganisms, other cells, and foreign particles. Happens during the inflammatory phase. It helps to prevent infection.
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What is the proliferative phase of wound healing?
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The proliferative phase extends from day 3 or 4 to day 21 post injury. Fibroblasts (connective tissue cells) begin to synthesize collagen. This increases the strength of the wound. Capillaries grow across the wound, increasing the blood supply. Fibroblasts move from the bloodstream into the wound, depositing fibrin. As the capillary network develops, the tissue becomes granulation tissue. When the granulation tissue matures, marginal epithelial cells migrate to it, proliferating (growing) over the connective tissue to fill the wound.
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What is fibrin?
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Fibrin is connective tissue.
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What is collagen?
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Collagen is a whitish protein substance that adds tensile (elasticity) strength to the wound.
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What is granulation tissue?
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Young connective tissue with new capillaries formed in the wound healing process. Granulation tissue is a translucent red color. It is fragile and bleeds easily.
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What is eschar?
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Thick necrotic tissue. (Dried plasma proteins and dead cells)
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What is the maturation phase of wound healing?
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The maturation phase begins about day 21 and can extend 1 or 2 years after the injury. Fibroblasts continue to synthesize collagen. The collagen fibers reorganize into an orderly structure. During this phase the wound is remodeled and contracted. The scar becomes stronger but the repaired area is never as strong as the original tissue.
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What is a keloid?
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A hypertrophic scar containing an abnormal amount of collagen.
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What is exudate?
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Exudate is material, such as fluid and cells, that has escaped from the blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces.
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Serous exudate
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Exudate that consists chiefly of serum (the clear portion of the blood) derived from blood and the serous membranes of the body, such as the stomach. It looks watery and has few cells.
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Purulent exudate
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Exudate that consists of leukocytes, liquefied dead tissue debris, and dead living bacteria. It is thick, yellow, green, tan, or brown in appearance.
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Pus
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A thick liquid associated with the inflammation and composed of cells, liquid, microorganisms, and tissue debris.
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Suppuration
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The process of pus formation.
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Pyogenic cells
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The bacteria that produce pus.
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Sanguineous (hemorrhagic) exudate
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An exudate containing large amounts of red blood cells. Indicates damage to capillaries. This type of exudate is frequently seen in open wounds. It is pale, red and watery in appearance.
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Serosanguineous exudate
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Inflammatory material consisting of a combination of clear and blood-tinged drainage. It is bright red in appearance and indicates active bleeding.
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Hematoma
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Localized collection of blood underneath the skin that may appear as a reddish blue swelling (bruise). In severe cases, a hematoma can obstruct blood flow.
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Slough
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Yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous.
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What does granulation tissue look like?
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Pink or beefy red tissue with a shiny, moist, granular appearance.
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What does epithelial tissue look like?
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new pink or shiny tissue (skin) that grows in from the edges or as islands on the ulcer surface.
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Dehiscence
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The partial or total rupturing of a sutured wound. Usually involves an abdominal wound in which the layers below the skin also separate.
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Evisceration
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The protrusion of the internal viscera through an incision.
Causes: obesity, poor nutrition, multiple trauma, failure of suturing, excessive coughing, vomiting, and dehydration. |
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What are some signs of shock?
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Rapid thready pulse, cold clammy skin, pallor, lowered blood pressure.
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What are some signs and symptoms of a wound infection?
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Increased temperature, increased warmth at site, redness, edema, increased WBC count, increase or change in pain at site, increased drainage or change in exudate, introduction of odor.
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What is undermining?
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When the wound reaches under the skin surfaces. If left untreated, this can lead to sinus tracts or tunneling beyond the main wound surface.
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What is the RYB color code?
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This concept is based on an open wound- red, yellow, and black. The goals of wound care are to protect (cover) red, cleanse yellow, and debride black.
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Debridement
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The removal of the necrotic (dead) tissue from a wound. Debridement must occur before the wound can be staged or heal. Debridement can be achieved in 4 ways.
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Sharp debridement
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A scalpel, or scissors is used to separate and remove dead tissue.
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Mechanical debridement
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This is accomplished through scrubbing force or moist to moist dressings.
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Chemical debridement
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Collagenase enzyme agents such as papain-urea are currently most recommended for this use. More selective than sharp or mechanical.
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Autolytic debridement
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Dressings that contain wound moisture, such as hydrocolloid and clear absorbent acrylic dressings, trap the wound drainage against the eschar. The body's own enzymes in the drainage break down the necrotic tissue. This method causes the least damage to healthy and surrounding tissues.
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If more than one color is present in a wound, which color does the nurse treat first?
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The nurse would treat the most serious color first. Black, then yellow, then red.
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What are the reasons for applying dressings to a wound?
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1. To protect the wound from mechanical injury.
2. To protect the wound from microbial contamination. 3. To provide or maintain moist wound healing. 4. To provide thermal insulation. 5. To absorb drainage or debride a wound or both. 6. To prevent hemorrhage (when applied w/ pressure) 7. To splint or immobilize the wound site and thereby facilitate healing and prevent injury. |
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How do you determine what type of dressing to use?
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A. the location, size and type of wound.
B. the amount of exudate. C. whether the wound requires debridement or is infected. D. frequency of dressing change, ease or difficulty or dressing application and cost. |
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Transparent Dressing
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Adhesive plastic, semipermeable, nonabsorbent dressings that allow exchange of O2 b/w the atmosphere and the wound bed. They are impermeable to bacteria and water.
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Hydrocolloid dressing
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Waterproof adhesive wafers, pastes, or powders. Wafers, designed to be worn up to 7 days, consist of two layers. The inner layer has particles that absorb exudates and form a hydrated gel over the wound. The outer layer provides an occlusive seal.
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What are montgomery straps and why are they used?
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Montgomery straps are tie tapes used for wounds that require frequent dressing changes. These straps prevent skin irritation and discomfort caused by removing the adhesive each time the dressing is changed.
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Wound cleaning
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The removal of debris (foreign materials, excess slough, necrotic tissue, bacteria, and other microorganisms).
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What is wound irrigation?
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Irrigation is the washing or flushing out of an area.
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What is gauze packing used for?
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Gauze packing using the damp to damp technique has been used to pack wounds that require debridement. The gauze is packed into the wound to absorb exudate but they are not allowed to dry before removal.
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What is a bandage?
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A bandage is a strip of cloth used to wrap some part of the body.
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What are elasticized bandages used for?
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Elasticized bandages are applied to provide pressure to an area. They are commonly used as tensor bandages or as partial stockings to provide support and improve the venous circulation in the legs.
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What are circular turns used for?
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Circular turns are used to anchor bandages and to terminate them. They usually are not applied directly over a wound b/c of the discomfort the bandage would cause.
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What are spiral turns used for?
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Spiral turns are used to bandage parts of the body that are fairly uniform in circumference, for example, the upper arm or upper leg.
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What are figure-eight turns used for?
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Figure-eight turns are used to bandage an elbow, knee, or ankle, because they permit some movement after application.
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What is a binder?
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A binder is a type of bandage designed for a specific body part; for example, the triangular binder (sling) fits the arm. Binders are used to support large areas of the body, such as the abdomen, arm or chest.
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What is the application of heat used for?
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Heat promotes soft tissue healing and increases suppuration. Heat is often used for clients with musculoskeletal problems such as joint stiffness from arthritis, contractures, and low back pain.
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What are the physiologic effects of heat?
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Heat causes: vasodilation (dilation of the blood vessels), increases capillary permeability, increases cellular metabolism, increases inflammation, and can have a sedative effect.
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What is the application of cold used for?
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Cold lowers the temperature of the skin and underlying tissues and causes vasoconstriction, which reduces blood flow to the affected area and thus reduces the supply of O2 and metabolites, decreases the removal of wastes, and produces skin pallor and coolness.
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What are the physiologic effects of cold?
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Cold causes: vasoconstriction, decreases capillary permeability, decreases capillary metabolism, slows bacterial growth, decreases inflammation, and has a local anesthetic effect.
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