Galen Nur 155 Exam 3 with complete solutions verified & updated 2023/24

Types of wounds Intentional or unintentional Open or closed Acute or chronic Partial thickness, full thickness, complex transparent film autolytic debridement, semi-permeable allows skin to breathe. uses: burns, IV sites, stage 1& 2 pressure ulcers, skin tears how do you apply an abdominal binder? start at typhoid, fasten from the bottom up used for support to keep dressing intact remove every two hours to asses underlying skin and wound Risk factors for pressure ulcers Fecal and unitary incontinence Friction and shearing immobility inadequate nutrition (decreased protein, Vitamin C, zinc) Decreased mental status excessive body heat (moisture) advanced age chronic conditions Diminished sensation Incorrect positioning Signs of infected pressure ulcer? Change in color, odor, or drainage. Sever infections cause fever and increased WBC. During your assessment of a new patient, the nurse notices a Stage I pressure ulcer, what are the signs that this nurse is correct about this pressure ulcer being a stage one? Non-blachable No opening What do you do for a stage I pressure ulcer? Apply barrier creams Reposition patient Q2hr As you assess your new patient you notice a sore on a bony premise that is blister-like, with partial thickness skin loss, pt is complaining of pain where the wound is present which stage is this pressure ulcer? Stage II What type of dressing do you use for a stage II pressure ulcer? Mepaplex or Duoderm Full thickness skin loss, involving damage or necrosis of subcutaneous is what stage pressure ulcer? Stage III Full thickness skin loss with tissue necrosis, damage to the muscle and bone, wound goes through nerves and not painful with tunneling present, which stage is this wound? Stage IV Treating pressure ulcers Minimize direct pressure Reposition Q2hr Schedule and DOCUMENT position change use assistive devices Dressing changes as ordered Keep sheets dry and wrinkle free Keep pt dry if incontinent ROM 3reps 2x daily What is regeneration? replacement of destroyed tissue by the same kind of cells Primary intention healing tissue surfaces are approximated (closed) and there is minimal or no tissue loss, formation of minimal granulation tissue and scarring Secondary intention healing wound in which the tissue surfaces are not approximated and there is extensive tissue loss; formation of excessive granulation tissue and scarring and greater risk of infection tertiary intention Wounds that are left open purposely for 3-5 days to allow edema and infection to resolve. serous clear, watery plasma purulent containing pus, milky like sanguineous dark bloody drainage Serosanguineous bright red blood Purosanguineous pus in the blood When should you use heat therapy? Vasodilation Chronic Increase capillary permeability, cellular metabolism, inflammation musculoskeletal problems joint stiffness arthritis contractures and back pain When do you use cold therapy? Vasoconstriction acute pain often used for sport injury (sprains, strains, fractures) decreased capillary permeability, cellular metabolism, inflammation Factors that affect respiratory function? Age Environment lifestyle health status medications stress eupnea normal breathing Tachypnea rapid breathing bradypnea slow breathing apena absence of breathing hypoventilation very shallow breathing, may cause increased levels of carbon dioxide. or high levels of oxygen Hyperventilation very rapid breathing more CO2 is eliminated than provided. orthopnea ability to breathe only in an upright position Dyspena difficulty breathing Hypoxia Low oxygen saturation of the body, not enough oxygen in the blood Signs and symptoms of hypoxia Rapid pulse rapid shallow respirations increased restlessness or lightheadedness flaring of the nose substernal or intercostal retractions cyanosis (bluish discoloration of the skin, nails beds, and mucus membranes due to reduced hemoglobin-oxygen levels) hypoxemia too much oxygen in the blood Hydrogels used to liquefy necrotic tissue or slough, rehydrate the wound bed and fill in dead space, partial thickness wounds, skin tears and pressure ulcers Alginate used to eliminate dead space or pack wounds and to support debridement. How do you irrigate a wound? use pressure and start from the inside and make your way out to the edges of the wound. should always be done after the soiled dressing has been removed. Dehiscence partial or total separation of wound layers Evisceration The displacement of organs outside of the body. Notify PCP immediately what are the conditions that decrease cardiac output? CHF, hypovolemia How do you promote oxygen use? Change position frequently ambulating exercise semi fowlers or high fowlers allow for maximum chest expansion in clients who are confined to bed What can you do to implement oxygen therapy? Check vital signs and O2 levels raise head above 30 degrees use methods of delivery of oxygen (liter flow per min) What are the factors affecting skin integrity? Gentetics & Heredity Age Chronic Illnesses & treatments Medications (antibiotics cause diarrhea, steroids increase BP, Diabetes) Poor nutrition What is an Intentional wound? Trauma during therapy Example: operations/Venipunctures What is an Unintentional Wound? Accidental Example: fractured arm in auto collision Wound depth is confined to the skin, that is the dermis & epidermis; healed by regeneration? Partial thickness In wound contamination, what kind contaminated wound is a surgical wound in which the respiratory, GI, genital/urinary tract has been entered, but show no signs of inflammation? Clean-Contaminated wounds What wound type penetrates the skin/underlying tissues, is usually unintentional, and is an open wound? Example: bullet wound Penetrating wound What is the way of closing a wound that only lasts about 7-10 days, has a jagged laceration, and is normally for deep tissue wounds? Sutures What is the type of wound that is caused by a sharp instrument (ex: surgical cut), can be deep or shallow? Incision When classifying wounds by depth, what type of wound involves the dermis, epidermis, subcutaneous tissue, and possibly muscle & Bone, and will require connective tissue repair? Full thickness What kind of wound is cause by a blow from a blunt instrument (ex: baseball bat), skin is bruised because of damaged blood vessels? Contusion In wound contamination, what are the infected wounds in which there is minimal inflammation, and the respiratory, GI, genital/Urinary tracts are NOT entered, and are primarily closed wounds? Clean wounds What are the sutures that dissolve/not removed, and are used in deep tissues? Absorbent Sutures What kind of wound is primarily a surface scrape? Abrasion In wound contamination, what wounds include open, fresh, accidental wounds, and surgical wounds that had a major break in the sterile field/or had a large spill from the GI tract, and show evidence of inflammation? Contaminated Wounds What kind of wound is an open wound that penetrates the skin and often the underlying tissues by a sharp instrument (goes in-out, traps bacteria? Puncture wound In closing a wound, what is used for 5-7 days, used for superficial wounds, fall off by themselves, and allow the wound to breathe? Steri-strips In wound contamination, what includes wounds containing dead tissue/wounds with evidence of a clinical infection, such as purulent drainage? Dirty/Infected wounds In wound classification, what type of wound is where tissues are torn apart, often from accidents (ex: machinery), and the open wound edges are often jagged? Laceration wound When a patient has a skin tear what kind of wound closing technique would you use? Surgical Glue When measuring wounds what should you check for? length, width, diameter, depth, redness, drainage, and tunneling, What kind of closing technique is used for 2-3 weeks, is lightweight titanium, used for high-tension areas (head, joints, hips---Can NOT use on hands, feet, neck, and face)? Surgical Staples What is a WOUND VAC? Vacuum-Assisted Wound Care A piece of foam attached to a pump to remove drainage---decreases inflammation--- What are the common drains? Penrose Drain Jackson-Pratt Drain Hem-o-vac