Solutions
What are some nursing interventions for wound care? Correct Answer--
repositioning patients
-adequate nutrition
-adequately hydrated
-decreasing any bed sores--Braden Scale Assessment
What is the Braden Scale Assessment? Correct Answer-Valid tool to
assess pressure ulcer risk
What are the 6 components of the Braden scale Assessment? Correct
Answer-1.) sensory perception
2.) Moisture-people sitting in moisture, incontinence, sweating, any type
of drainage
3.) Activity
4.) Mobility
5.) Nutrition
6.) Friction and shear
What do we look at with wound care? Correct Answer--understanding
the cause of the wound
-what type we have
-how it's healing
,-any factors affecting it
-assess/implement wound care
Define etiology Correct Answer-cause of the wound
Define wound Correct Answer-disruption of integrity of skin
Define clean surgical wound Correct Answer-have minimal loss of
tissue because its a clean cut and stitched to hold edges efficiently and
heal by primary intention
What are the two types of wounds? Correct Answer-acute and chronic
wounds
Define acute wound Correct Answer-progress through time and orderly
repaired process that results in restoration of both anatomical functions
and integrity
Define chronic wound Correct Answer-fail to precede through orderly
healing processes because due to vascular comprimise, chronic
inflammation, or underlying disease in the body
What are the nursing roles for wound care? Correct Answer--assess
-analysis and plan
-implement care
, -evaluate and document
What does the nurse do in assessing wound care? Correct Answer--
patient:ability for healing
-wound: monitor, measure
-environment: identify factors affecting wound
What does the nurse do in analysis and plan for wound care? Correct
Answer-plan to optimize healing for patient and wound
What does the nurse do in implement care in wound care? Correct
Answer--patient= optimize for healing
-wound: dressing/local wound care
-environment: address concerns
Whats does the nurse do in evaluate and document in wound care?
Correct Answer-Reassess if needed
What exactly should a nurse assess when looking at a wound? Correct
Answer--how quickly the wound can heal/whether it will heal (limited
circulation)
-risk of infection
-patient's ability to follow advice or follow the plan for them
-who to call (wound team, dietician, social work, physician, PT, OT,
pharmacist)