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NUR155 Unit 6-8 Test 3 study guide
Skin Integrity and Wounds
· Apply clinical judgment with these dressings and pressure stages:
o Aquaphor gauze: This is an example of the dressing type called Impregnated non-adherent.
The purpose is To cover, soothe, and protect partial- and full-thickness wounds without exudate.
Require secondary dressings to secure them in place, retain moisture, and provide wound
protection. It is indicated for Postoperative dressing over staple/ sutures Superficial burns.
o Duoderm: This is an example of the dressing type called Hydrocolloids. designed to be worn
for up to 7 days, consist of two layers. The purpose is to absorb exudate; to produce a moist
environment that facilitates healing but does not cause maceration of surrounding skin; to
protect the wound from bacterial contamination, foreign debris, and urine or feces; and to
prevent shearing.It is indicated for Pressure ulcers stage II-IV Autolytic debridement of eschar
Partial-thickness wounds.
o Adaptic: This is an example of the dressing type called Impregnated non-adherent. The
purpose is to provide protection against contamination and friction; to maintain a clean moist
surface that facilitates cellular migration; to provide insulation by preventing fluid evaporation,
and to facilitate wound assessment.
o Tegaderm: This is an example of the dressing type called Transparent film. allow the
exchange of oxygen between the atmosphere and wound bed. They are impermeable to
bacteria and water.
· Apply safe clinical judgment related to teaching and implantation of hot and cold
therapy: use and contraindications of both
-The rebound phenomenon occurs at the time the maximum therapeutic effect of the hot or cold
application is achieved and the opposite effect begins. EX: heat produces maximum
vasodilation in 20 to 30 minutes; beyond 30 minutes brings tissue congestion, and the blood
vessels then constrict. With cold applications, maximum vasoconstriction occurs when the
involved skin reaches a temperature of 15°C (60°F). The ruddiness of the skin of a person who
has been walking in cold weather is due to oxygenated red blood cells trapped in the skin when
vasoconstriction occurs. Below 15°C, vasodilation begins.
-Contraindication → The first 24 hours after traumatic injury. Heat increases bleeding and
swelling. Noninflammatory edema. Heat increases capillary permeability and edema. A skin
disorder that causes redness or blisters. Heat can burn or cause further damage to the skin.
Cold can increase tissue damage by decreasing blood flow to an open wound. Cold can further
impair the nourishment of the tissues and cause tissue damage. In clients with Raynaud’s
disease, cold increases arterial spasm. Some clients have an allergy to cold that may be
manifested by an inflammatory response, for example, erythema, hives, swelling, joint pain, and
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occasional muscle spasm. Some react with a sudden increase in blood pressure, which can be
hazardous if the person is hypersensitive
-Heat Therapy: Vasodilation, Increases capillary permeability, Increases cellular metabolism,
Increases inflammation, Sedative effect
-Cold therapy: Vasoconstriction, Decreases capillary permeability, Decreases cellular
metabolism, Slows bacterial growth, decreases inflammation, Local anesthetic effect
· Discuss safe patient care related to the purpose of binders and bandages, how to use
them, nursing interventions and rationales, risks associated with the use of these
devices.
-Bandage: 5 types. circular, spiral, spiral reverse, recurrent, and figure-eight.
● Circular Turn → used to anchor bandages and to terminate them. Circular turns usually
are not applied directly over a wound because of the discomfort the bandage would
cause.
● Spiral Turn → used to bandage parts of the body that are fairly uniform in
circumference, for example, the upper arm or upper leg.
● Spiral reverse Turns → are used to bandaging cylindrical parts of the body that are not
uniform in circumference, for example, the lower leg or forearm.
● Recurrent turns → are used to cover distal parts of the body, for example, the end of a
finger, the skull, or the stump of an amputation.
● Figure-eight turns → are used to bandage an elbow, knee, or ankle, because they
permit some movement after application.
- Whenever possible, bandage the part in its normal position, with the joint slightly flexed, This
avoids putting strain on the ligaments and the muscles of the joint. • Pad between skin surfaces
and over bony prominences, This prevents friction from the bandage and consequent abrasion
of the skin. • Always bandage body parts by working from the distal to the proximal end, This
aids the return flow of venous blood.
-Inspect and palpate the area for swelling. • Inspect for the presence of and status of wounds
(open wounds will require a dressing before a bandage/ binder is applied). • Note the presence
of drainage. Inspect and palpate for the adequacy of circulation (skin temperature, color, and
sensation) because Pale or cyanotic skin, cool temperature, tingling, and numbness can
indicate impaired circulation.
-Instruct the client’s caregiver on the importance of and how to: 1. Cleanse hands thoroughly
before handling dressing supplies and applying the bandage. 2. Report skin breakdown,
redness, pain, or pallor of the affected area. 3. Check for adequate peripheral circulation after
applying the bandage
-Binder: Used to support large areas of the body, such as the abdomen or chest. Help to
prevent dehiscent
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● Arm Sling → flex the elbow to an 80° angle. The thumb should be facing upward or
inward toward the body.
● Straight Abdominal Binder → Place the binder smoothly around the body, commonly
with the upper border of the binder at the waist and the lower border at the level of the
gluteal fold. A binder placed over the waist interferes with respiration; one placed too low
interferes with elimination and walking.
· Apply clinical judgment on the use of drains and drainage devices, the purpose of
use, and safe patient management
-When you have surgery, sometimes because they instill fluid they want to implant a drain
which nurses have to take care of as well as teaching the client how to take care of it. UAP can
empty drain but RN must make sure it is done appropriately. The surgeon inserts the wound
drainage tube during surgery. Generally, the suction is discontinued from 3 to 5 days
postoperatively or when the drainage is minimal. Instruct the caregiver to observe the wound
daily for signs of infection, such as redness, edema, tenderness, or purulent drainage. The
client’s temperature should be measured twice daily.
-Jackson Pratt (JP): This is a close system. this will be seen in mastectomy, wrist
augmentation, abdominal surgery. Sometimes it will go into the liver area where they have
gallbladder surgery and they had some bowel leakage, so they would put the drain in to put that
out, therefore the pockets will be green instead of red. Empty every shift but if they are filling
up then it needs to be emptied and recharge with suction.connected to a reservoir that
maintains constant low suction. To remove the drain, wear gloves, and need doctor orders,
there is a stitch that holds the drain near the skin that would have to be clipped and removed.
This is not a sterile procedure but Do cover the hole with a dressing when removed. Remove
quickly to reduce pain. Inspect to make sure it is intact. Document what the tip looks like it
should look intact. After empty clean it with alcohol, squeeze it to activate the suction then close
it.
-Penrose Drain: Open system. Insert during surgery, we don’t know how much has been
inserted, has a suture holding it in place. Because we have negative pressure in our body it has
to be sutured or it can get sucked into the body. This can be done in thoracotomy, removal of a
lung segment. This requires a dressing to cover it, they may drain sponges.
-Hemovac Drain: “Wound Drainage Reservoir”. Seen in orthopedic surgery. Place it on a flat
surface, press down while it is open, then close it and this is how you are going to create
suction. Have a stronger suction than JP drain and that is because of the spring-loaded which
gives it more suction.
· Explain collaborative relationships needed to provide and improve the care of
patients with impaired skin integrity and wounds. (Patient education and communication)
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NUR155 Unit 6-8 Test 3 study guide
Skin Integrity and Wounds
· Apply clinical judgment with these dressings and pressure stages:
o Aquaphor gauze: This is an example of the dressing type called Impregnated non-adherent.
The purpose is To cover, soothe, and protect partial- and full-thickness wounds without exudate.
Require secondary dressings to secure them in place, retain moisture, and provide wound
protection. It is indicated for Postoperative dressing over staple/ sutures Superficial burns.
o Duoderm: This is an example of the dressing type called Hydrocolloids. designed to be worn
for up to 7 days, consist of two layers. The purpose is to absorb exudate; to produce a moist
environment that facilitates healing but does not cause maceration of surrounding skin; to
protect the wound from bacterial contamination, foreign debris, and urine or feces; and to
prevent shearing.It is indicated for Pressure ulcers stage II-IV Autolytic debridement of eschar
Partial-thickness wounds.
o Adaptic: This is an example of the dressing type called Impregnated non-adherent. The
purpose is to provide protection against contamination and friction; to maintain a clean moist
surface that facilitates cellular migration; to provide insulation by preventing fluid evaporation,
and to facilitate wound assessment.
o Tegaderm: This is an example of the dressing type called Transparent film. allow the
exchange of oxygen between the atmosphere and wound bed. They are impermeable to
bacteria and water.
· Apply safe clinical judgment related to teaching and implantation of hot and cold
therapy: use and contraindications of both
-The rebound phenomenon occurs at the time the maximum therapeutic effect of the hot or cold
application is achieved and the opposite effect begins. EX: heat produces maximum
vasodilation in 20 to 30 minutes; beyond 30 minutes brings tissue congestion, and the blood
vessels then constrict. With cold applications, maximum vasoconstriction occurs when the
involved skin reaches a temperature of 15°C (60°F). The ruddiness of the skin of a person who
has been walking in cold weather is due to oxygenated red blood cells trapped in the skin when
vasoconstriction occurs. Below 15°C, vasodilation begins.
-Contraindication → The first 24 hours after traumatic injury. Heat increases bleeding and
swelling. Noninflammatory edema. Heat increases capillary permeability and edema. A skin
disorder that causes redness or blisters. Heat can burn or cause further damage to the skin.
Cold can increase tissue damage by decreasing blood flow to an open wound. Cold can further
impair the nourishment of the tissues and cause tissue damage. In clients with Raynaud’s
disease, cold increases arterial spasm. Some clients have an allergy to cold that may be
manifested by an inflammatory response, for example, erythema, hives, swelling, joint pain, and
Downloaded by madiba South Africa stuvia ()
, lOMoARcPSD|44532475
occasional muscle spasm. Some react with a sudden increase in blood pressure, which can be
hazardous if the person is hypersensitive
-Heat Therapy: Vasodilation, Increases capillary permeability, Increases cellular metabolism,
Increases inflammation, Sedative effect
-Cold therapy: Vasoconstriction, Decreases capillary permeability, Decreases cellular
metabolism, Slows bacterial growth, decreases inflammation, Local anesthetic effect
· Discuss safe patient care related to the purpose of binders and bandages, how to use
them, nursing interventions and rationales, risks associated with the use of these
devices.
-Bandage: 5 types. circular, spiral, spiral reverse, recurrent, and figure-eight.
● Circular Turn → used to anchor bandages and to terminate them. Circular turns usually
are not applied directly over a wound because of the discomfort the bandage would
cause.
● Spiral Turn → used to bandage parts of the body that are fairly uniform in
circumference, for example, the upper arm or upper leg.
● Spiral reverse Turns → are used to bandaging cylindrical parts of the body that are not
uniform in circumference, for example, the lower leg or forearm.
● Recurrent turns → are used to cover distal parts of the body, for example, the end of a
finger, the skull, or the stump of an amputation.
● Figure-eight turns → are used to bandage an elbow, knee, or ankle, because they
permit some movement after application.
- Whenever possible, bandage the part in its normal position, with the joint slightly flexed, This
avoids putting strain on the ligaments and the muscles of the joint. • Pad between skin surfaces
and over bony prominences, This prevents friction from the bandage and consequent abrasion
of the skin. • Always bandage body parts by working from the distal to the proximal end, This
aids the return flow of venous blood.
-Inspect and palpate the area for swelling. • Inspect for the presence of and status of wounds
(open wounds will require a dressing before a bandage/ binder is applied). • Note the presence
of drainage. Inspect and palpate for the adequacy of circulation (skin temperature, color, and
sensation) because Pale or cyanotic skin, cool temperature, tingling, and numbness can
indicate impaired circulation.
-Instruct the client’s caregiver on the importance of and how to: 1. Cleanse hands thoroughly
before handling dressing supplies and applying the bandage. 2. Report skin breakdown,
redness, pain, or pallor of the affected area. 3. Check for adequate peripheral circulation after
applying the bandage
-Binder: Used to support large areas of the body, such as the abdomen or chest. Help to
prevent dehiscent
Downloaded by madiba South Africa stuvia ()
, lOMoARcPSD|44532475
● Arm Sling → flex the elbow to an 80° angle. The thumb should be facing upward or
inward toward the body.
● Straight Abdominal Binder → Place the binder smoothly around the body, commonly
with the upper border of the binder at the waist and the lower border at the level of the
gluteal fold. A binder placed over the waist interferes with respiration; one placed too low
interferes with elimination and walking.
· Apply clinical judgment on the use of drains and drainage devices, the purpose of
use, and safe patient management
-When you have surgery, sometimes because they instill fluid they want to implant a drain
which nurses have to take care of as well as teaching the client how to take care of it. UAP can
empty drain but RN must make sure it is done appropriately. The surgeon inserts the wound
drainage tube during surgery. Generally, the suction is discontinued from 3 to 5 days
postoperatively or when the drainage is minimal. Instruct the caregiver to observe the wound
daily for signs of infection, such as redness, edema, tenderness, or purulent drainage. The
client’s temperature should be measured twice daily.
-Jackson Pratt (JP): This is a close system. this will be seen in mastectomy, wrist
augmentation, abdominal surgery. Sometimes it will go into the liver area where they have
gallbladder surgery and they had some bowel leakage, so they would put the drain in to put that
out, therefore the pockets will be green instead of red. Empty every shift but if they are filling
up then it needs to be emptied and recharge with suction.connected to a reservoir that
maintains constant low suction. To remove the drain, wear gloves, and need doctor orders,
there is a stitch that holds the drain near the skin that would have to be clipped and removed.
This is not a sterile procedure but Do cover the hole with a dressing when removed. Remove
quickly to reduce pain. Inspect to make sure it is intact. Document what the tip looks like it
should look intact. After empty clean it with alcohol, squeeze it to activate the suction then close
it.
-Penrose Drain: Open system. Insert during surgery, we don’t know how much has been
inserted, has a suture holding it in place. Because we have negative pressure in our body it has
to be sutured or it can get sucked into the body. This can be done in thoracotomy, removal of a
lung segment. This requires a dressing to cover it, they may drain sponges.
-Hemovac Drain: “Wound Drainage Reservoir”. Seen in orthopedic surgery. Place it on a flat
surface, press down while it is open, then close it and this is how you are going to create
suction. Have a stronger suction than JP drain and that is because of the spring-loaded which
gives it more suction.
· Explain collaborative relationships needed to provide and improve the care of
patients with impaired skin integrity and wounds. (Patient education and communication)
Downloaded by madiba South Africa stuvia ()
