NUR 109 Exam 5 Term 2 Questions and Answers Graded A+
the tissue that normally forms during the healing of a
granulation tissue is
wound, beefy red
never do what to a dry dressing rip ott, soak dressing in NS before removal
never clean a wound with what betadine or h2o2, impedes wound healing
sterile NS or sterile h2o, clean from center of the wound
what should wounds be cleaned with
outward using gauze pads
Provides a moist environment and allows you to visualize
what would you use transparent dressing for? the wound; used for superficial wounds.
bony prominices, superficial burns, small cuts, abrasion
indicated for dry wound where rehydration of eschar is
desired; also for deeper wounds where structures such as
hydrogel dressings tendons need to be kept moist
can be used when infection is present
low absorptive capacity, medium to high hydrating
absorbs exudate while providing slight pressure on
hydrocolloids wound bed to prevent hypergranulation
not for infected wounds
non adherant foam sheets that absorb minimum to large
hydrocellular foams amounts of exudate,
used for venous ulcers
from seaweed
alginates safe to use in sinuses and fistulae and absorbs heavy
exudate
used for abrasions, minor cuts, staple or sutures, 1 or 2
non adhesives
degree burns, and shallow wounds
bacitracin- antibiotic for gram pos bacteria
bactroban- for staph or strep, not gram pos bacteria
neomycin sulfate- triple antibiotic for staph, gram pos and
,NUR 109 Exam 5 Term 2 Questions and Answers Graded A+
strep
antifungal- yeast infections
5 types of topical dressings
silver sulfadiazine- bacteria and yeast and burns, infec-
tions
debride wound
identify infection
wick up dead space
absorb extra exudate
DIWAMOPI
maintain moist enviorment
open wound edges
protect site
insulate site
location
type of wound
size
apperance
what kind of information do you need to consider when drainage
documenting? (10) odor
surrounding tissue
sign of infection
pain
response to tx
Etiology factors
systemic support
pressure injury tx
principle based topical therapy
Evaluate regularly
skin tear classification (6)
, 1. control bleeding and clean the wound according to
protocol
2. realign skin flap
3. assess degree of tissue loss and skin or flap color using
classification system
4. assess the surroundings skin condition for fragility,
swelling, discoloration, or bruising
5. ass the person their wound and their healing envior-
ment
6. if the skin or flap is pale dusky or darkened reassess in
24-48 hours or at the first dressing change
1a- can be realigned, not pale, dusky, dark
1b-can be realigned, pale flap
how many skin tear catagories 2a-cannot realign, not pale, dusky dark flap
2b-cannot realign, flap is pale dusky or dark
3- no skin flap
wound that is closed
(hematoma, surgical incision that is staple, sewn)
healing occurs by epithelization, heals quickly with minmal
scar
primary intention
Wound healing where edges can't be easily approximated
and wound fills with granulation, wounds with tissue loss
or contamination
secondary intention wound granulization, wound contraction then epitelization
teritary intention
the tissue that normally forms during the healing of a
granulation tissue is
wound, beefy red
never do what to a dry dressing rip ott, soak dressing in NS before removal
never clean a wound with what betadine or h2o2, impedes wound healing
sterile NS or sterile h2o, clean from center of the wound
what should wounds be cleaned with
outward using gauze pads
Provides a moist environment and allows you to visualize
what would you use transparent dressing for? the wound; used for superficial wounds.
bony prominices, superficial burns, small cuts, abrasion
indicated for dry wound where rehydration of eschar is
desired; also for deeper wounds where structures such as
hydrogel dressings tendons need to be kept moist
can be used when infection is present
low absorptive capacity, medium to high hydrating
absorbs exudate while providing slight pressure on
hydrocolloids wound bed to prevent hypergranulation
not for infected wounds
non adherant foam sheets that absorb minimum to large
hydrocellular foams amounts of exudate,
used for venous ulcers
from seaweed
alginates safe to use in sinuses and fistulae and absorbs heavy
exudate
used for abrasions, minor cuts, staple or sutures, 1 or 2
non adhesives
degree burns, and shallow wounds
bacitracin- antibiotic for gram pos bacteria
bactroban- for staph or strep, not gram pos bacteria
neomycin sulfate- triple antibiotic for staph, gram pos and
,NUR 109 Exam 5 Term 2 Questions and Answers Graded A+
strep
antifungal- yeast infections
5 types of topical dressings
silver sulfadiazine- bacteria and yeast and burns, infec-
tions
debride wound
identify infection
wick up dead space
absorb extra exudate
DIWAMOPI
maintain moist enviorment
open wound edges
protect site
insulate site
location
type of wound
size
apperance
what kind of information do you need to consider when drainage
documenting? (10) odor
surrounding tissue
sign of infection
pain
response to tx
Etiology factors
systemic support
pressure injury tx
principle based topical therapy
Evaluate regularly
skin tear classification (6)
, 1. control bleeding and clean the wound according to
protocol
2. realign skin flap
3. assess degree of tissue loss and skin or flap color using
classification system
4. assess the surroundings skin condition for fragility,
swelling, discoloration, or bruising
5. ass the person their wound and their healing envior-
ment
6. if the skin or flap is pale dusky or darkened reassess in
24-48 hours or at the first dressing change
1a- can be realigned, not pale, dusky, dark
1b-can be realigned, pale flap
how many skin tear catagories 2a-cannot realign, not pale, dusky dark flap
2b-cannot realign, flap is pale dusky or dark
3- no skin flap
wound that is closed
(hematoma, surgical incision that is staple, sewn)
healing occurs by epithelization, heals quickly with minmal
scar
primary intention
Wound healing where edges can't be easily approximated
and wound fills with granulation, wounds with tissue loss
or contamination
secondary intention wound granulization, wound contraction then epitelization
teritary intention
