Wound Care exam Study Guide with Complete Solutions

Wound Care exam Study Guide with Complete Solutions List the principles of surgical asepsis and explain the rationale for each principle. - Answer--sterile object remains sterile only when touched by another sterile object -place only sterile objects on sterile field -sterile object or field out of range of vision or an object held below a person's waist is contaminated -sterile object becomes contaminated by prolonged exposure to air -a sterile object or field becomes contaminated by capillary action when a sterile surface comes in contact w/ a wet contaminated surface -b/c fluid flows in direction of gravity, sterile object becomes contaminated if gravity causes a contaminated liquid to flow over surface of an object (keep wet hands up above elbows, dry from fingers to elbows) EMILLECT 2024/2025 ACADEMIC YEAR ©2024 EMILLECT. ALL RIGHTS RESERVED. FIRST PUBLISH OCTOBER 2024. Page 2/24 -the edges of a sterile field or container are contaminated (1-inch border) risk factors for pressure ulcer development and nursing interventions to reduce ulcer development - Answer-SHEAR-keep HOB 30 degree angle. reposition frequency is determined by tissue tolerance, lvl of activity, and mobility. std=every 1-2 hrs for bed bound, every 1 hr for chair. use support surfaces to redistribute wt FRICTION-minimal layers of bed linens between pt and the surface. keep heels off bed. teach pt's to reposition wt every 15 min. use assisitive devices when transferring or turning pt. MOISTURE-use an incontinence cleanser and moisture barrier cream, toileting schedule, fecal incontinence collector or condom cath, use underpads or diapers that wick moisture AWAY from skin rather than trap it NUTRITION-nutrition assessment, ensure adequate intake of PROTEIN, fat, and carbs, consult RD, ensure adequate fluid intake INFECTION- AGE-thin skin increases EMILLECT 2024/2025 ACADEMIC YEAR ©2024 EMILLECT. ALL RIGHTS RESERVED. FIRST PUBLISH OCTOBER 2024. Page 3/24 Partial-thickness wound - Answer-wounds that heal by primary intention and shallow wounds that only involve loss of epidermis/dermis heal by resurfacing of wound with new epidermal cells Partial-thickness wound repair - Answer-Inflammatory response-[erythema/edema inc WBC to site]. usually subsides in 24 hrs Epidermal repair-[epidermal cells migrate across wound]. moist env-heal in ~4days, dry env-heal in 7 days Dermal repair-[epidermis thickens and anchors to cells]. resumes normal fxn. pink, dry, and fragile skin. occurs concurrently w/ epidermal repair Full-thickness wound - Answer-involve tissue loss and extend to at least Sub Q layer. can be acute (surgical wound) or chronic (pressure ulcer) can be healed by primary or secondary intention Full-thickness wound repair - Answer-Hemostasis-[controls bleeding]. platelets cause coag and vasocontriction, and break down and release growth factors (GF initiate entire wound healing process). DOES NOT occur in wounds healing by secondary intention! (comprimises repair process) EMILLECT 2024/2025 ACADEMIC YEAR ©2024 EMILLECT. ALL RIGHTS RESERVED. FIRST PUBLISH OCTOBER 2024. Page 4/24 Inflammation-[establish clean wound bed & bacterial balance]. brings WBC to area, cleans site, releases addt'l GF. lasts 3 days in acute wounds, 3 days in chronic wound (pressure ulcer) Proliferation-[prod. of new tissue, epithelialization, contraction]. w/ primary intention new capillary networks form to provide O2 and nutrients and synthesis of collagen. wound contracts as collagen fibers increase in size. epithelial cells migrate and cover defect (occurs faster in moist env!!!!). w/ pressure ulcer, takes longer. as granulation tissue fills defect, contraction and epithelialization can occur. contraction is more important in secondary wounds b/c it reduces amnt of gran