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The flashcards below were created by user
NurseNatalie
on FreezingBlue Flashcards.
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In there is a red spot over a bony prominence that does not blanch, what stage ulcer is this?
Stage 1
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If you find an ulcer that has gone through the dermis and epidermis What stage ulcer is this?
Stage 2
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If you find an ulcer that tunnels and you can see bone and tendons, What stage ulcer is this?
Stage 4
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If you find an ulcer that has full thickness tissue loss and can see fat, What stage is this?
Stage 3
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What would you do nutritionally to encourage wound healing?
- Vitamin C- helps with collagen synthesis
- Vitamin E
- Zinc
- Maintain Hydration Status
- Protein before any surgery
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What is hemorrhagic and what could cause it?
- Excessive bleeding
- Dislodging of a clot
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Hematoma
- Bleeding under the skin.
- *Circle the border... look for expansion
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Dehiscence
A wound that starts to heal at top and bottom but reopens in the middle
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Evisceration
When organs come out of a wound
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A wound has yellow and watery fluid coming out... What kind of drainage is this?
Serous
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A wound has pus coming out (white yellow or green)? What kind of drainage is this?
Purulant
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A wound has bloody drainage. What is this from? And What kind of drainage is this?
- From damage on the capillary level
- Sanguienous
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If there is pink drainage, what kind drainage
Serosanguinous
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What are some nursing diagnosis' for skin integrity and wound care?
•Risk for infection•Imbalanced nutrition: less than body requirements•Acute or chronic pain•Impaired physical mobility•Impaired skin integrity•Risk for impaired skin integrity•Ineffective tissue perfusion•Impaired tissue integrity
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In the Norton scale a score 14 or less indicates what?
Pressure ulcer development
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When should the patient have had a tetanus exam?
Within the last 5 years
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What are 3 common sites of pressure ulcers
- above the buttocks
- Back of the head
- Heels
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What is a normal WBC count?
4500- 10000
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When there is an infection, What cell is high?
Leukocytes
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What protien helps promote healing?
Albumin
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How often should you turn a patient with pressure ulcers?
Every 2 hours
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Tegaderm is an example of what kind of wound dressing?
What stage ulcer would you use this on?
Why?
- Transparent film
- Stage 2
- it is airtight and holds in moisture while minimizing infection
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What is the purpose of an impregnated nonadherent wound dressing?
It is used for a wound that is draining alot. It is infused with saline to help drain moisture
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What is an example of a hydrocolloid dressing?
- DuoDerm
- Meant to stay in place 3-5 days
- Meant to absorb fluid and drainage but also keep it moist
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Clear absorbant acrylic is what?
- Dermabond
- Clear liquid band aid used instead of sutures
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What is the purpose of polyurathane foam?
Used around the site of a wound to collect excess drainage
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What is alginate?
Seaweed and then a dry dressing on top of that?
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Chemical debridment
Uses topical enzyme or maggots to get rid of dead tissue
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Surgical debridment
the removal of devitalized tissue by using a scalpel, scissors, or other sharp instrument
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Mechanical debridment
want the dressing to adhere to the wound and pull dead tissue off.
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What examples of dry heat?
- heat packs
- Hot water bottle
- electric pads
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Moist heat
- compresses
- soaks
- Sitz Baths
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A dehydrated patient has a wound What would be the best application of heat.... Moist or dry?
Warm moist heat does not promote sweating or insensible fluid loss
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What are some examples of dry cold
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What are some examples of moist cold?
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