Chapter 48 part 1

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Author:
Gandrews
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75778
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Chapter 48 part 1
Updated:
2011-04-01 21:17:43
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wounds healing
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wound healing
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  1. To maintain proper wound healing, blood sugar levels need to be maintained between what levels?
    70-110
  2. Tunneling wound that will not have appropriate wound healing
    Fistula
  3. For maitenance of skin and wound healing, clients need how many calories a day?
    1500kcal/day
  4. What two vitamins do clients need for proper wound healing
    A and C
  5. Occurs when tissue oxygenation fuels cellular function
    Tissue Perfusion
  6. What two types of clietns are espesically at risk for tissue perfusion?
    People with Diabetes or people who are in shock
  7. Prolongs the inflammatory phase, delays collagen synthesis, and prevents epithelialization and tissue destruction.
    Wound infection
  8. Name at least 3 signs of a wound infection
    Pus, change in odor, volume, redness of tissue, fever, pain/tenderness
  9. A proper dressing does not allow a full thickness wound to become what?
    dry, with scab formation
  10. Seperates Dermis and epidermis
    Dermal-epidermal junction
  11. occurs when normal red tones of the ligh- skinned client are absent. Paling or whitening of skin
    Blanching
  12. A red moist tissue composed of new blood vessels, the presence indicated prgression toward healing
    Granulation tissue
  13. Soft, yellow, or white tissue (stringy substance attached tot he wound bed) needs to be removed before the wound is able to heal
    Slough
  14. Name some factors that influence pressure ulcer development
    Impaired Seneory perception, Impaired mobility, alteration in LOC, Shear, Friction, Moisture
  15. Balck or brown necrotic tissue which needs to be removed before healing can proceed
    Eschar
  16. Describes the amt of color, consistency and odor of wound drainage and is part of wound assessment
    Exudate
  17. Wound that proceeds through an orderly and timely reparative process that results in sustained restoration on anatomical and functional integrity
    Acute wound
  18. Wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity
    Chronic wound
  19. Wound extending into the dermis
    Full thickness
  20. loss of epidermis
    Partial thickness
  21. Continue exposure to insult to wound impedes wound healing for what type of wound?
    Chronic
  22. Healing process class.
    Wound that is closed. Stapled or sutured. Healing occurs by epithelialization. heals quickly
    Primary intention wound
  23. Healing class
    Wound edges are not approximated. Wound that is left open until if fills w/ scar tissue. Surgical wounds that have tissue loss.
    Secondary intention
  24. Wound left open for several days, then wound edges are approximated. Wounds that are contaminated and require signs of inflammatinon
    Tertiary Intention
  25. For partial thickness wound repair, the inflammatory response is limited to how many hours after wounding
    24 hours
  26. For Full thickness wound repair, the infalmmation stage last approximately how many days?
    3 days
  27. Response that causes redness and swelling to the area with a moderate amount of serous exudate
    Inflammatory response
  28. Stage in wound repar that has appearance of new blood vessels for reconstruction. Begins and lasts from 3 to 24 days.
    Proliferation stage
  29. Maturation, the final stage of healing. sometimes takes more than a year.
    Remodeling
  30. Hemmorghage infections are most likely between what amt of hours?
    24-48 hours
  31. Bleeding from a wound site, internally or externally
    Hemorrage
  32. Name the 6 subsclases that the Braden scale measures?
    Sensory perception, moisture, activity, mobility, nutrition, friciton and shear
  33. The golden standard for pressure ulcer risk assessment?
    Braden Scale
  34. The lower the score of the on the Braden Scale...
    The higher risk for injury the pt will be
  35. Partial to total seperation of wound layers. A client who is at risk for poor wound healing is at risk for this.
    Dehiscence
  36. Protrusion of visceral organs througn a wound opening
    Evisceration
  37. Name some factors that afftect pressure ulcer formation and healing
    Nutrition, tissue perfusion, infection, age, psychosocial impact of wounds
  38. If we find an ulcer, initail action is to...
    document the location, size, color and what kind of drainage there is.
  39. How often do acute wound need monitoring?
    every 8 hours
  40. What do we clean pressure ulcers with
    normal saline, noncytotoxic solution
  41. the removal of nonviable, necrotic tissue
    Debridement
  42. Type of Debridement. Wet to dry saline gauze dressing, wound irrigation and whirlpool treatments
    Mechanical debridement
  43. Type of Debridement. uses synthetic dressing over a wound to allow the eschar to be self- digested by the action of enzymes that are present in wound fluids
    Autolytic Debridement
  44. type of debridement. uses a topical enzyme preparations, Dakins solutions, or steril maggots.
    Chemical Debridement
  45. the removal of devitalized tissue by using a scapel, scissors, or other sharp instruments
    Surgical Debridement
  46. to control the bleeding of a wound in a first aid situation...
    apply direct pressure on the wound with a sterile or clean dressing
  47. If a wound is healing by secondary intention, the dressing needs to support what kind of environment?
    Moist
  48. Wet to dry dressing are only for what?
    Debridement
  49. What should the nurse do with dead wound space?
    Fill it with dressing material
  50. If a wound drain or wound vac is blocked, what should the nurse do?
    notify the health care provider
  51. A client shoul not be in a chair no longer than?
    2 hours
  52. Type of dressing that Protects the wound from surface contamination.
    Hydrocolloid
  53. Maintains a moist surface to maintain healing
    Hydrogel
  54. Uses negative pressure to support healing
    Wound V.A.C
  55. Before touching a wound and after performing hand hygiene the nurse should wear what?
    Sterile gloves
  56. Before performing the dressing change, the nurse should make the sure the patient is....
    medicated
  57. To clean a wound you need to start from the _ toward the_
    wound incicsion toward the surounding skin
  58. For irrigating a wound, allow the solution to flow from the _ to the _ contaminated area
    least to most.
  59. what size needle and what size syringe are used for wound irrigation that removes exudates
    19 gauge needle and 35 ml syringe
  60. portable untis that exert a safe, constant, low-pressure vacuum to remove and collect drainage
    Drainage evacuation
  61. Designed for the body part to be supported. Breast, abdominal
    Binder
  62. Name conditions that affect heat and cold therapy
    very young and old clients, open wounds, broken skin, stomas, areas of edema, scar formation, peripheral vascualr disease (diabetes, arteriosclerosis), confusion, unconsciousness, spinal cord injury, abscessed tooth or appendix
  63. name some therapeutic effects of heat
    vasodialation, reduces blood viscosity, reduces muscle tension, increased capillary metabolism, increases capillary permeabiltiy
  64. name some theraputic effects of cold therapy
    vasoconstriction, local anesthesia, reduced cell metabolism, increased blood viscosity, decreased muscle tension
  65. the adjusts best to what kind of temp adjustments?
    minor
  66. a person is better to tolerate _ exposures to temperature extremes
    Short exposures
  67. When a wound specimen is obtained for culture to determine whether infection is present, the specimen should to be taken from:
    The wound, after it has been cleansed with normal saline
  68. Which of the following interventions is most appropriate in managing fecal and urinary incontinence in a client?
    A) Keeping the buttocks exposed to air at all times
    B) Using an incontinence cleanser, followed by application of a moisture barrier ointment
    C) Cleansing frequently, applying an ointment, and covering the areas with a thick absorbent towel
    D) Applying a large absorbent diaper that is changed when completely saturated
    B) Using an incontinence cleanser, followed by application of a moisture barrier ointment
    (this multiple choice question has been scrambled)
  69. The
    nurse is to collect a specimen for culture after assessing the client's
    wound drainage. The best technique for obtaining the culture is to:
    Cleanse the wound first

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