Nursing 101 exam 5 Set 2

• Self-care abilities for wound care
• Self-care abilities for medication administration
• Self-care abilities for hygiene
• a where of Facilities
• Family caregiver availability, skills responses
• Other susceptible cohabitants
• Community Resources

• Client understands importance of wound care
• Client is able to change dressing and care for the wound

• Client understands the importance of hygiene
• how to contain potentially infectious material
• Knows the importance of hand washing

• Client understands medication therapy
• knows expected outcomes and potential risks
• Client has physical dexterity to take or administer medications

Presence of running water, trash containers to facilitate wound care and contain potentially infectious material

• Caregiver understands the importance of wound care and can contain potentially infectious material
• Caregiver is avail when client needs them
• Caregiver is able to care for the client

is there anyone else in the home that are susceptible/ high risk for infection

• Availability of and familiarity with sources of finance, supplies, home health
• Health Department

• They are used for wounds that require frequent changing.
• The straps stay on the skin and tie across the bandage
• They prevent skin irritation that would happen if the tape was taken on and off many times

• you can see the wound
• self adhesive
• keeps it moist, promotes healing
• stays on joints

• consists of serum (the clear portion of blood)
• Looks watery
• has few cells

Thicker than serous because of the presence of pus

Leukocytes, liquid filled dead tissue debrisand both dead & living bacteria

• consists of large amounts of RBC 
• damage to capillaries that is severe enough to allow the escape of RBC

• tissue softened by prolonged wetting or soaking
• can be caused by moisture from incontinence

• area with loss of the superficial layers of skin
• denuded area

Once the maximum amount of therapeutic time is up the heat or cold begins to have the opposite effect

• Promotes tissue healing
• Causes Vasodilation blood flow bringing O2, nutrients, antibodies and leukocytes to the site
• Used for joint stiffness, musculoskeletal problems, arthritis, contractures and low back pain

• 1st 24 hr after injury heat increases bleeding and swelling
• Can causes edema or worsen existing edema because it increases capillary permeability

Too much heat causes vasodilation which drops the blood pressure and can cause fainting

• increases bleeding
• increases capillary permeability which increases edema

• on skin disorder that causes redness or blisters
• Localized Malignant Tumors

heat increases cell metabolism and increases circulation which may speed up metastases

• Sports injuries
• sprains
• strains
• fractures
• To limit swelling and bleeding

Too much cold can increase BP and induce shivering and if left too long can cause tissue damage

• Open Wounds -causes tissue damage due to increased blood flow
• Impaired circulation -can further impair nourishment of the tissue and cause damage

Freedom of disease causing microorganisms

Free of microorganisms including sproes and viruses

caused by testing or treatment

originates in the hospital

practices intended to confine a specific microorganisms to a specific area, limiting the number, growth and spread

practices that keep an area or object free of all microorganisms, also called sterile technique

Hand Hygiene

Start over with new sterile package

• Protect and cover
• These wounds are in late regeneration phase
• change infrequently to decrease chance of tissue disruption
• Gentle cleanse
• protect periwound with alcohol free barrier film
• USE clear absorbent hydrocolloid dressing

• characterized by liquid to semiliquid "slough" that is often seen with purulent drainage or previous infection
• cleanse remove dead tissue using moist saline dressing and irrigate
• use absorbent dressing like hydrogel or alginate
• apply topical antimicrobial to minimize bacteria growth

• wounds covered with thick necrotic tissue
• Debridement
• then treat as red or yellow

Black then yellow and then red

• Sharp- cut dead tissue away
• Mechanical - scrubbing wet to dry
• chemical - collagen enzyme cleaning solution
• autolytic - fly larvae

• a combination of friction and pressure
• as patient slides down in the bed from Fowlers Position
• Deep internal tissues move downward
• while skin tissues remain in place
• Causes damage to blood vessels and tissue

• causes abrasions
• caused by nurses moving pt up in the bed by scooting

• surgical/therapeutic
• incision

occur by accident

No break in the skin

skin is open

decreased blood supply and O2

• uninfected, usually closed
• minimal inflammation
• Not in tracts (resp, GI, Urinary)

• Surgical wound
• entered resp, GI, Urinary, or genital tract
• No s/s of infection

• open, fresh,
• accidental
• major break in sterility or large spillage form GI tract
• s/s of infection

• contains dead tissue
• clinical evidence of infection

• bed wrinkle free
• client in position where they will not slide

• immobility
• friction and shearing
• inadequate nutrition
• Fecal and Urinary incontinence
• Decreased Mental Status
• Diminished Sensation
• Excessive body heat
• advanced age

keep skin clean and dry

• decreased circulation
• weaker pulses in feet and legs
• wounds on limbs take longer to heal

• I-nonblanchable erythema signaling potential ulceration
• II- partial thickness skin loss involving epidermis and possibly the dermis
• III- full thickness skin loss involving damage of necrosis of subcutaneous tissue that may extend down to the fascia (deep crater)
• IV- full thickness skin loss with tissue necrosis or damage to the muscle, bone or supporting structure

• start at the center
• circular motion moving outward
• 3 times
• CLEAN to DIRTY
• Do Not Dry

• top to bottom
• inside to outside
• clean to dirty
• new swab with each stroke
• 1 down the middle
• 2 away from you
• 3 side towards you
• 4 away
• DO NOT DRY

• wrap from distal to proximal
• to increase blood flow return

• wash hands
• apply clean gown, try neck, tie back over lapping in back
• apply mask, tie top, tie bottom
• apply goggles
• apply gloves

• remove gloves (do not Touch)
• wash hands
• remove goggles
• remove gown when ready to leave room
• remove mask
• If gown, goggle, and mask are soiled Put On A New Pair Of Gloves before removing them

use same precautions for every patient regardless of Dx or possible infection

thorough hand hygiene

generic infection control precautions for all clients except those with diseases transmitted through the air

• Contaminated Sharps
• Skin Contact
• Contact with Mucous Membrane

• Normal defense mechanisms (are they compromised?)
• Ability to care for themselves
• mode of transmission
• what care procedure is being done
• PPE?
• visitors understanding, knowledge of situation

• Microorganisms live everywhere
• Microorganisms can be good or bad
• Effect can vary with in situation
• 3 major modes of transmission (Contaminated "sharps", skin contact, mucous membrane contact)

• Begins with Hand washing  seconds
• clients hands also need washed

• washes away microorganisms
• not sterile

Protein promotes healing

Helps flush

body restores itself while sleeping

• the time it takes to go back to normal
• it should take 1/2 to 3/4 to amount of time that person was laying on that spot

bright red flush of skin that appears after pressure is removed.

• wound should be quickly supported by a large sterile dressing soaked in saline. 
• Place the client in the bed with the knees bent to decrease pull on the incision.
• Notify Surgeon

the protrusion of the internal viscera through an insicion

is the partial or total rupturing on a sutured wound