ATI Wounds

  1. The primary focus of prevention and treatment of pressure ulcers is?
    To reieve th pressure and provide nutrition an hydration
  2. When evisceration happens, what should the nurse do?
    cover organs with saline soaked sterile dressings. Do not reinsert organs. Position client in supine position with hips and knees bent. observe client for shock
  3. If infection in wound after surgery, how long will it take for symptoms and what are the signs
    2-7 days. Purulent drainage. Pain. Redness and edema. Increased pulse and resp rate and WBC count
  4. What drainage has WBCs tissue, debris, and bacteria?
  5. How much water should a client with a wound drink daily?
    2000-3000ml/day if no hear/ renal failure
  6. Where is the syringe placed when irrigating a wound?
    One inch above wound, never occlude the wound
  7. To watch for systemic infection (sepsis) from pressure ulcers, what should the nurse look for?
    Change in LOC. Persistant Fever. Tachycardia. Tacypnea, Oliguria. Increased WBC
  8. What are signs of dehiscence?
    Increase in Flow of serosnaguinous fluid. History of straining. Client says something gave way
  9. What is hydrocolloid dressing used for an how
    occlusive dressing that swells in presence of exudate. used as protective layer. Helps maintain a granulation wound bed. can be used up to 5 days
  10. Wound stage. This wound will heal rapidly and had low risk of infection. no or minimal scarring
    Primary intention
  11. Wound stage. has extensive draining and tissue debris probably spontaneous opening of previously closed wound
    Tertiary Intention
  12. What type is of drainage is the result of infection
  13. A burn will heal by which healing process?
    Secondary intention
  14. How is hydrogel used?
    May be used in deep wounds, it provides a moist wound bed. Aslo for radiation bc it helps manage pain
  15. How should a Stage 1 pressure ulcer be treated?
    Relieve pressure. Encourage frequent turning or positioning
  16. Wound stage. has longer healing time, increased infection risk and scarring.
    Secondary intention
  17. Name factors affecting wound healing
    Increased age ( loss of skin turgor, skin fragility decreased circ, slower tissue regen, dec absorb or nutrients, dec collagen, impaired immune system), tissue profusion, obesity, chronic diseases (diabetes), chronic stress, smoking, wound stress
  18. What do we document for wound care each time?
    Location, type of wound, statud of wound and type of drainage, type of dressings and materials. Client teaching. How client tolerated it
  19. For wounds, how high should the head of bed be and why?
    30 degress of less bc it takes pressure off of heals, sacrum, buttocks
  20. Risk factors for Pressure not metnioned before are?
    Obesity, anemia, fever, edema, reanl failure, chf, chronic lung disease, sedation
  21. What are risk factors for dehiscence?
    Chronic disease, advanced age, obesity, invasive abdom cancer, vomitting, Dehydration. Malnurtion, Ineffective suturing. Ab surgery
  22. How should a stage IV pressure ulcer be treated?
    Perform dressing change every 12 hours. use antimicrobials
  23. What level should serum albumin be above?
    3.5 g/dl
  24. How should a stage 3 pressure ulcer be treated?
    clean and debride with either wet to dry, surgical intervention, protelytic enzymes. Use Antimicrobials
  25. Drainage is present in what stages?
    Inflammation and proliferation
  26. How should a stage II pressue ulcer be treated?
    Keep a moist environment with saline or occlusive dressing
Card Set
ATI Wounds
ATI wound care