Untitled Flashcards Set

week4studyguide2025 

1. Dressing types to promote healing,

   1. Hydrocolloid - moist environment promoting healing and protecting new tissue

   2.  Calcium alginate primary dressing - wet to dry stage 3-4

   3. Silicone absorban dressing

2. Wound stages description

   1. Stage 1 - nonflammable skin, skin intact

   2. Stage 2 - skin barriers are broken to epiderm or dem

   3. Stage 3 - full thickness but no bone exposure ulcer goes till fat layer SUBCUTANEUS TISS

   4. Stage 4 - full-thickness bone, muscle exposure. Undermining tunneling

   5. unstageable

3. Healing stages

   1. Inflammatory

   2. Primary intention - closed surgical parallel

   3. Secondary deep- heals down to up 

4. Wound drainage types

   1. Serous- Clear, watery plasma

   2. purulent- pus THICK yellow green tan brown

   3. Serisanginous - bloody liquid (sanguin and serous combo) pale red

   4. Sanguineous- bleeding bright red 

5. Causes of delays in wound healing

   1. Immunocompromised, diabetic, edema

   2. Immunosuppressant agents

   3. Antineoplastic agents 

   4. Corticosteroid 

   5. NSAIDS

   6. Anticoagulants

   7. Pedal pulse less than 2 

6. The phase of healing in a wound

   1. Inside to outside 

   2. Lost muscle fat or dermis is not replaced

   3. If it reopens, it has the same classification ex stage 4 always stage 4 even after healing doesnt become 3

   4. Filled with granulation scar tissue

7. Risk factors for pressure ulcer and injury

   1. Moisture

   2. Aging skin 

   3. Chronic illnesses

   4.  Immobility Malnutrition

   5. Fecal and urinary incontinence

   6. Altered level of consciousness

   7. Spinal cord and brain injuries

   8. Neuromuscular disorders

   9. External pressure compressing blood vessels

   10. Friction or shearing forces tearing or injuring blood vessel

8. Ostomy care steps

   1. Empty bag into biohazard waste bag?

   2. Clean skin and stoma with soapy water (povidone-iodine)

   3. Replace adhesive 

   4. ⅛” larger than stoma

   5. Empty when ⅓ - ½ full

9. Urinary incontinence types and nursing teaching on preventing irritation

   1. Pee comes out can't hold pee

   2. Stay on the toilet after peeing 

   3. Pelvic floor training kegels etc

10. Providing teaching about ileostomy care to a client

    1. Permanent 

    2. Small frequent meals

    3. Hydrate 

    4. Limit fiber for 6 weeks 

    5. gassy

11. Procedure for Wound Irrigation

    1. Top to bottom

    2. Sodium chloride 0.9%

    3. Clean before culture

12. Eviscerated wound nursing priority

    1. Keep organs moist 

    2. Put organs packed inside

13. What interventions should the nurse use to help maintain the integrity of the client's skin?

    1. R: reposition every 1-2 hrs

    2. I: inspect skin every shift

    3. S: suspend heels off the bed 

    4. K: keep head of bed LESS than 30 degrees unless medically contradicted

    5.  Hygiene - no diapers

    6. Linen = less is best

    7. Keep dry and clean

    8. Barrier cream!

    9. Vitamins ABCDEK

14. Instructions should be included in teaching a client with constipation.

    1. Increase fiber 

    2. Avoid eggs dairy

    3. More water 

    4. Bed rest, reduced fluids/fiber, CNS disorders, narcotics

    5. Raw vegetables (unless immune compromised)

15. Enema insertion and know types

    1. Hold oil retention for 30 min

    2. Hold up 12-15 in 

    3. Cramping, bring the bag down a little

    4. Sims position

    5.