Test 4 - ch 32 wounds - part 2

what is the purpose of a JP drain?

labs low: albumin, prealbumin, total lymphocyte count.... labs high: hemoglobin A1C, glucose

Mrs. Jordan's Braden scale score is a 9... how at risk is she for pressure injuries?

what is a t-tube

how do you assess risk of pressure injury?

why is proper nutrition (esp with older adults) important related to skin?

Mr. Smith's Braden scale score is a 20... how at risk is she for pressure injuries?

semipermeable membrane dressings that are adhesive and waterproof, occlusive, decrease contamination, allow site visual

application of commercially prepared enzymes to speed up the body’s autolytic process

any sores? drainage? change in size? redness of hips when sitting? new tattoo/piercing? time occurred? are examples of :

uses the body’s own enzymes and defense mechanisms to loosen and liquefy necrotic tissue, occlusive dressing

black of RYB means

physical and mental conditions / activity and mobility / incontinence

why are RNs worried about moisture and incontinence related to our patient's skin?

mental status, continence, mobility, activity, nutrition

in acute care setting, when to do skin assessment?

what is the purpose of a t-tube?

wounds left open ___________.

discolored skin? bumps? rough patches? moisture? thin/thick? swelling? how pt takes care of skin? are all examples of :

when charting on wounds, it is important to chart what?

patients have increased anxiety and fear with wounds due to:

noticed any problems with bowels/urination? use pads/briefs? incontinent? are examples of:

surgeries/wounds/procedures do not effect pt sexuality, social relationships, self-concept

what is the purpose of a chest tube (mediastinal placement)

precut special gauze dressings are to go where?

pain ...

non adherent gauze does not include sterile petrolatum gauze and telfa gauze

is the sore painful? do you take anything for it? does it help? how often? how much? are examples of:

what do you call a wound with all three wound classifications (RYB)

uses external physical force to dislodge and remove debris and necrotic tissue

assistance in walking/moving? confined to bed? chair? can you change positions independently? are examples of:

Red of RYB means

what is gauze?

what are the closed types of drains?

in long term care setting, when to do skin assessment?

use the ____ amount of tape necessary to dress wound

what is the purpose of gauze?

factors to assess in focused assessment of skin

specialized device for pressure redistribution designed for management of tissue loads, micro-climate, etc is what?

where is chest tube placed?

when all colors present (RYB), the wound is treated first from _____ to _____.

psychological effects of wounds and pressure injuries include : pain, anxiety, fear, ADLs, Changes in body image

age / gender,sex/ wt / build / continence/ skin type / mobility/ nutrition/ special population specific risks

after debridement of black of RYB, wound is treated as _____.

which is not a nursing diagnosis for wounds/pressure injuries

gained or lose wt? describe meals? liquid intake? food/vitamin supplements? dentures? dysphagia? anemic? are examples of

what is RYB wound classification ?

what is the purpose of Penrose?

what is Penrose?

Yellow of RYB means

what is a hemovac?

three basic types of primary dressings: dressings that maintain moisture, absorb moisture, and add moisture?

why do we do skin assessments? choose best answer...

in home health care setting, when to do skin assessment?

wounds left closed ___________.

what is a Jackson-pratt (JP) drain?

what is the purpose of a hemovac

debridement is recommended to be accomplished through which of these methods

which is not a way to mechanically decried a wound?

dry gauze is used to cover wounds, esp surgical wounds

put in order: material to absorb, nonabsorbent material, and thick/absorbent material

what are the open types of drains?