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Pressure ulcers and wound careMedical-Surgical Nursing-7th edition

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You notice purulent drainage when changing a dressing. No culture is ordered for this change, so you...
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obtain a wound culture anyway
When changing a NPWT unit dressing, the system should be in de vac mode for _______ minutes.
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30-45 minutes
_______ dressings are for infected wounds. They shouldn't be used in dry wounds.
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Calcium alginate
_______ dressings provide a moist environment and are soothing and decrease pain in a wound.
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Hydrogel
_______ is most useful on shallow, or moderately deep dermal ulcers.
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Hydrocolloid
_______ dressings can be used on clean, granulating wounds.
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Hydrocolloid
This type of dressing is self adhesives and traps the wounds moisture over the wound. Ideal for small, superficial wounds or to protect increased risk skin...
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Film dressing
4 x 4's are used in wounds that...
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have exudate or need wound drainage
A Tefla is used on wounds...
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that are clean and with little or no drainage
When removing tape from a wound, it should be pulled _______ the wound.
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toward
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What types of clients are at increased risk of developing pressure ulcers?
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Neurologically impaired, chronically ill in LTC, decreased mental status, ICU, oncology, hospice, and/or orthopedic.
A surgical wound heals by _______.
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primary intention
A wound involving loss of tissue like a burn, pressure ulcer or severe laceration heals by _______.
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secondary intention
What are the 3 components of partial-thickness wound healing?
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Inflammatory response, epithelial proliferation and migration, and re-establishment of the epidermal layers.
What are the 3 phases involved in the healing process of a full-thickness wound?
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Inflammation, proliferative, and remodeling.
_______ occurring after hemostasis indicates a slipped surgical suture, a dislodged clot, infection or erosion of a blood vessel by a foreign object.
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Hemorrhage
How can internal hemorrhage be detected?
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Look for distention or swelling; change in type/amount of drainage; and signs and symptoms of hypovolemic shock.
When is the risk of hemorrhage after surgery the greatest?
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24-48 hours after
What 3 factors increase the risk of wound infection, related to the wound itself?
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Wound contains dead/necrotic tissue; foreign bodies in or near the wound; blood supply/local defenses are low.
What are the signs and symptoms of an infected wound?
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Fever, tenderness, pain, increased WBC, and/or inflamed wound edges.
  
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