Galen Nur 155 Exam 3
Intentional or unintentional
Open or closed
Types of wounds
Acute or chronic
Partial thickness, full thickness, complex
autolytic debridement, semi-permeable
allows skin to breathe.
transparent film
uses: burns, IV sites, stage 1& 2 pres-
sure ulcers, skin tears
start at typhoid, fasten from the bottom
up
how do you apply an abdominal binder? used for support to keep dressing intact
remove every two hours to asses under-
lying skin and wound
Fecal and unitary incontinence
Friction and shearing
immobility
inadequate nutrition (decreased protein,
Vitamin C, zinc)
Risk factors for pressure ulcers Decreased mental status
excessive body heat (moisture)
advanced age
chronic conditions
Diminished sensation
Incorrect positioning
Change in color, odor, or drainage. Sev-
Signs of infected pressure ulcer? er infections cause fever and increased
WBC.
During your assessment of a new pa-
tient, the nurse notices a Stage I pres-
Non-blachable
sure ulcer, what are the signs that this
No opening
nurse is correct about this pressure ulcer
being a stage one?
What do you do for a stage I pressure Apply barrier creams
ulcer? Reposition patient Q2hr
, Galen Nur 155 Exam 3
As you assess your new patient you
notice a sore on a bony premise that
is blister-like, with partial thickness skin
Stage II
loss, pt is complaining of pain where
the wound is present which stage is this
pressure ulcer?
What type of dressing do you use for a
Mepaplex or Duoderm
stage II pressure ulcer?
Full thickness skin loss, involving dam-
age or necrosis of subcutaneous is what Stage III
stage pressure ulcer?
Full thickness skin loss with tissue necro-
sis, damage to the muscle and bone,
wound goes through nerves and not Stage IV
painful with tunneling present, which
stage is this wound?
Minimize direct pressure
Reposition Q2hr
Schedule and DOCUMENT position
change
Treating pressure ulcers use assistive devices
Dressing changes as ordered
Keep sheets dry and wrinkle free
Keep pt dry if incontinent
ROM 3reps 2x daily
replacement of destroyed tissue by the
What is regeneration?
same kind of cells
tissue surfaces are approximated
(closed) and there is minimal or no tissue
Primary intention healing
loss, formation of minimal granulation tis-
sue and scarring
wound in which the tissue surfaces are
not approximated and there is extensive
Secondary intention healing tissue loss; formation of excessive granu-
lation tissue and scarring and greater risk
of infection
tertiary intention
, Galen Nur 155 Exam 3
Wounds that are left open purposely for
3-5 days to allow edema and infection to
resolve.
serous clear, watery plasma
purulent containing pus, milky like
sanguineous dark bloody drainage
Serosanguineous bright red blood
Purosanguineous pus in the blood
Vasodilation
Chronic
Increase capillary permeability, cellular
metabolism, inflammation
When should you use heat therapy?
musculoskeletal problems
joint stiffness
arthritis
contractures and back pain
Vasoconstriction
acute pain
often used for sport injury (sprains,
When do you use cold therapy?
strains, fractures)
decreased capillary permeability, cellular
metabolism, inflammation
Age
Environment
lifestyle
Factors that affect respiratory function?
health status
medications
stress
eupnea normal breathing
Tachypnea rapid breathing
bradypnea slow breathing
apena absence of breathing
hypoventilation
, Galen Nur 155 Exam 3
very shallow breathing, may cause in-
creased levels of carbon dioxide. or high
levels of oxygen
very rapid breathing more CO2 is elimi-
Hyperventilation
nated than provided.
ability to breathe only in an upright posi-
orthopnea
tion
Dyspena difficulty breathing
Low oxygen saturation of the body, not
Hypoxia
enough oxygen in the blood
Rapid pulse
rapid shallow respirations
increased restlessness or lightheaded-
ness
Signs and symptoms of hypoxia flaring of the nose
substernal or intercostal retractions
cyanosis (bluish discoloration of the skin,
nails beds, and mucus membranes due
to reduced hemoglobin-oxygen levels)
hypoxemia too much oxygen in the blood
used to liquefy necrotic tissue or slough,
rehydrate the wound bed and fill in dead
Hydrogels
space, partial thickness wounds, skin
tears and pressure ulcers
used to eliminate dead space or pack
Alginate
wounds and to support debridement.
use pressure and start from the inside
and make your way out to the edges of
How do you irrigate a wound?
the wound. should always be done after
the soiled dressing has been removed.
Dehiscence partial or total separation of wound layers
The displacement of organs outside of
Evisceration
the body. Notify PCP immediately
CHF, hypovolemia
Intentional or unintentional
Open or closed
Types of wounds
Acute or chronic
Partial thickness, full thickness, complex
autolytic debridement, semi-permeable
allows skin to breathe.
transparent film
uses: burns, IV sites, stage 1& 2 pres-
sure ulcers, skin tears
start at typhoid, fasten from the bottom
up
how do you apply an abdominal binder? used for support to keep dressing intact
remove every two hours to asses under-
lying skin and wound
Fecal and unitary incontinence
Friction and shearing
immobility
inadequate nutrition (decreased protein,
Vitamin C, zinc)
Risk factors for pressure ulcers Decreased mental status
excessive body heat (moisture)
advanced age
chronic conditions
Diminished sensation
Incorrect positioning
Change in color, odor, or drainage. Sev-
Signs of infected pressure ulcer? er infections cause fever and increased
WBC.
During your assessment of a new pa-
tient, the nurse notices a Stage I pres-
Non-blachable
sure ulcer, what are the signs that this
No opening
nurse is correct about this pressure ulcer
being a stage one?
What do you do for a stage I pressure Apply barrier creams
ulcer? Reposition patient Q2hr
, Galen Nur 155 Exam 3
As you assess your new patient you
notice a sore on a bony premise that
is blister-like, with partial thickness skin
Stage II
loss, pt is complaining of pain where
the wound is present which stage is this
pressure ulcer?
What type of dressing do you use for a
Mepaplex or Duoderm
stage II pressure ulcer?
Full thickness skin loss, involving dam-
age or necrosis of subcutaneous is what Stage III
stage pressure ulcer?
Full thickness skin loss with tissue necro-
sis, damage to the muscle and bone,
wound goes through nerves and not Stage IV
painful with tunneling present, which
stage is this wound?
Minimize direct pressure
Reposition Q2hr
Schedule and DOCUMENT position
change
Treating pressure ulcers use assistive devices
Dressing changes as ordered
Keep sheets dry and wrinkle free
Keep pt dry if incontinent
ROM 3reps 2x daily
replacement of destroyed tissue by the
What is regeneration?
same kind of cells
tissue surfaces are approximated
(closed) and there is minimal or no tissue
Primary intention healing
loss, formation of minimal granulation tis-
sue and scarring
wound in which the tissue surfaces are
not approximated and there is extensive
Secondary intention healing tissue loss; formation of excessive granu-
lation tissue and scarring and greater risk
of infection
tertiary intention
, Galen Nur 155 Exam 3
Wounds that are left open purposely for
3-5 days to allow edema and infection to
resolve.
serous clear, watery plasma
purulent containing pus, milky like
sanguineous dark bloody drainage
Serosanguineous bright red blood
Purosanguineous pus in the blood
Vasodilation
Chronic
Increase capillary permeability, cellular
metabolism, inflammation
When should you use heat therapy?
musculoskeletal problems
joint stiffness
arthritis
contractures and back pain
Vasoconstriction
acute pain
often used for sport injury (sprains,
When do you use cold therapy?
strains, fractures)
decreased capillary permeability, cellular
metabolism, inflammation
Age
Environment
lifestyle
Factors that affect respiratory function?
health status
medications
stress
eupnea normal breathing
Tachypnea rapid breathing
bradypnea slow breathing
apena absence of breathing
hypoventilation
, Galen Nur 155 Exam 3
very shallow breathing, may cause in-
creased levels of carbon dioxide. or high
levels of oxygen
very rapid breathing more CO2 is elimi-
Hyperventilation
nated than provided.
ability to breathe only in an upright posi-
orthopnea
tion
Dyspena difficulty breathing
Low oxygen saturation of the body, not
Hypoxia
enough oxygen in the blood
Rapid pulse
rapid shallow respirations
increased restlessness or lightheaded-
ness
Signs and symptoms of hypoxia flaring of the nose
substernal or intercostal retractions
cyanosis (bluish discoloration of the skin,
nails beds, and mucus membranes due
to reduced hemoglobin-oxygen levels)
hypoxemia too much oxygen in the blood
used to liquefy necrotic tissue or slough,
rehydrate the wound bed and fill in dead
Hydrogels
space, partial thickness wounds, skin
tears and pressure ulcers
used to eliminate dead space or pack
Alginate
wounds and to support debridement.
use pressure and start from the inside
and make your way out to the edges of
How do you irrigate a wound?
the wound. should always be done after
the soiled dressing has been removed.
Dehiscence partial or total separation of wound layers
The displacement of organs outside of
Evisceration
the body. Notify PCP immediately
CHF, hypovolemia
