Skin/Sterile Field
What scale do nurses use when predicting a pressure score risk
What is the Braden Scale?
Describe the different types of Wound Drainage
Sanguineous: Sanguineous exudate is fresh bleeding
Serous: Drainage is clear, thin, watery plasma. Small amounts are considered normal wound drainage
Serosanguinous: Exudate contains serous drainage with small amounts of blood present
Purulent: Exudate is thick and opaque. It can be tan, yellow, green, or brown. It is never considered normal
A device which can assess how much urine is in the bladder
What is Bladder Scanning?
Interventions to help initiate voiding
Run water in nearby sink, Deep breathe, Have male patients stand instead of sit/lay, Pour warm water over perineum, Sitz bath/warm water bath
Fever over 101 F, Malaise, Change in LOC, Increased Pain, Expanding Redness/Swelling around the wound, Loss of Movement of the wounded area can indicate what?
What is Signs and Symptoms of a Systemic Infection?
Functions of the skin include
What is Protection, Sensation, Temperature regulation, Secretion & Excretion?
When completing a dressing change, what is the proper way to cleanse the wound
Clean incision first then move outward, incision must be cleaned from top to bottom
The nurse understands that the minimal output requirement for a patient per hour is
What is 30cc/hr?
Stoma Assessment includes? What are normal/abnormal findings?
Stoma Site, Surrounding Skin, and Stoma Size
Should be pink/red. Never pale, dusky or dark; should not be receding or protruding
Assess for irritation or breakdown
Assess using stoma measuring device. Too big of a gap between the stoma & the appliance can cause skin breakdown & irritation
A wound with redness, warmth, tenderness, purulent or malodorous drainage
What is Signs and Symptoms of a Localized infection
The area of the sterile field which is considered unsterile
What is the outside 1 inch edge of the sterile field?
This type of dressing can be used on wounds with minimal or no exudate to retain moisture
What is a Transparent Film?
Describe the different Ostomy Locations
Ileostomy - ileum is brought through intestinal wall
Colostomy- colon is brought through abdominal wall
Relieve constipation, Reduce flatus, Relieve fecal impaction, Cleanse bowel before surgery or diagnostic tests, Stimulate peristalsis
What are Enemas?
Spontaneous opening of an incision which can often be caused by Excessive Coughing, Sneezing, Vomiting
What is a Dehiscence?
Steps in opening a Sterile Dressing package
•Perform hand hygiene
•Open sterile package away from the body
•Touch only the outside wrapper
•Do not reach across a sterile field
•Always face the sterile field/package
•Allow at least 6 inches between the body & the sterile field
Describe the components of a Wound Assessment
Location, Type of wound, Degree of tissue damage, Wound bed, Wound size, Wound edges and periwound skin, Signs of infection, Pain
How to prevent a CAUTI
Appropriate securement, Empty drainage bag regularly, Ensure unobstructed flow, Maintain closed system, Perineal hygiene, Fecal incontinence device, Educate about proper maintenance
One 8 ounce glass of tea
Four 8-ounce glasses of water
5-ounces of apple juice
1 Tbsp of creamer
50mL/hr for 12 hours
1965 ml
Name the different types of Debridement
What is Enzymatic Debridement, Autolytic Debridement, Sharp/Surgical Debridement Mechanical Debridement, and Chemical Debridement
List at least 5 Risk Factors for Developing a Pressure Ulcer
•Pressure
•Friction/Shearing
•Immobility/ Inactivity
•Inadequate nutrition & dehydration
•Weight loss, muscle atrophy, loss of sub-Q tissue
•Hypoproteinemia→ Edema
•Moisture/Incontinence (fecal or urinary)
•Obesity
•Edema
•Decreased mental status
•Diminished sensation (paralysis, stroke)
•Excessive body heat
•Advanced age
•Chronic medical conditions
What are examples of Active and Passive Drains and what is their purpose?
Active Drains- Hemovac, Jackson-Pratt
Passive drain- Penrose drain
Permits drainage of excessive exudate or fluid buildup
Used for Continuous Bladder Irrigation
What is a Triple Lumen Catheter
Three lumens: Drainage, Balloon, Irrigation
Order: 40 mg Tylenol liquid for a 3-day-old infant. Label reads: 160 mg/5 mL. How much will the nurse measure for this child?
1.25 mL
For prevention of diabetic ulcers developing, what should patients be taught
What is Meticulous Foot Care?