Hot application
What should a nurse do before hot application
Assess the skin
A newly sprained wrist should have cold therapy. What 2 things does the cold do?
decreases swelling and decreases pain
Bone that is visible in a sacral pressure injury is what stage
IV
for a Stage I pressure injury, what type of dressing could you apply
a thin film dressing (padded duoderm)
At what temperature should irrigations be administered
room temp
Color of skin indicates the heat application should be discontinued
Red
What is color of skin would indicate the need for removal of an ice pack after only 10 min
Mottling
After discovering a reddened area, how long should a nurse wait after repositioning the patient before checking again....
30 - 45 minutes
A patient who has a sprained ankle that is wrapped with ACE bandage. Toes are cold and cyanotic. this is a sign of
ACE wrap is too tight
When irrigating a wound you should direct the flow from the least contaminated to the most contaminated. True or False
True
Maximum time for effective heat application
20 to 30 min
Maximum time for effective cold application
20 minutes
first stage of wound healing
inflammation
A non adherent dressing does not allow drainage to seep through the barrier and be absorbed on the other side.
False
Which body cavities are considered sterile and therefore when irrigating, must use sterile technique
Respiratory
Genitourinary
Eyes
The nurse is applying a heat pack to pt lower extremity what must be done prior to placing the pack
Apply a cloth barrier
Maximum vasoconstriction occurs and the opposite effect starts to take place. What is this called
Rebond phenomenon
An area of red skin, that does not blanche with fingertip pressure is classified as.....
Stage I
After removing staples the nurse notes the incision begins to gap open. This is called
dehiscence
soaks the patient perineal area providing, comfort, promotes healing and cleanses the area
Sitz bath
Of these options, which should the nurse apply directly to the skin area for "Moist heat application"?
Dry towel, petroleum jelly, warm moist towel, heat delivery device
warm moist towel
Proper method for applying cold therapy
place a cloth barrier between the cold device and the patient skin
What type of wound treatment draws the wound edges together by negative pressure?
wound vac
Immediately after surgery the nurse notes sanguineous drainage on the patient's dressing. What should the nurse do next?
Mark and initial the edges of the drainage
Note date and time
What position should the patient be in for a vaginal irrigation?
Lithotomy