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NSG2000 Exam 3 Questions And Answers Graded A+
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NSG2000 Exam 3 Questions And Answers Graded A+ NSG2000 Exam 3 Questions And Answers Graded A+ NSG2000 Exam 3 Questions And Answers Graded A+
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NSG2000 Exam 3acute trauma - ANS accident, irregular borders; skin tear-mechanical course; the elderly
acute surgical - ANS staples, sutures, skin adhesive; intact (wound is closed), well approximated
edges
surgical clean/clean contaminated - ANS no infection, intentional (appendicitis, fistulas)
surgical contaminated/dirty - ANS high infection, lots of debris, left open to heal, large bacterial load
(healing takes months to years to heal)
Moisture associated skin damage (MASD) - ANS risk: excessive sweating, increased skin temp,
change in skin pH, deep skin folds
S&S: rash that may have pain, burning or itching; higher risk for pressure injuries
chronic wounds - ANS acute wounds that encounter complications, long time to heal; alterations in
blood flow to an area (venous sufficiency), peripheral artery disease & diabetes, fat has no blood
flow
Phases of wound healing - ANS inflammatory, proliferative, maturation
inflammatory wound healing phase - ANS time of injuries up to 3-6 days afterwards, blood vessels
constrict, phagocytosis (WBC), lots of neutrophils (for immunity)
proliferative wound healing phase - ANS begins at day 3 and lasts up to 24 days;; loss of tissues
replaced with granulation and collagen, new blood vessels begin to form, edges pull in to help close
area; helps cover and resurface wound (scar tissue)
maturation wound healing phase - ANS combination of inflammatory and proliferative, open for 5-10
days then closed with no signs of infection (C-Section); long time to heal and usually healed with a
wound vac
,factors that impact healing - ANS age, overall wellness, decreased leukocyte count, infection,
medications, nutrition, tissue perfusion, low Hgb levels, obesity, chronic disease, smoking, wound
stress, meds (NSAIDS + Steroids inhibit healing), wound stress (coughing)
assessment appearance - ANS day 1-4 bright red
day 5-14 bright pink
day 15-1 yr.: pale unless dark pigmented skin
how do you measure a wound? - ANS 3D; length, width, depth (if tunneling, then use a q-tip to
detect how long, how deep and how far it goes in)
when testing drainage, what do you assess? - ANS amount, color, consistency, odor
Types of exudate - ANS serous, sanguineous, serosanguineous, purulent
how do you close a wound? - ANS staples, sutures, surgical glue
how does scarring appear on light and dark skin? - ANS light=silver, dark=pale pink
when using drains and tubing what should you look for? - ANS what it looks like around/under the
drain, what type of drainage, if you are able to give the patient a showering, notify provider with any
concerns
how long after a drain is removed should you change the gauze? - ANS 24 hrs.
active - ANS closed
passive - ANS open
Penrose drain - ANS passive/open, lots of exudate, 24-48 hrs; if gauze saturated then change them
using sterile
, portable bulb suction device - ANS active/closed, JP: empty bulb every 8 hr; if half full empty sooner;
always apply suction; amount should decrease by 30-100 then removed; use something to measure
then throw it in the toilet
large bottle drainage - ANS active/closed; hang it on bed, used after trauma or long surgery, change
when half full and mark output
Circular portable wound suction device - ANS active/closed, hemovac (circular, low pressure), w/
spring
wound vac - ANS active/closed, multi-layer, clear dressing over top then allows it to be flat, high
pressure. the wound vac must be exact size of wound
NSG interventions for wound care - ANS -hydration and nutrition
-wound care
-wound dressing
wound dressings - ANS occlusive, non-occlusive, semi-occlusive, hydrocolloid, wet-to-dry, open to air
Occlusive wound dressing - ANS often used as an immediate wound hygiene control and also
prevents blood loss until debridement is performed
debridement - ANS removal of foreign material and dead or damaged tissue from a wound
semi-occlusive dressing - ANS allows wound to breathe (air can penetrate in and out) but at the
same time, protects the wound from outside liquids
Non-occlusive dressing - ANS could allow contaminates to pass through the bandage and contact the
wound (think permeable)
Hydrocolloid wound dressing - ANS - provides moderate absorption-
change every 3-7 days
- protects and cushions
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