question

what are the indications for heat therapy?

answer

Reduces muscle tension vasodilation

question

how does heat therapy reduces muscle tension??

answer

Promotes muscle relaxation, which lowers pain d/t spasm or stiffness

question

2 ways heat therapy does vasodilation?

answer

increase blood flow to the injured part, which brings nutrients and removes waste. It lessens congestion of blood in the injured tissues

question

what are the conditions of heat therapy??

answer

inflamation/ edema infected wound surgical wound arthritis and joint disease localized joint pain muscle stains lo back pain menstrual cramps perineal inflammations

question

types of heat therapy??

answer

Aquathermia pad Sitz bath Paraffin Bath Commercial Hot packs Heating pad

question

aquathermia pad

answer

water-flow pad 105-110 circulates waterproof plastic or rubber pad connected to electronically control unit 20-30 mins

question

2 types of aquathermia pad

answer

moist vs dry

question

dry aquathermia pad

answer

just put it on

question

moist aquathermia

answer

applied wet towel or pad

question

sitz bath

answer

100-105 for perineal area ( NOT LEGS) heat therapy ro pelvic region

question

when will you use sithz baths??

answer

May be ordered following rectal surgery, childbirth, for painful hemorrhoids or vaginal inflammation

question

paraffin bath

answer

heated paraffin wax

question

why would you use paraffin bath??

answer

Treat painful arthritis of the hands and feet with penetrating heat therapy Relieves pain and stiffness

question

commercial hot pack/ heating pad

answer

commercial hot packs : Hit or Kneaded to mix the chemicals that release heat Deliver dry heat therapy to injured area heating pad : Electrical pads Moist and dry

question

safety issue for heat therapy?

answer

do not use when bleeding dry heat small pad to avoid pain

question

never do while using heating pad ??

answer

Avoid using high settings Never lie on the heating pad Never use safety pins through pad Not recommended in acute care facilities

question

important things for heat therapy

answer

apply heat for proper intervals because it is too long, will get the opposite effect. damage cells, blistering and other complications.

question

indications for Cold Therapy 3

answer

vasoconstriction low localized pain by acts as anesthesia less bleeding by increasing blood viscosity which causes coagulate at site of injury

question

what is vasoconstriction ?

answer

reduced blood flow to an injured part prevents edema and reduces in inflammation

question

what are conditions for cold therapy??

answer

Strains, sprains, fractures, muscle spasms(direct trauma) Laceration or puncture wound Minor burn Injections Arthritis (numbing pain) Joint trauma Area of injury or pain where cancer is suspected

question

what are some contraindications of cold therapy??

answer

Edema is already present Patient has poor circulation Patient is shivering Patient is disoriented or unresponsive

question

safety for cold therapy

answer

59 F less than 20 min at a time

question

before applying cold assessment ?

answer

Circulation and Pulses Skin color and temp Edema Sensation (response to stimuli)

question

adverse reactions

answer

Burning or numbness Mottling of the skin Erythema Extreme paleness of skin Bluish discoloration of skin

question

what are types of cold therapy?

answer

moist cold therapy - wet compressess dry cold therapy -icepacks -ice collar

question

what are ice pacts for?

answer

muscle sprain local hemorrhage or hematoma 2/3 of ice

question

what is ice collar ?

answer

after dental surgery or tonsillectomy

question

Source : Ice, or any cold preparation temp/time

answer

59 F 20-30

question

source : Heat, dry application

answer

105-115 degrees F 20-30 minutes

question

source Heat, sitz bath

answer

100-110 degrees F 20 minutes

question

temperature control blankets?

answer

Used to treat hypo/hyperthermia Delivers constant flow of warm or cool air or water over large body surface, resulting in temperature regulation

question

special considerations

answer

unconscious/ spinal cord injury painful stimuli children thinner skin which increase for burs older adults less sensitivity to pain diabetes or arteriosclerosis less circulation and cold therapy even worst edema or scarring inflamed appendix or abscessed tooth rupture causing microorganisms to spread

question

what are edema or scarring prone to??

answer

more risk for burns or tissue damage d/t sensation is less d/t thickening of skin layers

question

Diabetes or arteriosclerosis prone to??

answer

nerve endings are less sensitive d/t less circulation and cold therapy less even more.

question

how are wounds classified?

answer

How the wound was made (intentional or accidental ) Size of the wound Depth of the wound Cleanliness of the wound

question

what are the kinds of wounds?

answer

abrasion contusions laceration incision puncture bullet wound extreme temperatures wounds ulcers

question

abrasion?

answer

scraping top layers of skin

question

contusion

answer

blood vessel trauma, bruise. color determines the age

question

laceration

answer

jagged, torn wound

question

incision

answer

sharp cut tissue with sharp object. clean edge, scar.

question

puncture

answer

deep, penetrates several layers of tissue. sharp object ( knife)

question

bullet wound

answer

different appearance

question

extreme temperature wounds

answer

severity depends on duration of exposure. hot or cold

question

ulcers

answer

inadequate flow flow to the tissue stasis its not pressure ulcers and are diabetic.

question

what are the degree of cleanliness

answer

clean - uninfected surgical wound. 5% of contamination clean-contaminated - it is is in a non sterile place. GI, GU, Respiratory 3-11% contaminated- GI products, ecoli, acute inflammation( appendicitis) or sterile technic is broken . 17% dirty - already infected. gangrene. infection is 20%

question

physiology of wound

answer

primary intention secuntary intention tertiary intention it could be all 3 stages at once and it is progressive.

question

primary intention

answer

the edges of the wound are approximated together (as in a surgical wound) small skin is lost

question

secondary intention

answer

wound edges do not approximate or pus forms and prevents tissue from growing together. larger scar, and wound contraction. less granulated tissue

question

tertiary intention

answer

wound left open and then later sutured.

question

what to look in a wound healing

answer

and the wound odor, describe the dressing, detailed about dressing

question

what are the phases of wound?

answer

inflammation phase reconstruction/ proliferative phase maturation phase

question

inflammatory phase

answer

1-4 days - constictriction of blood vessels - Phagocytes remove debris and protect against infection - Wound becomes red, warm, swollen and painful d/t increased blood flow to the area. - Blood clots dissolve and the sides of the wound begin to grow together and seal up..

question

reconstruction/ proliferative phase

answer

starts 3rd or 4th day and last 2-3 weeks Macrophages (phagocytic) continue to clear debris from the wound Fibroblasts synthesize collagen which adds strength to the tissue. New capillary networks form and begin to supply nutrients to support the collagen Wound forms a raised purplish colored scar.. protein and it A and C to promote healing.

question

maturation phase

answer

The final phase of healing May take up to 2 years Collagen is lysed (broken down) and resynthesized by the macrophages producing strong scar tissue.. keloid

question

types of wound drainage

answer

sanguineous serosanguinous serous purulent

question

sanguineous

answer

bright red, active bleeding

question

serosanguinous

answer

pale red, watery, serous and sanguineous

question

serous

answer

clear, watery plasma

question

purulent

answer

thick yellow green tan. INFECTION pus

question

factors impair wound healing?

answer

age malnutrition obesity impaired oxygenation smoking drugs ( anti-inflammatory, meds, quemo) radiation wound stress moisture exposure .

question

what is a hyperbaric oxygen chamber??

answer

when wound is not healing forcing oxygen into plasma. air pressure in chamber > environment accelerates process of healing

question

wound healing complications??

answer

hemorrhage infection cellulitis fistula sinus dehiscence evisceration

question

hemorrhage?

answer

fresh surgical wounds monitored for this external bright red bleeding from wound

question

what could happen is hemmorage is internal??

answer

hypovolemic shock could occur

question

signs and symptoms of hemorrhage?

answer

decrease blood pressure, increase respiration , diaphoresis, cold clammy skin

question

what is hemmorage is external?

answer

apply pressure with steril dressing

question

internal bleeding/ hemmorage will have this symptoms

answer

patient is pale, cool, diaphoretic, with thready pulse and rapid respirations.

question

with hemorrahge you must

answer

monitor vital signs and notify physician.

question

infections

answer

wound infected during or after surgery color may be brown yellow or green with odor

question

most common infection?

answer

staphylococcus aureus !!!! ecoli, proteus,

question

what is abscess?

answer

localized infection

question

a big type of infection is

answer

gas gangrene

question

what is gas gangrene

answer

Wound with extensive muscle damage infected with clostridium Causes necrosis and gas bubbles in the soft tissue Amputation may result

question

nursing measurements for gas gangrene

answer

pain medication, anti biotics

question

what are symptoms to prevent infection??

answer

redness, swelling, warmth, pain, loss of function, low grade temp. Perform diligent wound care using aseptic technique. Promote good hydration and nutrition. Notify physician of complications. Obtain wound cultures, if ordered. Administer antibiotics, if ordered

question

what is cellulitis

answer

Inflammation of tissue surrounding the wound characterized by redness and induration

question

what is fistula

answer

An abnormal passage between two organs or an internal organ to the body surface

question

what is sinus

answer

A abnormal canal or passageway from inside the body to the outside..

question

what is dehiscence

answer

The spontaneous opening of an incision, the edges of the wound separate A sign of impending dehiscence may be an increased flow of serosanguineous drainage

question

what happens when dehiscence occurs ?

answer

Dehiscence usually occurs between the fifth and twelfth post-operative day.

question

what to do with dehiscence

answer

steril dressing over it (gauze) , keep patient calm, MPO ( no drink or eat) , notify the doctor

question

what is evisceration?

answer

protrusion of an internal organ through an incision

question

what to do with evisceration???

answer

keep the dressing with sailing.. moist.

question

patient teaching to prevent dehiscence and evisceration.

answer

Teach patient to support incision with pillow during coughing and position changes. Treat for nausea to avoid stress on incision when vomiting. evisceration occurs, apply sterile dressings soaked in normal saline over the wound opening and cover with dry gauze. Notify physician immediately.

question

what are wound closure

answer

Usually held together by staples or sutures

question

for skin sutures

answer

Sutures beneath the skin are made of absorbable material such as chromic or clear gut and are not removed Large retention sutures may be used if there is a danger of dehiscence..

question

what are drains and drained devices??

answer

Drains may be placed during surgery into a stab wound to allow drainage of blood or fluids Drains may be active (attached to suction or a suction device) or passive (allowed to drain on their own)..

question

types of dressing?

answer

gauze - air to reach wound/ wet to dry telfa- plastic coding to wound surfipads or abdominaal pads (ABD) - large and thick absolve drainage transparent or semi occlusive - let oxygen in and moist but not bad things in hydrocolloid or occlusive - drainage, moisture and liquified narcotic tissue hydrogel - dressing must be cut first

question

wet to dry dressing

answer

Sterile procedure Used as a packing Helps mechanically debride wounds with necrotic tissue As the gauze dries the dead tissue adheres to the gauze and sticks to the dressing as it is removed.

question

what to avoid for wet to dry dressing ?

answer

adding saline when removing dressing for it defeats the purpose Too-wet dressings may cause Common used agents..

question

how do you measure wound?

answer

Measure by length, width and depth. Sometimes a diameter is given for a round wound documentation

question

in what do we measure

answer

cm

question

depth is measured by

answer

put q tip measure the wound and then put it against a ruller

question

what are the treatment of wounds

answer

Grossly contaminated wounds are cleaned at each dressing change Antibiotic solutions may be ordered for wound irrigation Surgical wounds and open wound dressing require sterile technique May require hydrocolloid or wet-to-dry dressing..

question

how do you do irrigation?

answer

from the cleanest to the dirtiest.

question

what is debridement

answer

The removal of dead or damaged tissue from a wound It is performed to promote wound healing by removing the necrotic tissue..

question

what is debridement medical maggots

answer

Known as "biotherapy" Used for non-healing wounds that contain necrotic tissue Useful when multiple surgical debridement is not feasible.

question

what is tape application

answer

ask if allergic Place tape so that wound remains covered by the dressing and tape adheres to intact skin Should be long and wide enough to adhere firmly to intact skin on either side of dressing. Place tapes at the ends of the dressing Place tape opposite to body action in the wound location, should not go across a joint or crease Turn under the end leaving a tab for easy removal When removing pull tape toward wound on all sides.. Montgomery straps for frequent dressing changes

question

cleaning ulcers

answer

Clean ulcers at each dressing change, use only normal saline. Note: If granulation tissue is present and does not exhibit s/s of infection, cleaning is contraindicated. When irrigating wound, use gentle pressure to avoid damaging the fragile tissue. Cover ulcer with a dressing selected for the characteristics of the wound

question

stage 1

answer

film dressing. clear ones

question

nursing measures for pressure ulcers

answer

Assess skin for pale color, warmth in calf area, skin that will not blanch, redness, pain. Notify physician of signs of an ulcer. Elevate feet. Apply TEDs/SCD as ordered. Encourage ambulation. Reposition at least every 2 hrs. Keep bed linens dry and wrinkle free. Clean skin soiled with urine or feces with warm water and mild cleansing agent Use lotions/protective dressings to reduce friction and shearing. Keep HOB as low as possible to reduce shearing. Use special mattress to reduce pressure on skin. Protect skin from moisture. Have patient use trapeze bar to reposition self, if possible. Remind patient and family to reposition often to relieve pressure and not any new areas of redness on bony prominences.

question

stasis ulcers

answer

Ulcers on the lower legs caused by poor circulation to the legs r/t burns, diabetes, severe varicose veins or sickle cell anemia Treatment is with wet-to-dry dressings, surgical debridement, unna paste boot or other dressing (the only ulcer to use Unna Boot)..

question

Suture Removal

answer

Sutures often are removed by the physician Sutures are cut and pulled through the skin Sterile technique should be used Parts of sutures left under the skin may cause inflammation Staple removal requiresa special instrument Steri-Strips are usuallyapplied after removalof sutures or staples..

question

eye irrigation

answer

Supine with affected eye down Inner to outer canthus to decrease absorption of contaminants thru nasolacrimal duct

question

ear irrigation

answer

Body temp solution Never push fluids under pressure

question

contraindication for ear irrigation (never do it ) if

answer

Vegetable in ear Has cold Increase temperature Ear infection Injured/ruptured tympanic membrane

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