Overview of Wound Care
Terms in this set (14)
TRUE/FALSE: A contaminated or traumatic wound may show signs of infection within 24 hours. A surgical wound infection usually develops postoperatively within 14 days.
FALSE: A contaminated or traumatic wound may show signs of infection early, within 2 to 3 days. A surgical wound infection usually develops postoperatively within 4 to 5 days.
TRUE/FALSE: Healing by primary intention is expected when the edges of a clean surgical incision are sutured or stapled together, tissue loss is minimal or absent, and the wound is uncontaminated by microorganisms.
TRUE: This is the correct definition of healing by primary intention
Which of the following may indicate internal hemorrhage? (Select all that apply.)
A. Distention or swelling of the affected body part
B. An elevated white blood cell count
C. A decreased blood pressure and increased pulse
D. A change in the type and amount of drainage from a surgical drain
A, B, C, D
The nurse can detect internal bleeding by looking for distention or swelling of the affected body part, a change in the type and amount of drainage from a surgical drain, or signs of hypovolemic shock such as a decreased blood pressure, increased pulse, and cool, clammy skin. An elevated white blood cell count would be an indication of infection.
Which of the following patients has the least risk for developing a wound infection?
A. An 80-year-old man who has a burn
B. A 17-year-old patient who has a metal fragment lodged in his thigh
C. A 30-year-old female who had an episiotomy after childbirth
D. A patient receiving chemotherapy who has a surgical incision
E. A patient with peripheral vascular disease and an ulcer on the heel
C. A 30- year- old female who had an episiotomy after childbirth
The chances of wound infection are greater when the wound contains dead or necrotic tissue (as with a burn), there are foreign bodies in or near the wound, and the blood supply and local tissue defenses are reduced or the patient is immunocompromised.
Protrusion of visceral organs through a wound opening
Increased white blood cell count, fever, purulent drainage
Hypotension, tachycardia, hematoma formation
Abnormal passage between two organs, chronic drainage
Partial or total separation of wound layers; patient states that it feels like something has given way
When teaching a patient about wound healing, the nurse should tell the patient
A. Inadequate nutrition delays wound healing and increases risk of infection.
Inadequate nutrition—including proteins, carbohydrates, lipids, vitamins, and minerals—delays tissue repair and increases risk for infection. Both full-thickness wounds and partial-thickness wounds heal more efficiently in a moist, protected environment. Long-term steroid therapy may diminish the inflammatory response and reduce the healing potential. Steroids slow collagen synthesis. Fat tissue has less blood supply, which decreases transport of nutrients and cellular elements required for healing.
The nurse is caring for a patient who had knee replacement surgery 5 days ago. The patient's knee appears red and is very warm to the touch. The patient requests pain medication. Which of the following would be a correct explanation of what the nurse has assessed?
A. These are expected findings for this postoperative time period.
B. The patient is becoming dependent upon pain medication.
C. The nurse should observe the patient more closely for wound dehiscence.
D. The patient is demonstrating signs of a postoperative wound infection.
D.The patient is demonstrating signs of a postoperative wound infection.
The risk for infection is greatest 4 to 5 days postoperative. Symptoms of wound infection include fever, tenderness and pain at the wound site, an elevated white blood cell count, and the edges of the wound may appear inflamed. If drainage is present, it is odorous and purulent, which causes a yellow, green, or brown color, depending on the causative organism.
The nurse is caring for a patient after major abdominal surgery. Which of the following demonstrates correct understanding of wound dehiscence?
A. The nurse should be alert for an increase in serosanguineous drainage from the wound. Correct
B. Wound dehiscence is most likely to occur during the first 24 to 48 hours after surgery.
not necessarily indicate surgery is necessary.
C. The nurse should administer cough suppressant to prevent wound dehiscence.
D. The condition is an emergency that requires surgical repair.
A. The nurse should be alert for an increase in serosanguineous drainage from the wound.
An increase in drainage is a symptom of a potential dehiscence. Wound dehiscence most commonly occurs before collagen formation (3 to 11 days after injury). To prevent dehiscence, place a folded thin blanket or pillow over an abdominal wound when the patient is coughing. This provides a splint to the area, supporting the healing tissue when coughing increases the intra-abdominal pressure. Evisceration is an emergency that requires surgical repair. Dehiscence does not necessarily indicate surgery is necessary.
The nurse reports a patient has a wound on his abdomen that is healing by secondary intention. The nurse understands this means the patient:
A. has a drain.
B. is at greater risk for infection.
C. is at greater risk for wound dehiscence.
D. is healing naturally.
B. is at greater risk for infection.
Healing by secondary intention indicates the patient has a wound where there is tissue loss and the wound edges are not well-approximated. There is greater opportunity for development of infection without the protective epidermal barrier and longer healing time.
A postoperative diabetic patient had an exploratory laparotomy (incision in the abdomen) 5 days ago. The patient's history indicates obesity with a BMI of 32 and smoking 1 pack/day. Based on this information, the nurse understands the patient should be observed for:
A. Developing a blood clot.
B. Developing a fistula.
C. Wound dehiscence.
C. Wound dehiscence.
This patient is at risk for poor wound healing due to the chronic illness of diabetes, being obese (BMI >30), and smoking. Fatty tissue has a poor blood supply for healing and smoking increases the patient's likelihood of coughing. The nurse should observe for an increase in serosanguineous drainage, an indication of potential dehiscence. The nurse should teach the patient to splint the abdomen with a pillow when coughing as a sudden strain on the incision could lead to dehiscence.