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Exam 3 Fundamentals - Wound care module 17 & 18
Terms in this set (129)
disruption of normal skin structure or function
greater risk of infection
follows normal healing process
heals slowly and repair does not occur
factors influencing wound healing
hemocrit below 33%
hemoglobin below 10g/100mL
reduce inflammatory response
depresses fibroblast activity
depresses bone marrow production
a patient has a large abdominal wound, which will require irrigation and packing after discharge. Which statement made by patient indicates need for further teaching?
1. "i'll lie so the wound is vertical to basin during irrigation"
2. "I'll use slow, continuous pressure while irrigating wound"
3. I'll warm the irrigation solution to body temperature before using"
4. "i'll irrigate wound starting at the bottom and moving to top"
a patient tells you that the HCP said his sutures are coming out today. Which action is most important before removing the sutures?
1. assembling equipment
2. checking for HCP order
3. perform hand hygiene in view of patient
4. explaining removal process to patient
a patient has an extensive abdominal wound and is to have half of the staples removed and incision line cleaned. Which action should you take during preparation and interaction? Select all that apply
1. position patient in semi-fowler position
2. place upper tip of staple remover under staple to ease removal
3. administer analgesic 30 minutes before removal
4. lift up on staple when depressing extractor handles
5. clean incision before removing staples starting at sides next to incision
6. remove all staples at top of incision and leave the rest
patient is to have sutures removed from back after surgery. you are performing procedure correctly by taking which step?
1. snipping suture at end proximal to knot
2. wiping area with disinfectant swap to prevent wound infection
3. removing suture in smooth, continuous manner
4. holding scissors in non dominant hand and pickups in dominant hand
you note approximately 50 mL of bright red drainage in JP drain 6 hours after surgery. Which intervention should be included in patient care? Select all that apply
1. empty drain 24 hours from now
2. pinning drainage tube to patient gown
3. placing vaseline gauze around tube insertion site
4. securing drain above wound
5. emptying drain now
6. squeeze drain flat before putting in drainage plug
patient had surgery to repair incisional hernia. surgical incision was approximated and stapled at time of procedure. which type of wound healing is occurring in the surgical site?
in preparing to irrigate a wound, which intervention helps to reduce the risk of infection during irrigation? select all that apply
1. using sterile technique
2. directing flow of solution from healthy tissue to infected tissue
3. warming irrigation solution to body temperature
4. cleaning suture line after doing wound irrigation
5. irrigating with continuous pressure of 3 psi
you need to emply the JP drain collection device every 8 hrs. after draining fluid from container, how should you reestablish the closed suction system?
1. close port after emptying drain
2. compress bulb portion of container and close the port
pump container several times before closing
4. leave 10mL of wound fluid in container to keep level constant
patient wound is managed with negative-pressure wound therapy. when you evaluate the negative pressure wound dressing, you note air under the seal of the transparent dressing. what interventions would be appropriate? select all that apply.
1. turn up suction
2. check seal of dressing
3. check to be sure connections to suction are intact
4. remove and replace transparent dressing
5. reevaluate in 30 minutes since finding may not be significant
2, 3. air under seal represents issue with seal.
NAP reports to you that the outer dressing from pt abdominal wound healing by secondary intention has moist, clear, red-tinged drainage. after you verify finding, how would you describe this type of drainage?
4. blood tinged
you are removing a moist-to-dry dressing from packed wound 6 hours after it was placed in wound. which observation indicates packing technique was incorrect?
1. patient experiences some pain when dressing removed
2. removed gauze is still wet
3. necrotic tissue seen in removed packed gauze
4. wound bed looks pink with some granulation of tissue
2. packing needs to be dry upon removal meaning dressing was too wet when placed
place the following steps for application of hydrocolloid dressing in correct order
1. hold dressing in place 30-60 seconds
2. secure with nonallergenic tape
3. remove paper backing from adhesive side of wafer and place over wound
4. select proper size so it extends onto periwound skin at least 1"
5. mold wafer to affected body part
4, 3, 5, 1, 2
patient has small surgical wound with necrotic tissue requiring mechanical debridement. which of the following dressing options is used in this type of treatment?
1. dry telfa pad placed between wound and outer layer of gauze abdominal dressing
2. moist-to-dry dressing placed on wound bed
3. hydrogel dressing
4. self-adhesive transparent film
you are caring for a patient with a painful burn wound. the wound care would be most appropriate if you applied which type of dressing?
2. hydrogel is soothing
you are reviewing the charts of a group of patients to be seen. which patients are at most risk for wound-healing problems? select all that apply.
1. 58yo woman on immunosuppressive drugs for arthritis
2. 34yo man with diabetes mellitus
3. 42yo woman using steroids for asthma
4. 65yo African-American man who is 10lbs overweight
5. 80yo woman with osteoporosis
6. 2oyo man receiving radiation treatment near wound
1, 2, 3, 6
after applying abdominal binder to patient, patient begins to experience shallow, rapid respirations. what is the first appropriate nursing action to take?
1. notify HCP
2. elevate head of bed
3. check pt vital signs
4. remove and reapply abdominal binder
pt with large infected wound needs negative pressure therapy and asks you how technique works. which statement is accurate?
1. several foam pieces packed firmly into wound bed; solution poured over foam, and pressure pushes fluid into wound
2. measured foam pad placed over open area along with occlusive dressing. negative pressure removes drainage and contracts wound bed
3. wound bed flooded with solution, foam placed around edges of wound bed, pressure used to remove solution and wound drainage
4. skin protectant coated lightly inside wound and several damp gauze pads with prescribed solution placed in wound. vacuum device removes fluid and heals wound
pt has elastic bandage applied to left leg that holds large dressing in place over surgical incision. which evaluation approach should you take to determine if patient has neurological changes?
1. palpate distal pulses of left foot
2. observes color of skin on left foot
3. inspects surface of bandage for drainage
4. asks patient to rate level of pain
4. increase of pain indicates neurological and vascular changes
you are mentoring student nurse on surgical floor and observe student removing dry gauze dressing from pt who had abdominal laparotomy 24 hrs ago. student applies a pair of clean gloves, uses dominant hand to remove all gauze dressings at one time, and places them in a plastic trash bag. what would be your best reaction to this technique?
1. good aseptic technique
2. should remove one layer of gauze at a time to be sure not to pull underlying drain
3. use sterile gloves
4. moisten gauze first with saline
general surgery patient has 4" long incision that has developed a wound infection. on inspection there is a moderate amount of yellowish drainage that has a distinct odor. HCP ordered foam dressing and ABD pad is secondary dressing for covering foam. since dressing is to be changed every 24 hrs, which is best material to secure ABD pad?
1. non allergenic tape
2. transparent film dressing
3. Montgomery ties
4. adhesive tape
3. frequent dressing changes pose risk of skin abrasion and tears
which of the following wounds would heal by secondary intention? select all that apply
1. open surgical wound requiring packing
2. surgical incision closed with staples
3. pressure ulcer
4. full thickness burn
1, 3, 4
which of the following are examples of chronic wounds? select all that apply
1. surgical incision
2. abrasion from motor vehicle accident
3. stab wound
4. peripheral vascular venous stasis ulcer
5. pressure ulcer
true/false: A wound that has healed by primary intention will have more scar formation than a wound that has healed by secondary intention.
false. Wounds that heal by secondary intention have more scar tissue formation because of the volume of tissue needed to fill the defect.
Hemorrhage occurring after hemostasis indicates
1. a slipped surgical suture
2. a dislodged clot
4. erosion of a blood vessel by a foreign object
detect internal bleeding
1. look for distention or swelling of the affected body part
2. look for change in the type and amount of drainage from a surgical drain
3. look for signs of hypovolemic shock
hypovolemic shock signs
increased pulse, decreased BP, cool/clammy skin
surgical site infection
presents within 30 days if there is no implanted device or one year if there is a device left in place during the procedure.
superficial incision infection
involves only skin and subcutaneous tissue at the incision
deep incision infection
involves organs or body cavities in the area of surgery.
contaminated or traumatic wound
shows signs within 2-3 days
surgical wound infection
develops post-operative within 4-5 days
signs of infection
fever, tenderness and pain at the wound site, elevated WBC count, 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.
occurs with abdominal surgical wounds after a sudden strain, such as coughing, vomiting, or sitting up in bed
abnormal passage between two organs or between an organ and the outside of the body
The nurse enters the patient's room to answer the call light. The patient states he coughed and it felt liked "something has given way." The nurse observes the patient's abdominal wound and finds the wound edges have separated and the intestine appears to be bulging out of the incision. What complication of wound healing is the nurse seeing in the scenario above?
a. Fistula formation
b. Protrusion of visceral organs, in this case the intestine, through a wound opening is an evisceration.
The nurse enters the patient's room to answer the call light. The patient states he coughed and it felt liked "something has given way." The nurse observes the patient's abdominal wound and finds the wound edges have separated and the intestine appears to be bulging out of the incision. What should the nurse's next action be after applying sterile gloves?
a. Apply sterile towels saturated with sterile normal saline.
b. Notify the health care provider.
c. Reinforce the dressing.
d. Replace the intestinal protrusion, apply Steri-strips, dressing, and abdominal binder.
e. Have the patient splint the abdomen with a folded towel.
a. The nurse places sterile towels soaked in sterile saline over the protruding tissues. The patient should be on NPO status, observed for signs and symptoms of shock, and prepared for emergency surgery.
which of the following may primarily contribute to the development of dehiscence and evisceration rather than fistula? select all that apply
which patients may be at risk for impaired wound healing? select all that apply
1. 50yo male with knee surgery
2. 40yo female with hemoglobin value of 14 and needing hysterectomy
3. obese patient who underwent abdominal surgery
4. 17yo female who smokes and has purulent drainage from open wound obtained 2 weeks ago
5. malnourished AIDS patient with ulcer on buttocks
6. elderly patient with peripheral vascular disease and a foot ulcer
3, 4, 5, 6
Which of the following patients has the most risk factors for impaired wound healing?
a. An 80-year-old underweight alcoholic with an infected toe
b. A 30-year-old diabetic with anemia
c. An obese patient who smokes
d. A child with bronchitis who is taking steroids to facilitate breathing
a. This patient has three risk factors for impaired wound healing—age, malnutrition, and infection.
wound healing is delayed
when drainage accumulates in wound bed
A patient is returning from surgery with an abdominal incision. Because a large amount of drainage is anticipated, which type of drainage system would you expect for the patient to have?
a. Jackson-Pratt drain
b. Hemovac drainage system
c. Wound V.A.C.
d. Penrose drain
b. A Hemovac drainage system can be used for larger amounts (up to 500 mL) of drainage. An example of when a Hemovac drain may be used is with an exploratory laparotomy (major abdominal surgery).
The nursing assistant measures the contents from a wound drain. Why should the NAP do this?
a. To determine if the amount of drainage is decreasing with time
b. To record the patient's input
c. To record the patient's output
d. To determine adequate blood replacement
e. It is inappropriate to delegate emptying of a drain to NAP.
c. The nursing assistant would measure the drainage to record the amount on the patient's output record.
equipment for emptying a wound drainage system
Graduated measuring cylinder
Sterile specimen container, if culture is needed
Goggles, if splash risk is present
expected outcome from emptying wound drainage system
Wound healing continues.
Vacuum is re-established.
Tubing is patent.
Which of the following indicates an expected outcome related to wound drainage systems?
a. Drain tube is loose and able to move within wound bed.
b. There is an absence of drainage in the Jackson-Pratt drain reservoir and the incision appears slightly swollen.
c. The patient is complaining of pain, and the drainage appears thick and cloudy.
d. The Penrose drain is located next to incision and has a safety pin in the drainage tube.
d. An expected outcome is that the drainage device is properly located and intact. A safety pin prevents the tubing from migrating into the wound.
The patient is watching the nurse empty his Hemovac. The patient asks why the nurse compresses the Hemovac after emptying it. The nurse's best response is:
a. "To make sure that all of the drainage is out of it"
b. "The drain is compressed to reestablish vacuum."
c. "To make the drain reservoir smaller"
d. "Why are you worrying about your drain?"
b. Compressing the drain reservoir reestablishes the vacuum, enabling the drain to exert negative pressure and draw fluid from the wound bed.
Where should the nurse discard the drainage once it is emptied from the drain reservoir?
a. In the sink
b. In a specimen container placed in a biohazard bag
c. In the commode
d. After measuring the drainage, gently reinsert into the patient to maintain blood volume.
when should the drainage evacuator be emptied? select all that apply
1. 8-12 hours
2. when full
3. 24 hrs
4. 1/2 to 2/3 full
which of the following should be examined when evaluating the effectiveness of drain function? select all that apply
1. amount of drainage
2. color of drainage
3. distance of drain from incision site
4. condition of wound
Roy Banks had surgery for repair of an abdominal aneurysm. He has a 10 cm (4 inches) abdominal incision and a Jackson-Pratt drain. What preventive measure can you instruct the patient to take to prevent dehiscence?
a. Avoid coughing and position change.
b. Notify you if his pain worsens.
c. Perform hand hygiene frequently.
d. Splint his abdomen with a folded towel or pillow when coughing or changing position.
d. You should instruct the patient to splint his abdomen when moving or coughing to provide support to the tissues.
Two hours after Roy's surgery, you empty the Jackson-Pratt evacuator of 20 mL serous drainage. What action should you take next?
a. Notify the health care provider and maintain patient on NPO status.
b. Document the amount on the patient's output record.
c. Increase the IV by 20 mL to replace the fluid loss.
d. Nothing, because this is a normal finding.
b. You should document the amount on the patient's output record and continue to monitor.
what should you be observing when evaluating the patient and the drain to determine if drain if functioning correctly? select all that apply.
1. vital signs and insertion site
2. if evacuator is compressed
3. capillary refill
4. pt level of comfort
5. type and amount of drainage
Autolytic debriding products
applied to wounds to allow the enzymes to self-digest dead tissue
Enzymatic debriding agents
applied directly to the wound bed and act by breaking down dead tissue.
requires frequent dressing changes
precut drain sponge
What is the primary advantage of using Montgomery ties?
a. Less chance of an allergic response
b. Secures the dressing better than tape
c. Works best on extremities
d. Reduces skin irritation
d. Frequent removal of tape for dressing changes is irritating to the skin. The use of Montgomery straps secures dressings and facilitates changes without removing the tape each time.
true/false: Tape is unnecessary for transparent dressings.
true. Transparent dressings are thin, self-adhesive elastic films (e.g., OpSite or Tegaderm). Because they are self-adhesive, tape is unnecessary.
true/false: An advantage of transparent dressings is the ability to be used with moist wounds.
false. These dressings are inappropriate for moist surfaces, such as a wound bed or moist periwound skin, because the adhesive is unable to stick to wet skin.
true/false: The nurse can assess wounds more easily with transparent dressings.
true. Because these dressings are clear, the nurse is able to assess the wound without removing the film.
true/false: Transparent dressings are used for treating superficial wounds and full-thickness wounds.
false. Transparent dressings are used to manage only superficial wounds.
true/false: Transparent dressings are an excellent choice to stop bleeding because they can be used to apply pressure to the wound site.
false. These dressings are inappropriate for moist surfaces because the adhesive is unable to stick to wet skin. For best results, these dressings should be used on clean, debrided wounds.
true/false: Transparent dressings prevent tissue dehydration.
true. With the use of a transparent dressing, a moist exudate forms over the wound surface, which prevents tissue dehydration and allows for rapid, effective healing by speeding epithelial cell growth.
provide a moist environment for wound healing while facilitating the softening and subsequent removal of wound debris. Indicated as primary dressings for minimally to moderately exudative partial- and full-thickness wounds. ; clean stage II and noninfected shallow stage III pressure ulcers in anatomic locations where the product does not roll or melt
glycerin- or water-based dressings designed to hydrate a wound, thus promoting moist wound healing and autolysis. Recommended for dry to minimally exudative wounds with or without depth and are a good choice for painful or burn wounds since the dressings do not adhere to a wound base.
absorb serous fluid or exudate to form a hydrophilic gel that conforms to the shape of the wound. Because these dressings absorb and hold exudate, they create a moist environment and promote granulation, epithelialization, and autolysis.
absorb light-to-heavy amounts of exudates, are comfortable, and can easily be made to fit a wound. These properties make them especially useful for treating draining pressure ulcers.
moist to dry dressings
wounds requiring debridement
postoperative with minimal drainage
negative pressure wound therapy
commonly used for dehisced wounds, diabetic foot ulcers, pressure ulcers, vascular ulcers (includes venous ulcers and arterial ulcers), burn wounds, surgical wounds (especially infected sternal wounds) and trauma-induced wounds
device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together. The use of negative pressure removes fluid from the area surrounding the wound, thus reducing local peripheral edema and improving circulation to the area. ; used to treat acute and chronic wounds
3-4 days post wound VAC therapy
bacterial counts in the wound drop
pale areas in wound
indicates an increase in fibrous tissue
redder areas in wound
indicates granular tissue
The nurse is teaching the patient's spouse how to perform a moist-to-dry dressing change. Which action, if made by the spouse, indicates further teaching is needed?
a. The spouse uses a sterile cotton tipped applicator to place gauze in tunneled area.
b. Wearing sterile gloves, the spouse moistens new gauze with prescribed solution, wrings it out and unfolds it prior to gently packing into wound base.
c. With gloved hand, the spouse removes gauze dressings, one layer at a time, taking care to avoid dislodging drains or tubes.
d. The spouse moistens the old dressing with sterile normal saline before removing it from the wound.
d. The purpose is to debride the wound. The spouse should avoid remoistening the gauze.
You are changing a wound V.A.C. dressing. You perform hand hygiene, apply clean gloves, assemble supplies, position and drape the patient, place a disposable bag within reach of the work area, and turn the V.A.C. unit off. You then disconnect the tubes from each other to drain the fluids into the canister and tighten the clamp on the canister tube. With the dressing tube unclamped, you then introduce 30 mL of normal saline into the tubing. The patient asks, "What kind of medicine are you putting into my tube?" Your best response is:
a. "This isn't medicine; it's saline to help loosen the foam so it won't stick to your wound when I remove it."
b. "This is normal saline; we use it to keep your wound moist so that it will heal quicker."
c. "This isn't medicine; it's saline used to help make the wound edges shrink, which promotes comfort."
d. "This is a solution used to clean the area and keep the wound bed sterile."
a. Instilling normal saline facilitates loosening of foam when tissue adheres to the foam.
You are changing a wound V.A.C. dressing. You have removed the previous dressing, irrigated, measured the wound, removed your gloves and performed hand hygiene. You have applied sterile gloves, selected the black polyurethane foam, and cut it to the size and shape of the wound. You place the foam in the wound, leaving space between the foam and the wound edges. You then apply the transparent dressing over the foam and secure the tubing to the V.A.C. unit. You check that both clamps are open and turn the power button on with the pressure set as ordered. What step did you perform incorrectly?
a. It is unnecessary for you to wear gloves when preparing the V.A.C. foam.
b. You chose the wrong type of foam.
c. You should have placed the foam in contact with the wound margins.
d. You should have made sure the clamps were closed before turning on the unit.
c. You should be sure that the foam is in contact with the entire wound base and margins and tunneled and undermined areas to maintain negative pressure to the entire wound.
during evaluation you determine whether expected outcomes have been met. Which of the following are appropriate statements? Select all that apply
1. patient reports pain level of 5 during dressing change, and a level 3 after dressing change, compared to yesterday's report of a level 7.
2. dressing on heel remains clean, dry, intact.
3. wound edges appear inflamed with foul odor noted
4. wound decreasing in size with less drainage and skin appearing less red and more pink
1, 2, 4
Wound appears inflamed and tender, drainage is evident and/or an odor is present.
1. Monitor patient for signs of infection—fever and/or increased white blood cell (WBC) count.
2. Notify health care provider.
3. Assess drainage for appearance and odor.
4. Obtain wound cultures as ordered.
Wound drainage increases
1. Increase frequency of dressing changes
2. notify HCP
Wound bleeds during dressing change.
1. observe color/amount of drainage
2. Protect wound.
3. Cover wound with sterile moist dressing.
4. Instruct patient to lie still.
5. Stay with patient to monitor vital signs.
6. Notify health care provider.
Wound is inflamed, tender; drainage, necrosis and/or an odor is present.
1. remove dressings
2. obtain culture as ordered
3. notify HCP
Dressing does not stay in place.
1. evaluate dressing size
2. dry patient skin prior to application
Outer layer of patient's skin tears on removal of dressing.
use non-adhesive backed dressing
Patient reports increase in pain.
1. Instill normal saline to moisten foam and other filler dressings to allow it to loosen from granulation tissue.
2. If using black foam, switch to the PVA foam.
3. Patient may need more analgesia.
4. Decrease pressure setting.
5. Change from intermittent to continuous cycling.
6. Change type of NPWT system.
What type of dressing would you expect to use to treat the skin tear on Roy's elbow?
a. Wet-to-dry moist
b. Wound V.A.C.
d. Transparent dressings are used to treat superficial wounds such as a skin tear.
You are changing Roy's gauze dressing over his abdominal incision. In which direction should you remove the tape?
a. Toward the abdominal wound
b. Away from the abdominal wound
c. You should first moisten the tape to ease removal.
d. The direction is unimportant as long as you remove the tape quickly.
a. Tape should be removed by pulling parallel to the skin and toward the dressing. This is less stressful on the suture line/wound edges. Tape over hairy areas is removed in the direction of hair growth.
You have removed the tape but find that the gauze dressing has adhered to some dried bloody drainage of Roy's surgical incision. What should you do next?
a. Go ahead and remove the dressing because this will help debride the wound.
b. Have the health care provider remove the dressing in case removal causes bleeding.
c. Moisten the dressing with sterile water or normal saline.
d. Moisten the dressing with hydrogen peroxide.
c. You should moisten the dressing with sterile normal saline or sterile water before removing the gauze to minimize trauma to the wound as it is removed.
Roy has an abdominal incision and a drain. Which should you clean first?
a. Around the drain
b. The incision
c. From the most-contaminated area to the least-contaminated area
d. As long as sterile technique is maintained, order is insignificant.
b. You should clean from the least-contaminated area (the incision) to the most-contaminated area (the drain).
When you are changing the dressing over Roy's skin tear on his elbow, you note purulent drainage, and Roy complains of increased pain. What should you do next?
a. Apply a gauze dressing instead of a transparent dressing.
b. Dry Roy's skin thoroughly before reapplication.
c. Give Roy his pain medication.
d. Obtain a wound culture.
d. You should obtain a wound culture according to facility policy because these are signs and symptoms of infection.
Which of the following are functions of dressings?
1. to promote hemostasis
2. wound debridement
3. keep wound bed dry
4. prevent contamination
5. increase circulation
To promote hemostasis, Wound debridement, to prevent contamination
Which the following patients would be expected to benefit from a moist to dry dressing?
1. 24 yo pt with open and infected wound from spider bite
2. 7 yo with abrasion on knee
3. 5o yo with post-operative knee surgery
5. 30 yo who had large cyst removed and has necrotic tissue present in crater type wound
A 24 y/o patient with an open and infected wound from a spider bite; A 30 y/o who had a large cyst removed and now has some necrotic tissue present in the crater type wound
The nurse is observing the patient's wife perform the moist-to-dry dressing change. Which actions, if made by the patient's wife, indicate that further instruction is needed?
1. premedicates for pain
2. packs wound tightly
3. leaves contact/primary dressing dripping moist
4. when removing old dressing, leaves dry even if it sticks to wound
A patient with a vaccuum assisted closure continues to complain of pain. What measures may be taken?
1. switch to white PVA soft foam
2. decrease pressure setting
3. administer pain medications
4. switch to PVA black foam
5. keep suction in "off" position
1, 2, 3
Wound appears inflamed and tender, drainage is evident, and/or an odor is present
Monitor patient for signs of infection, for example, fever, increased WBC, purulent drainage. Notify MD. Obtain wound cultures as ordered
Patient or caregiver is unable to perform dressing change
Provide additional teaching and support. Obtain services of home care agency as needed
Wound drainage increases requiring frequent dressing changes
Notify HCP, who may consider drain placement or alternate dressing method
Patient reports a sensation that "something has given way under the dressing"
Observe wound for increased drainage or dehiscence or evisceration. Cover wound with sterile moist dressing. Instruct patient to lie still. Notify HCP
Wound bleeds during dressing change
Observe color and amount of drainage. If excessive, you may need to apply direct pressure. Obtain vital signs. Notify HCP of findings
During a sterile dressing change, when are gloves changed?
1. after old dressing is removed and before setting up sterile field
2. after old dressing is removed and before cleaning wound
3. after old dressing is removed, after cleaning wound, before applying new dressing
4. it is unneccesary to change gloves
A patient states that she is unable to get her transparent dressing to stay in place. What instruction should the nurse provide the patient?
1. we can check with the HCP to see if you can get an at home care nurse
2. make sure you have a margin of 1-1/2" around the wound
3. this type of dressing doesn't stay in place and requires frequent changes
4. you are probably applying it incorrectly
5. why don't you try a different type of dressing
2. Make sure that you have a margin of 1-1.5 inches around the wound and that the skin is thoroughly dry before applying the dressing
How can the nurse determine that negative pressure is being achieved with a wound V.A.C.?
The nurse can check for air leaks by listening with a stethoscope or by moving the hand around the edges of the wound while applying light pressure.
A patient asks the nurse why the Montgomery ties are being used instead of regular tape. The nurse's best response is:
"Montgomery ties avoid frequent removal of tape, which is irritating to the skin during dressing changes."
correct sequence for changing a gauze dressing?
Remove old dressing, discard gloves and perform hand hygiene, create sterile field, apply sterile gloves, clean wound, blot dry, apply new dressing.
A patient has a 4-day-old postoperative incision. Which would be a normal finding when changing the dressing?
Small amount of serous drainage
localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear.
most common sites for the development of pressure ulcers
Lateral and medial malleoli
true/false: Reddened areas should not be massaged to increase circulation.
true. Massaging reddened areas increases breaks in the capillaries in the underlying tissues and increases the risk of injury to underlying tissue and pressure ulcer formation.
true/false: Casts can cause pressure ulcers.
true. Pressure ulcers can occur when an external source such as a cast edge applies unrelieved pressure to skin.
Factors Contributing to Pressure Ulcer Development
incontinence, friction and shear, immobility, loss of sensory perception, level of activity, and poor nutrition
You are using an assessment tool to assess a patient's risk for pressure ulcer formation. The patient asks about the benefit of such a tool. Your best response is:
a. "It is a routine assessment that we do on everyone."
b. "It helps us identify people who are at risk for pressure ulcers and intervene."
c. "It helps us identify what you know about pressure ulcer development and prevention."
d. "It is a report sheet for the health care provider."
b. To prevent pressure ulcers, individuals at risk must be identified so that risk factors can be reduced through intervention.
true/false: Redness or discoloration is the first stage of skin breakdown.
true. If redness or discoloration is noted, this could be the first stage of skin breakdown. The discoloration may vary from pink to a deep red. The nurse can assess the area further by determining whether the area blanches when gentle pressure is applied.
true/false: In dark-skinned patients, discoloration of the skin is a deeper shade than normal.
true. In dark-skinned patients, the discoloration appears as a deepening of normal ethnic color or a persistent red, blue, or purple hue.
true/false: The potential for skin breakdown increases when the patient is unable to change position.
true. The potential for friction and shear increases when patient is completely dependent on others for position changes.
Clinically significant malnutrition
The serum albumin level is less than 3.5 g per dL.
The lymphocyte count is less than 1800 per mm3.
Body weight decreases more than 15%.
true/false: In the care of pressure ulcers, cotton-tipped applicators are used to measure wound depth.
true. A cotton-tipped applicator is used for assessing wound depth. A transparent measuring tool may be used to measure the size (i.e., diameter) of the wound. A wound culture tube or needle aspiration is used to obtain a wound culture.
true/false: Normal saline is often used as a cleansing agent of pressure ulcers.
true. Normal saline is often used as an irrigating solution to remove wound debris. Normal saline is isotonic and will leave a wound moist without residue as compared with soaps and alcohol-based lotions that do.
It is suspected that a patient has a wound infection. The pain at the wound site has been increasing. The health care provider has ordered a wound drainage culture. The patient has a prn (as needed) order for propoxyphene/APAP (Darvocet). When should pain medication be administered?
a. 30 minutes before obtaining the wound culture
b. 30 minutes after obtaining the wound culture
c. 1 hour before obtaining the wound culture
d. Immediately before the wound culture is obtained
a. Ideally pain medication is given 30 minutes before dressing changes or obtaining a wound culture to allow for the drug to reach its peak effect.
true/false: To guarantee an accurate test result, you should obtain the specimen from the wound and not touch the surrounding skin.
true. An appropriate expected outcome is for the culture swab to remain uncontaminated by bacteria from the skin.
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