(PrepU) Wound Care - Wound Healing: Concept Exemplars

A 9-year-old client is brought to the emergency department with a sutured wound with purulent drainage. The area around the wound is red and warm to the touch, and the child is febrile. The parents want to know the significance of the purulent drainage. What is the best response by the nurse?

"If a wound heals on the surface but infection remains, it will open and drain." Purulent drainage indicates an infection in situ. A wound may heal over the top, but when infection remains, the wound may reopen at the base and drain the discharge. A wound will continually reopen and drain purulent discharge until the infection is eradicated. It is not related to antibiotics or the ineffectiveness of the sutures.

The nurse documents a fissure on the plantar aspect of a patient's foot. Which image best depicts this lesion?

A fissure is a linear crack in the skin as depicted in Option C. Erosion, a loss of superficial epidermis, is depicted in Option A. An ulcer, skin loss extending past the epidermis, is depicted in Option B. Scales, flakes secondary to desquamated, dead epithelium, is depicted in Option D.

A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline, then inserting it gently into the wound at a 90-degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method?

Depth When measuring the depth of a wound, the nurse moistens a sterile, flexible applicator with saline and inserts it gently into the wound at a 90-degree angle, with the tip down. The nurse then marks the point on the swab that is even with the surrounding skin surface, or grasps the applicator with the thumb and forefinger at the point corresponding to the wound's margin. Finally, the nurse removes the swab and measures the depth with a ruler. Size is measured with a ruler on the outside of the wound. Tunneling is measured by a finger probe or sterile probe instrument. Direction is a visual inspection.

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues?

Natural Natural debridement is accomplished when nonliving tissue sloughs away from uninjured tissue. Mechanical debridement involves the use of surgical tools to separate and remove the eschar. Enzymatic debridement encompasses the use of topical enzymes to the burn wound. Surgical debridement uses the use of forceps and scissors during dressing changes or wound cleaning.

A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain?

The status of the client's tetanus immunization Staging the wound is only done with pressure injuries. The presence of dirt or debris is something that will need to be addressed, but not the most important assessment. Understanding how the client stepped on the nail will need to be noted and is a possible educational opportunity for prevention, but it is not the most important assessment concern. Tetanus is caused by the Clostridium bacteria that can enter the body through a deep injury like stepping on a nail. The tetanus vaccine booster should be given every 10 years and is the best defense against developing the tetanus illness. Tetanus is a concern because it is a painful medical emergency that could lead to death. So, finding out the status of the client's tetanus immunization is the most important assessment information the nurse can collect from the client.

The nurse is caring for a client with an infected wound that is left to heal by secondary intention. Which observation does the nurse expect to make during assessment of the wound area?

The wound is healing slowly with epithelial and scar tissues present. Wounds healing by secondary intention undergo wound contraction resulting in a scar considerably smaller than the original wound. Cosmetically, this may be desirable because it reduces the size of the visible defect. Keloids result from abnormal wound healing, resulting in tumor-like masses caused by excess production of scar tissue. Sutures are present in wounds healing by primary intention.

A client has been diagnosed with an abscess. Upon assessment of the client, the nurse would expect to find:

a localized pocket of infection composed of devitalized tissue, microorganisms, and the host's phagocytic white blood cells. An abscess is a localized pocket of infection composed of devitalized tissue, microorganisms, and the host's phagocytic white blood cells—in essence, a stalemate in the infectious process. In this case, the dissemination of the pathogen has been contained by the host, but white cell function within the toxic environment of the abscess is hampered, and the elimination of microorganisms is inhibited. The other options do not describe an abscess.

A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound." The nurse asses the upper half of the wound edges, noticing that they are no longer approximated and the lower half remains well approximated. The nurse would document that following a sneeze, the wound

dehisced. Dehiscence is the partial or complete separation of wound edges. Evisceration is the protrusion of organs through the surgical incision. Pustulated refers to the formation of pustules. Hemorrhage is excessive bleeding.

When bandaging a client's ankle, the nurse should use which technique?

figure-eight The nurse uses a figure-eight technique to bandage a joint, such as an ankle, elbow, wrist, or knee. The nurse uses the circular bandaging technique to anchor a bandage; the recurrent technique to bandage a stump, hand, or scalp; and the spiral reverse bandaging technique to accommodate the increasing circumference of a body part such as when in a cast.

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

removing dead or infected tissue to promote wound healing Debridement is the act of removing debris and devitalized tissue in order to promote healing and reduce the risk of infection. Debridement does not directly stimulate the wound bed, and the goal is neither assessment nor the prevention of maceration.