Wound culture, Irrigation of the wound, preventing pressure injuries

When collecting a culture from a client's wound, according to evidence-based practice, which type of motion will the nurse use when applying the swab to the wound tissue to obtain the most accurate results?

Rolling motion The nurse would insert the swab into the wound and gently roll it over the wound surfaces to obtain a sample of the pathogens causing the infection. Using a pushing motion, up-and-down motion, or back-and-forth motion will not provide the most accurate results according to evidence-based practice and may actually cause injury to the wound tissues.

Place in order, from first to last, these actions the nurse will perform when providing wound care to a client with a pressure injury. Use all options.

1)Put on clean gloves. 2)Remove old dressing. 3)Assess the wound bed. 4)Open dressing materials. 5)Irrigate the wound bed. 6)Time and date the dressing. The nurse should first put on clean gloves, then remove the old dressing, assess the wound bed and surrounding skin, change gloves, open dressing materials, provide the wound care including irrigating the wound bed, then time and date the dressing once completed.

Which client is a greatest risk of developing a pressure injury?

47-year-old client with severe alcoholism and a traumatic brain injury resulting in unconsciousness The 47-year-old client with severe alcoholism (poor nutritional status) and a traumatic brain injury (immobile) is at greatest risk for developing a pressure injury. The 17-year-old does not have any noted risk factors, the 25-year-old is young and only on bedrest for 24 hours so is very unlikely to develop a pressure injury, and the 84-year-old is ambulatory, making them a low risk for a pressure injury. For the 84-year-old client, the greatest risk is for falls.

Which client would be at greatest risk for developing a pressure injury?

Adult client who is comatose A client who is comatose is at greatest risk for developing a pressure injury due to the inability to turn or move in bed. This client needs to be turned regularly to prevent development of a pressure injury. The other clients have no restrictions for movement and would not be at great risk for developing a pressure injury. An older client who is bedridden (not a factor with COPD) would also be at high risk for developing a pressure injury due to age-related skin alterations.

The nurse is collecting a wound culture from a client's puncture wound. What is the nurse's first step in the procedure?

Clean the wound. To obtain a wound culture, the nurse would first clean the wound, then obtain the wound culture, redress the wound, and document the procedure when complete. Cleaning the wound removes previous drainage and wound debris, which could introduce extraneous organisms into the collected specimen, resulting in inaccurate results.

The nurse is obtaining a wound culture and has removed the old dressing and discarded it, performed hand hygiene and applied fresh gloves. What should the nurse do next?

Cleanse the wound with a nonantimicrobial cleanser. After removing the old dressing, discarding it, performing hand hygiene and applying fresh gloves, the nurse should cleanse the wound with a nonantimicrobial cleanser to prevent the culture from being contaminated by extraneous wound debris. The assessment of drainage for amount, type, color, and odor should have happened when the nurse removed the old dressing, because the old dressing is part of that information. The wound bed should be dried after the wound is cleaned, not before, and the nurse should not open the culture tube until the wound is cleansed and patted dry.

When irrigating a client's wound, the nurse pours irrigation solution from the bottle into a sterile container. What is a recommended action for this step in the procedure?

Date and reuse leftover irrigation solution within 24 hours. After setting up a sterile field, if indicated, the nurse pours the warmed sterile irrigation solution into the sterile container. The nurse should date the solution bottle if any solution is leftover and use it within 24 hours. There is no need to shake the irrigating solution. The irrigating solution may be warmed for use but should never be chilled for use. Any solution remaining may be used, if kept in the sterile container, for up to 24 hours; therefore, the nurse should not discard the remaining solution.

When assessing a client's skin, the nurse observes an area of deep purple discoloration on the client's heel. The skin in that area is intact. How will the nurse document this finding?

Deep tissue injury The nurse should document this finding as a deep tissue injury. Deep tissue injuries are characterized by a purple or maroon localized area of discolored intact skin or blood-filled blister caused by damage to underlying soft tissue from pressure and/or shear. The description of stage 1 pressure injury includes intact skin with non-blanchable redness. In a stage 2 pressure injury, the skin would not be intact, and there is partial-thickness skin loss involving epidermis, dermis, or both. An unstageable pressure injury has slough, which is a yellowish stringy substance attached to the wound bed, or eschar, which is black or brown necrotic tissue covering the wound, which prevents knowledge of the depth of the wound.

The nurse is positioning a client with a pressure injury to prepare to irrigate the wound. How would the nurse direct the flow of irrigation solution over the wound?

From the upper end of the wound to the lower end The nurse would position the client's wound so that the irrigation solution would flow from the upper end of the wound to the lower end. In this way, gravity directs the flow of the liquid from the least contaminated area of the wound to the most contaminated area, thereby decreasing the risk of wound contamination. Directing the flow of irrigating solution from the lower end to the upper end, or from one side to the other side, does not ensure that the solution flows from the least contaminated area to the most contaminated area.

When irrigating an infected wound, which action by the nurse best helps to prevent contamination of the irrigation syringe?

Keeping the tip of the syringe at least 1 in (2.5 cm) above the wound The best way to prevent contamination of the irrigation syringe is to ensure it never comes in contact with the wound by keeping the tip of the syringe at least 1 in (2.5 cm) above the wound when irrigating the wound. Although the nurse should direct the flow of irrigation from the top of the wound downward, this is not to prevent contamination of the syringe. Positioning of the client is based on wound location not on preventing contamination of the syringe. Cleaning the tip with alcohol wipe after each use is not a recommended way to keep the syringe free of contamination.

Which assessment findings will the nurse use to determine the stage of a client's pressure injury? Select all that apply.

No bone, tendon, or muscle visible., Visible subcutaneous fat, Full-thickness tissue loss The assessment findings which will help the nurse determine the stage of a client's pressure injury are: subcutaneous fat is visible; there is full-thickness tissue loss; and no bone, tendon, or muscle is visible in the wound bed. This information should lead the nurse to document this as a stage 3 pressure injury. The skin being red and warm to the touch and the green foul drainage are indications of wound infection, but do not influence the staging of the client's pressure injury.

The nurse is caring for a client with an abdominal wound and prescriptions from the health care provider. Which prescription will the nurse initiate first?

Obtain a sterile wound culture The nurse should first obtain the sterile wound culture. The culture should be obtained as soon as possible, because it takes time for the results to return and must be done before the nurse can start the ciprofloxacin. Antibiotics interfere with microorganism growth and the primary reason for obtaining a culture is to identify the cause of the infection. Identifying the invading microorganisms helps to determine treatment options and select the most appropriate treatment. The culture should be obtained while the client is in bed; therefore, it should be done before assisting the client up to a chair. Consulting the dietician to assist the client with meal choices should wait until the culture is obtained and the antibiotic is started, because it is of less importance to the well-being and safety of the client.

A nurse is collecting a wound culture from a client from two different sites. Which actions should the nurse take while performing this procedure? Select all that apply.

Press and rotate the swab several times over the wound surfaces., Place the swab in the culture tube when done., Insert a swab into the wound. The nurse should carefully insert the swab into the wound and then press and rotate the swab several times over the wound surfaces. After collecting the specimen, the nurse should place the swab back in the culture tube. The nurse should be careful to keep the swab and the inside of the culture tube sterile at all times. This means that the nurse should avoid touching the swab to intact skin at the wound edges or to the outside of the tube, as this would contaminate both the swab with organisms not in the wound and the areas that the swab touches with organisms found in the wound. A different swab, not the same, should be used for each wound site to prevent cross-contamination.

The nurse is collecting a wound culture and has removed the current dressing and discarded it. What should the nurse do next?

Remove gloves and perform hand hygiene. After removing the current dressing and discarding it, the nurse should remove the gloves and perform hand hygiene. Then the nurse should apply fresh gloves; sterile gloves may be indicated if the wound edges must be separated to insert the culture swab. After hand hygiene and applying fresh gloves, the nurse would assess and clean the wound using a non-antimicrobial cleanser such as sterile saline, open the culture tube, obtain the culture and complete the procedure. Identifying the client using two client identifiers should happen before the procedure is begun along with explaining the procedure to the client.

The nurse observes a reddened area with intact skin over the client's coccyx. When gentle pressure is applied, the area does not blanch. How will the nurse document this finding?

Stage 1 pressure injury This finding should be documented as a stage 1 pressure injury. The description of stage 1 pressure injury includes intact skin with nonblanchable redness. In a stage 2 pressure injury, the skin would not be intact, and there is partial-thickness skin loss involving epidermis, dermis, or both. Deep tissue injuries are characterized by a purple or maroon localized area of discolored intact skin or blood-filled blister caused by damage to underlying soft tissue from pressure and/or shear. An unstageable pressure injury has slough, which is a yellowish stringy substance attached to the wound bed, or eschar, which is black or brown necrotic tissue covering the wound, which prevents knowledge of the depth of the wound.

The nurse is irrigating a client's wound using sterile technique. When directing the irrigating solution into the wound, what does the nurse use to collect the solution?

Sterile basin When irrigating a client wound, the nurse would place a sterile basin under the wound to protect the client and bed linens from the contaminated solution. The used wound dressing should be immediately discarded after removal and not used to collect solution, because this dressing is contaminated. A waterproof pad would not be used to collect the solution but may be used underneath the basin in case of splashes or spills to prevent soiling the bed linen. Gauze is not used to collect irrigating solution, this would be an expensive choice and does not protect the bed linen.

The nurse is caring for a client with a pressure injury on the heel of the foot. The injury is covered with stable black eschar. What is the best nursing intervention at this time?

Teach the client ways to relieve the pressure on the heel. The best nursing intervention at this time is to teach the client ways to relieve the pressure on the heel to prevent further damage. Stable eschar serves as "the body's natural (biological) cover" and is only removed by health care provider order. Teaching the client to reposition is a good intervention, but the client should be taught to reposition at least every 2 hours. The client would need adequate protein to promote healing, not carbohydrate.

The nurse is caring for a client with a pressure injury and is applying a saline-moistened dressing to the wound. What does the nurse understand to be the primary rationale for using a saline-moistened dressing?

To promote moist wound healing and protect the wound from contamination and trauma. Saline-moistened dressings are used to maintain a moist wound environment to promote moist wound healing and protect the wound from contamination and trauma. A moist wound surface enhances the cellular migration necessary for tissue repair and healing. It is important that the dressing material be moist, not wet, when placed in open wounds. Although a moist dressing may also prevent sticking to the wound, this is not its primary purpose.

The nurse is teaching a client's caregiver about ways to help prevent skin breakdown. What would the nurse teach as an important intervention to prevent pressure injury development?

Turn and reposition the client every 2 hours. Pressure injuries are a result of unrelieved pressure that damages underlying tissues. Teaching the caregiver to turn and reposition the client every 2 hours is an important intervention to help prevent unrelieved pressure from causing pressure injury to tissues. Keeping the head of the bed elevated will help to prevent aspiration but does not prevent pressure injury. The caregiver should be taught how to use a draw sheet to lift the client and then move the client up in bed. The client should not be pulled, because this causes a shearing force which can easily injure tissue. Reddened areas should not be massage so this should not be taught to the caregiver.

The nurse is irrigating a client's pressure injury. How would the nurse know when to stop irrigating the wound?

When the solution from the wound flows out clear The nurse knows to stop irrigating a wound when the solution from the wound flows out clear. The irrigation removes the exudate and debris, which turns the solution from the wound red to pink to clear, when finished. It is not necessary to use all the solution if the flow is clear already. The nurse should not stop when the return flow is red or pink, this color indicates the wound has not been thoroughly cleaned or irrigated yet.

The nurse has documented that a client has an unstageable pressure injury. Which statement best describes this type of wound? The wound:

has black brown eschar covering the top. Wounds that have slough (yellow, tan, gray, green, or brown stringy tissue) or eschar covering them are considered unstageable as it is not possible to determine their depth until the slough or eschar is removed. A wound that has exposed bone, tendon, or muscle visible would be considered stage 4. A wound that has redness with partial thickness loss of dermis would be considered stage 2, and a wound with bright red granulation tissue in the wound bed would be considered healing, although there is not enough information to stage this wound.