pressure ulcers and wound management prep u

The nurse is teaching a client about wound care at home following a Cesarean section to deliver her baby. Which client statement requires further nursing teaching

"Steri-Strips will hold my wound together until it heals -After a Cesarean section, a client will be sutured and have staples put in place for a number of days. The healthcare provider or nurse will remove staples. Steri-Strips are not strong enough to hold this type of wound together

shearing forces

A shearing force results when one layer of tissue slides over another layer. Clients who are pulled rather than lifted when being moved up in bed or from bed to chair to stretcher are at risk for injury from shearing forces

A nurse is using the RYB wound classification system to document patient wounds. Which wounds would the nurse document as a Y (yellow) wound

A wound that is characterized by oozing from the tissue covering the wound • A wound with drainage that is a beige color • A wound that requires wound cleaning and irrigation -The nurse would document a wound that is characterized by oozing form the tissue covering the wound as a Y (yellow) wound. The nurse would document a wound that has beige colored drainage and a wound that requires wound cleaning and irrigation as Y (yellow) wounds. A wound that reflects the color of normal granulation tissue would be a R (red) wound. A wound that is covered with thick eschar would be documented as a B (black) wound. A wound that is treated by using sharp, mechanical, or chemical debridement would be documented as a B (black) wound

A nurse is caring for a client who had an appendectomy and has been readmitted for wound care. The incision has been opened by the primary care provider to allow for drainage. The wound is draining copious amounts of yellow exudate. Which type of dressing should the nurse understand is appropriate for this wound

Alginates • Antimicrobials • Composites -Types of dressing that would be appropriate with this type of wound are alginates, antimicrobials, and composites. These all work with heavy drainage and infected wounds. Hydrocolloids would be used with light to moderate drainage and no infection. Hydrogels work with wounds that have minimal exudate

corticosteroids

Clients who are taking corticosteroids or require postoperative radiation therapy are at high risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing

`The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action

Elevate and support the stump -The nurse will first elevate and support the stump, then begin the process of bandaging. The bandage will be applied distally to proximally with equal tension at each turn; the nurse will monitor throughout the application to keep the bandage free from gaps between turns

A nurse uses a T-binder to secure the dressing to the anus of a client who has undergone hemorrhoidectomy for piles. Which interventions should the nurse follow to apply the T-binder

Fasten the crossbar around the waist. • Pass the tails through the client's legs. • Pin the tails to the belt of the T-binder -When applying a T-binder to secure the dressing to the anus of a client who has undergone hemorrhoidectomy for piles, the nurse fastens the crossbar of the T around the waist. Then the nurse passes the single or double tails between the client's legs and pins the tails to the belt. Adhesive sanitary napkins worn inside underwear briefs are an alternative to a T-binder for stabilizing absorbent materials. When managing a closed drain, the nurse cleans the insertion in a circular manner. After cleansing, the nurse places a precut drain sponge or gauze, which is open to its center, around the base of the drain

gauze dressings

Gauze dressing is ideal for covering fresh wounds that are likely to bleed, or wounds that exude drainage.

The nurse and client are looking at a client's heel pressure ulcer. The client states, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response

Necrotic tissue is devitalized tissue that must be removed to promote healing -The tissue the client is inquiring about is not normal. Dry brown or black tissue is necrotic. Slough is dead moist, stringy dead tissue on the wound surface that is yellow, tan, gray, or green. Undermining is tissue erosion from underneath intact skin at the wound edge

type of drains

Penrose drains are commonly used after a surgical procedure or for drainage of an abscess. Jackson-Pratt drains are typically used with breast and abdominal surgery. A Hemovac drain is placed into a vascular cavity where blood drainage is expected after surgery. Wound pouching is used on wounds that have excessive drainage

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide

The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment -A wound with heavy exudate will need a more absorptive dressing and a dry wound will require rehydration with a dressing that keeps the wound moist. The nurse would not keep the surrounding tissue moist. The nurse would not pack the wound cavity tightly, rather loosely. The nurse would not use wet-to-dry dressings continuously

The nurse is caring for a client who has a pressure ulcer on his back. What nursing intervention would the nurse perform

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair -Positioning devices such as pillows, foam wedges, or pressure-reducing boots can prove helpful to keep body weight off bony prominences. For example, a standard pillow placed under the calves raises the heels off the bed and alleviates pressure. The nurse should never use ring cushions, or "donuts," because they increase venous pressure. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible

obtaining a wound culture

The swab and the inside of the culture tube should be kept sterile. The wound should be cleansed prior to obtaining the culture. The culture swab should not touch the skin surround the wound site. In addition, if multiple sites have to be cultured then separate culture swabs should be used

The nurse is teaching a client about healing of a minor surgical wound by first-intention. What teaching will the nurse include

Very little scar tissue will form -Very little scar tissue is expected to form in a minor surgical wound. Second-intention healing involves a complex reparative process where margins of the wound are not in direct contact. Third-intention healing takes place when wound edges are intentionally left widely separated and are later brought together for closure

cleansing the wound

When cleansing a wound the nurse should use a new gauze or swab on each downward stroke using the cleansing agent. The wound should be cleaned from the inner to the outer portions of the wound. This keeps the wound from being contaminated with bacteria from outside the wound. The wound should be cleansed at least 1 inch (2.5 cm) beyond the end of the new dressing. Also, the wound should be cleansed in full or half circles beginning in the center and working toward the outside

a client that is most likely to develop a pressure ulcer from shearing forces is

a client sitting in a chair who slides down

abrasion

abrasion involves stripped surface layers of skin.

avulsion

avulsion has stripped away of large areas of skin and underlying tissues.

proliferative stage

epidermal cells, which appear pink, reproduce and migrate across the surface of the wound in a process called epithelialization -In partial-thickness wounds, in the third phase, the proliferative phase, epidermal cells reproduce and migrate across the surface of the wound in a process called epithelialization. The onset of vasoconstriction, platelet aggregation, and clot formation are part of the first phase of wound healing—hemostasis. The second phase, the inflammatory phase, is marked by vasodilation and phagocytosis as the body works to clean the wound. Maturation is the final stage of full-thickness wound healing, in which the number of fibroblasts decreases, collagen synthesis is stabilized, and collagen fibril become increasingly organized

The nurse has collected blood from a client for laboratory analysis. Which dressing supply will the nurse select to cover the site from which the blood was drawn

gauze -Gauze dressings absorb blood or drainage. Montgomery straps are strips of tape with eyelets which are used to secure a gauze dressing that needs frequent changing; they are not necessary for this type of wound. Transparent dressings like OpSite(tegaderm) are used to protect intravenous insertion sites. Hydrocolloid dressings like Tegasorb(duoderm) are used to used keep a wound moist

hydrocolloid dressing

hydrocolloid dressing helps keep the wounds moist

incision

involves a clean separation of skin and tissue with smooth, even edges

a bandage

is a strip or roll of cloth wrapped around a body part to help support the area around the wound

Penrose drain

is an open drainage system that exits the skin through a stab wound. The purpose a Penrose drain is to provide a sinus tract

laceration

laceration involves separation of skin and tissue with torn, irregular edges.

local capillary pressure

must be higher than external pressure for adequate skin perfusion

the layer of skin that is a potential source of energy

subcutaneous tissue -The subcutaneous tissue is the skin layer that is responsible for storing fat for energy. The epidermis is the outer layer that protects the body with a waterproof layer of cells. The dermis contains the nerves, hair follicles, blood vessels, and glands. The muscle layer moves the skeleton

An iv line should be covered with a

transparent film -Transparent film dressings are semipermeable, waterproof, and adhesive, allowing for visualization of the access site to aid assessment, as well as protecting the site from microorganisms. Gauze dressings do not allow the nurse to visualize the site without partially or completely removing the dressing

A nurse is evaluating a client who was admitted with second-degree burns. Which describes a second-degree burn

usually moist with blisters, they may be pink, red, pale ivory, or light yellow-brown -Second-degree burns are moderate to deep partial-thickness burns that may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. First-degree burns are superficial and may be pinkish or red with no blistering. Third-degree burns are full-thickness burns and may vary from brown or black to cherry-red or pearly-white; bullae may be present; can appear dry and leathery

proper procedure for wound care

working outward from the wound in parallel lines to it

the most appropriate food for wound healing

would be food high in protein vitamin c and a such as fish