Wound care

Round, Diameter and Length

The resulting wound is a __ hole in the skin that extends down into the deeper tissues, according to the __ and __ of the offending sharp item

Elderly

The skin of elderly individuals is thinner and less elastic, making the skin more susceptible to friction and shearing force.

Stasis Ulcers

This develops when venous blood flow is sluggish, generally in the lower extremities, allowing deoxygenated blood to pool in the veins.

T-tube

This tube is a passive drain. It is placed in the common bile duct after gallbladder surgery to drain excess bile from the area via gravity. It connects to a small collection bag but does not cause suction within the wound

A Penrose drain

This type of drain is an open drain A flat tube is inserted in the wound during surgery and then is brought out through a "stab wound" or slit in the skin.

A deep tissue injury (DTI)

This usually begins with an area over a bony prominence that differs from the surrounding tissue, in either temperature, texture, firmness, or discomfort level.

Surface Debris

When wound irrigation is ordered, the purpose is to remove __ without injuring granulation tissue

Incontinent of bowel or bladder

With incontinence of bowel or bladder, the skin of the perineal area tends to be wet much of the time, leading it to become macerated, or softened

Open or Closed

Wounds are categorized as either __ or __

4) The incidence of wound infection

A nurse practices sterile technique when changing the patient's dressing because it greatly decreases 1) Time spent changing the dressing 2) Patient discomfort during the procedure 3) The cost of changing the dressing 4) The incidence of wound infection

4) With erythema

A patient has a stage I pressure ulcer. The nurse correctly documents this as an area 1) With a small blister 2) That is excoriated 3) With a skin tear 4) With erythema

4) is at risk for stasis ulcers due to edema.

A patient has blood clots in the lower legs. The nurse correctly understands that this patient: 1) is at risk for a clean-contaminated wound. 2) is at risk for an ulcer, but the ulcer will likely have good approximation. 3) is at risk for contusions due to pooling blood. 4) is at risk for stasis ulcers due to edema.

Closed wound

A wound in which the skin remains intact

Clean

A wound that is not infected.

Bruise

A contusion is a closed discolored wound caused by blunt trauma, better known as a __.

2) Second intention closure will be used, using moist gauze and other dressings applied with sterile technique.

A patient has a stage 3 pressure ulcer. Which of the following is appropriate treatment for this wound? 1) First intention closure will be used, approximating the edges of the wound. 2) Second intention closure will be used, using moist gauze and other dressings applied with sterile technique. 3) First intention closure will be used, leaving the wound open while granulation tissue forms. 4) Third intention closure will be used, allowing the ulcer to drain and then suturing it once draining is complete.

3) "The first phase of healing involves warmth, redness, pain, and edema because the body is increasing blood supply to the wound. The blood carries fibrin to promote clotting and white blood cells to engulf damaged cells and germs."

A patient has returned from surgery, and the nurse is continuing the patient's education about what to expect as the surgical incision heals. Which of the following would be a correct statement? 1) "The first phase of healing involves inflammation, which is a dangerous overreaction of the body to the surgical wound. It must be treated aggressively with anti-inflammatories and steroids." 2) "The last phase of healing is the inflammatory phase, in which the body increases circulation to the area to build up collagen, thereby strengthening the scar and protecting the wound from reopening." 3) "The first phase of healing involves warmth, redness, pain, and edema because the body is increasing blood supply to the wound. The blood carries fibrin to promote clotting and white blood cells to engulf damaged cells and germs." 4) "As the wound begins to heal, it may begin to fill with red, semitransparent tissue. This indicates that inflammation has set in and means that the incision is at high risk for infection. Your physician may order prophylactic antibiotics to ward off infection."

1) penetrating wound.

A patient presents to the emergency department with a piece of metal from an industrial accident embedded in his abdomen. The nurse documents the injury as a: 1) penetrating wound. 2) puncture wound. 3) laceration. 4) closed wound.

3) "Gangrene is caused by anaerobic bacteria, which can only live in the absence of oxygen. We will débride the wound, begin antibiotics, and use a hyperbaric chamber to drive oxygen under high pressure into the wound."

A patient suffered a wound to the foot from a hatchet while on a hiking trip in the deep wilderness. Because of a delay in initial treatment, gangrene has developed. Alarmed, the patient's husband wants to know whether this condition can be treated. The nurse could correctly respond: 1) "Gangrene is caused by aerobic bacteria, which require oxygen to survive. We will débride the wound, begin antibiotics, and use a vacuum chamber to surround the wound with an oxygen-free environment." 2) "Gangrene is a very serious complication caused by Clostridia, a class of antibiotic-resistant bacteria. We will remove dead tissue from the wound, treat with the antibiotic vancomycin, and hope that this strain of the bacteria is not resistant to vancomycin." 3) "Gangrene is caused by anaerobic bacteria, which can only live in the absence of oxygen. We will débride the wound, begin antibiotics, and use a hyperbaric chamber to drive oxygen under high pressure into the wound." 4) "Gangrene's reputation as a fatal complication is overstated. We will treat with antibiotics just as we would treat any other infection. Depending on the scope of infection, we may apply a tourniquet to prevent toxins from the bacteria from spreading to the rest of the body."

Dehydrated, Edematous

A patient who is __ or __ from overhydration will have increased risk for skin breakdown.

4) Notify the physician.

A patient who is recovering from abdominal surgery vomits, and the nurse observes a sudden increase in serosanguineous drainage. The nurse should immediately perform which of the following actions? 1) Carefully replace any eviscerated organs in the abdominal cavity. 2) Help the patient transfer to a wheelchair so the patient can be quickly moved. 3) Order another member of the health-care staff to stay with the patient while the nurse assembles needed supplies. 4) Notify the physician.

4) serosanguineous, then serous.

A patient with a stasis ulcer has drainage that is pink at the beginning of the shift and red at the end of the shift. The nurse correctly documents this drainage in the patient's chart as 1) serous, then sanguineous. 2) serous, then serosanguineous. 3) serosanguineous, then sanguineous. 4) serosanguineous, then serous.

2) Increase in serosanguineous drainage

A patient's wound dehisces on the fifth postoperative day. The nurse is alerted to the dehiscence by which of the following signs? 1) Sudden and frank bleeding 2) Increase in serosanguineous drainage 3) Complaint of excruciating pain 4) Purplish and dark brown drainage

3) Granulation tissue can be seen at the base and edges of wound

A patient's wound is packed with wet-to-damp dressings. When changing the patient's dressing, the nurse determines that the wound is healing when 1) The drainage changes from serosanguineous to serous. 2) The area around the wound becomes bright red in color. 3) Granulation tissue can be seen at the base and edges of wound .4) The wound edges begin to show signs of healing.

Decubitus ulcer

A pressure ulcer, also known as a __

Open wound

A wound in which the skin integrity has been breached is

Pressure ulcer

A wound resulting from pressure and friction. The skin may be intact and erythemic (reddened), or the skin may be broken. If the skin is broken, the ulcer may be superficial or very deep.

Clean-contaminated

A wound that was surgically made, is not infected, but has direct contact with the normal flora in either the respiratory tract, urinary tract, or gastrointestinal tract. It has more potential to become infected.

Serosanguineous

Both blood and clear drainage are present. Combined, they turn dressing materials a pink color.

The Braden scale

The majority of pressure ulcers can be prevented with good nursing care, which starts with thorough assessment of the skin and pressure points. Many facilities use standardized scales of assessment, such as the __ scale

Staphylococcus aureus

The most common microbial pathogen associated with wound infections is __. This bacterium is present on the skin of all people, so it easily enters wounds unless special precautions are followed

Sacrum, Buttocks, Greater trochanters, Elbows, Heels, Ankles, Occiput

The most common sites for development of pressure ulcers are over bony prominences, such as the __,__,__,__,

Isotonic

The most commonly used irrigant is sterile normal saline because it is __ to the body.

1) report the name and dosage of any antibiotic the patient is on

The nurse calls the physician to report that a patient's surgical incision appears to be infected. The nurse should: 1) report the name and dosage of any antibiotic the patient is on 2) not report the patient's vital signs, because these data are not relevant. 3) report the finding, if present, that drainage from the wound is decreasing and erythema is present. 4) not report the patient's rating of any pain experienced, because this is subjective information.

3) A clean-contaminated wound is surgically created and has direct contact with normal flora, which increases the risk for becoming infected.

The nurse correctly explains to student nurses that a clean-contaminated wound is characterized by which of the following? 1) A clean-contaminated wound has colonized growth but has not shown signs of an infection. 2) A clean-contaminated wound is a wound that has been grossly contaminated by a break in asepsis. 3) A clean-contaminated wound is surgically created and has direct contact with normal flora, which increases the risk for becoming infected. 4) A clean-contaminated wound has a moderate amount of purulent drainage and necrotic tissue.

4) Impairment of collagen replacement

The nurse correctly identifies that healing can be delayed in the elderly patient because of 1) More rapid contraction of the skin 2) Deficiencies of vitamins A and C 3) The many medications an older patient takes 4) Impairment of collagen replacement

2, 3, 4, 5

The nurse correctly identifies which of the following patients as being at risk for pressure ulcers? Select all that apply. 1) An obese 53-year-old man comes to the clinic to attend a meeting of a weight-loss support group and reports that he recently got a dog that he has been walking twice a day. 2) An 82-year-old woman who walks with difficulty is brought to the clinic by her grandson for treatment for high blood pressure. 3) A 21-year-old man arrives at the clinic for follow-up care for injuries sustained during the accident that left him paraplegic. 4) A 28-year-old woman from Kenya brings her children to the clinic for vaccinations, and during therapeutic communication with the nurse, she mentions that she wears diapers due to an obstetric fistula, an opening between the vagina and bladder that can occur during traumatic childbirth. 5) A 45-year-old man with type 1 diabetes emails the clinic with a question regarding his recovery from a broken leg incurred while skiing.

2) 42-year-old following abdominal surgery with a history of diabetes mellitus

The nurse correctly understands that Montgomery straps will be utilized in which of the following patients? 1) 10-year-old who is 2 days postoperative following an emergency appendectomy 2) 42-year-old following abdominal surgery with a history of diabetes mellitus 3) 64-year-old who is 1 day postoperative with a history of myocardial infarction 4) 75-year-old who is 3 days postoperative following cholecystectomy but is otherwise healthy

All the above

The nurse explains to a female patient and her family that to prevent a pressure ulcer, it will be necessary to do which of following? SELECT ALL THAT APPLY. 1) Change her position every 2 hours. 2) Encourage good nutrition. 3) Have her sit up in a chair at least three times a day. 4) Keep her sheets free of wrinkles. 5) Place her on an egg-crate mattress.

Elderly, Emaciated or malnourished, Incontinent of bowel or bladder, Immobile, Impaired circulation or chronic metabolic conditions

Risk Factors for Pressure Ulcers

2) clean-contaminated.

The nurse would correctly document a surgical wound that penetrates the trachea and shows no sign of erythema, warmth, or edema as: 1) colonized. 2) clean-contaminated. 3) contaminated. 4) clean.

Burning or Tingling

The patient may complain of __ or __ at the site. Further damage and progression of the pressure ulcer can be prevented at this stage if appropriate measures are taken.

1) Gauze

The patient's pressure ulcer is being treating with wet-to-damp dressings to allow the wound to heal from the inside out. The nurse will correctly pack the wound with what type of dressing? 1) Gauze 2) Alginate 3) Hydrocolloid 4) Polyvinyl

2, 3, 4, 5

The physician has ordered irrigation of a wound, and performance of this task is delegated to the student nurse. Before beginning this patient care, the student nurse reviews the task with his supervisor. The student demonstrates understanding of the task by noting the following. Select all that apply. 1) Wounds are always irrigated with sterile normal saline because it is isotonic to the body. 2) The nurse should assess the amount, color, and consistency of debris removed and document these data in the patient's chart. 3) The equipment needed to deliver the correct amount of pressure is a 35-mL syringe with a 19-gauge Angiocath. 4) The purpose of irrigation is to remove debris from the wound without injuring fragile granulation tissue. 5) If the physician has ordered that a specimen of the wound drainage is to be tested, the specimen should be collected after irrigation.

Portion, not be removed

The ulcer cannot be staged until at least a __ of the wound bed is exposed to detect the depth of the ulcer. If eschar remains intact and stable, completely covering a site such as the heel, it should __

Nerve endings

This extra fluid in the interstitial space causes pressure on the __, resulting in pain or tenderness.

Immobile

This includes patients who are paralyzed or who have casts or splints, as well as those restricted to a bed or chair.

8, 35-mL syringe, 19-gauge

This is best accomplished by using mild pressure of __ pounds per square inch. To deliver the correct amount of pressure, you will use a __ with a __ Angiocath attached

Wound Dehiscence and Evisceration

This situation usually occurs suddenly; often the only warning is a pronounced increase in serosanguineous drainage from the wound

Infected

This wound is one in which the __ process is already established, as evidenced by high numbers of microorganisms and either purulent (containing pus) drainage or necrotic (dead) tissue. The classic signs of infection include erythema (redness), increased warmth, edema (swelling), pain, odor, and drainage.

Penetrating

This wound is similar to a puncture wound; the difference is that the offending object remains embedded in the tissue. The degree of damage depends on the size of the object and the tissues or organs affected by the penetration

Ischemia

Tissues and capillaries are compressed, resulting in reduced blood flow to the area, known as

Surgical incision

Unlike a __, it has jagged edges, often making closure of the wound more difficult and less aesthetically pleasing.

It can be black, brown, or tan.

What colors can an Unstageable pressure ulcer

Diabetes mellitus

What impairs healing and places the patient at risk for dehiscence or evisceration.

Sinus tract

What is a channel or tunnel that develops between two cavities or between an infected cavity and the surface of the skin, sometimes known as a fistula.

Contusion

What is a closed discolored wound caused by blunt trauma, better known as a bruise.

Eschar

What is a hard, dry, dead tissue that has a leathery appearance.

Serum-filled, Blood flow

Stage II This includes intact __ blisters and broken blisters that reveal a shallow, pink or red ulceration that can be either shiny or dry. Generally there is erythema surrounding the skin break. The erythematous area may feel warmer than the surrounding skin due to the increased __.

Edema

Stasis ulcers The resulting __ damages surrounding tissues and causes ulcers to develop. This chronic condition is very difficult to heal.

Valve, Blood clots

Stasis ulcers develop from chronic __ problems, ___, and other conditions that interrupt venous blood flow, such as chronic venous insufficiency.

Approximation

Surgical incisions, intentionally made with sharp instruments, are linear with more sharply defined edges than most wounds. The two edges of an incision should have good __, meaning they should be close together

Bony

Pressure Ulcers usually occurs when external pressure is exerted on soft tissues, especially over __ prominences for a prolonged period of time

Shearing force

Pressure ulcers also can develop as a direct result of friction or __, this Occurs when the patient's skin and another item, such as bed linens or the surface of a chair, move in opposite directions while they are being pressed together by the weight of the body

Stasis ulcers, Draining sinus tracts, and Surgical incisions.

Pressure ulcers are only one kind of wound found in hospitalized patients. Other wounds include _

Staged

Pressure ulcers are__, or classified, according to the extent and depth of damage for a total of six classifications. This staging scale is used solely for pressure ulcers

Sheepskin pads, Foam Eggcrate mattresses, Gel-filled pads and Mattresses, Air-filled mattresses and Overlays

Pressure-relieving devices include __,__,__ and beds that pump air through mattresses filled with tiny beads, known as air-fluidized beds.

Old

Purplish or dark drainage indicates __ drainage.

Erythemic

Reddened

Impaired circulation or chronic metabolic conditions

Chronic metabolic conditions such as diabetes result in impairment of circulation, which can increase the risk of ischemic tissue.

Sanguineous

Comes from the Latin word for "bloody" and means "containing blood." It refers to red, bloody drainage.

Serous

Comes from the Latin word for "serum," the clear liquid portion of the blood. It refers to clear to pale yellow drainage that looks like serum.

Purulent

Comes from the Latin word meaning "full of pus," and means "containing pus." It is thick yellow or green drainage and is a sign of infection.

Bilious

Comes from the word "bile," which is made by the body to help break down fats for digestion. It is a dark greenish color and is often present in wound drainage after gallbladder surgery.

1) A distended and firm abdomen

Concerned that the patient is developing complications after abdominal surgery, the nurse assesses for the cardinal sign of hemorrhage. The cardinal sign is 1) A distended and firm abdomen 2) Rapid, weak, and thready pulse 3) Pale mucous membranes 4) Cool, clammy skin

3) An open wound packed with moist gauze

During shift report, the nurse is told that one of the patients has a wound that is healing by third intention. The nurse will expect to see 1) A wound that has been sutured but is infected 2) Wound edges that are reddened but well approximated 3) An open wound packed with moist gauze 4) A wound that is erythematous and warm to the touch

1, 2, 3, 4

Following irrigation of a patient's wound, the nurse will need to document which of the following? SELECT ALL THAT APPLY. 1) The solution used for irrigation 2) The color of debris washed away 3) The amount of debris removed 4) The consistency of the debris 5) The length of time to irrigate

2) Applying sterile adhesive strips over the incision

Following the removal of the patient's abdominal sutures, a nurse will take precautions against the possibility of wound stretching or dehiscence by 1) Cautioning the client against getting the incision wet 2) Applying sterile adhesive strips over the incision 3) Measuring for and applying a Montgomery strap 4) Advising the patient not to lie on the stomach for 8 weeks

Hemorrhage

Frank bleeding (bright red blood) indicates __. which is not a sign of dehiscence.

1) Hemoglobin and serum protein levels

If a patient's high-protein, high-calorie diet is effective in aiding wound healing, the nurse will monitor the patient's laboratory data and find increases in 1) Hemoglobin and serum protein levels 2) Complete blood count (CBC), white blood cell (WBC), and calcium levels 3) Glucose and hemoglobin levels 4) Hematocrit and hemoglobin levels

8 hours

If the patient is restricted in mobility to any degree, assess the skin every __ at a minimum.

Irrigated and packed, Absorb

If the sinus tract opens onto the skin's surface, it usually has to be _ with strips of tiny gauzelike material to __ the drainage until the infection clears and the tract can be allowed to heal

Strict sterile

In the operating room, __ technique must be enforced. Surgical instruments, equipment, and personnel are all potential sources of infection.

Emaciated or malnourished

Is the state of being very lean or having very little muscle

Necrose

Ischemia deprives the involved tissues of adequate oxygen and nutrients, and, if this state persists, the cells will eventually __ (die)

Broken, Excoriated, or Blistered

Look for areas where the skin is __.__ or __.

Flaking or Peeling

Look for excessively dry skin as evidenced by __ or __.

Epidermis, Interstitial spaces

Although the skin is intact, there is injury to the tissues underneath the __, which may swell as blood leaks from broken blood vessels into the __

Vancomycin-intermediate Staphylococcus aureus

Although vancomycin is the current antibiotic of choice to treat MRSA, an even more resistant strain is now making an appearance. This strain, __ (VISA), is developing resistance even to vancomycin.

Laceration

An open wound made by the accidental cutting or tearing of tissue. Common sources include knives and pieces of glass and metal.

1) A 7-year-old with multiple food allergies who has a gunshot wound to the upper arm

As the nurse plans care for the following patients, she correctly recognizes that which patient is not at high risk for a delay in wound healing? 1) A 7-year-old with multiple food allergies who has a gunshot wound to the upper arm 2) A 42-year-old undergoing chemotherapy with an accidental knife wound to the right index finger 3) A 53-year-old recovering from hysterectomy who is on a restricted-calorie diet to lose weight 4) A 28-year-old involved in an industrial accident resulting in multiple lacerations to various parts of the body

Abrasion

An __ is a superficial open wound. they include scrapes, scratches, or rub-type wounds where the skin is broken, such as a carpet burn or a skinned knee. These wounds are generally superficial and heal well if they are kept clean

Montgomery straps

Applying __ will add extra support to the incision. (42-year-old following abdominal surgery with a history of diabetes mellitus)

Seropurulent

Both clear drainage and drainage with pus are present.

Purulent

Containing pus

Necrotic

Dead Tissue

Blood-filled blister

Deep Tissue Injury It may form a __ or a thin blister that overlies a dark wound bed. The blister may break and reveal a thin layer of eschar underneath

Healing process

If hemoglobin and serum protein levels are increasing, then the patient's diet is speeding the ____.

2 hours

If the patient is bedfast, assess the pressure points every __.

Remains embedded in the tissue

Penetrating Wounds the difference is that the offending object __

Edema

Swelling

Scant

One of the first things you will note is the amount of drainage on the old dressing, which is generally referred to as a __, small, moderate, or large amount.

Infection

One of the most common wound complications is an __

1) 53-year-old paraplegic

One of the nurse's four patients is more at risk for development of pressure ulcers than the other three. The patient the nurse is most concerned about is the 1) 53-year-old paraplegic 2) 26-year-old diabetic 3) 60-year-old with heart failure 4) 68-year-old with emphysema

dark burgundy, purple, or maroon color

A DTI may not include a blister at all. The area may simply turn a __, like a bruise. Any of these presentations represent injury to the underlying soft tissue

Thick and yellow or green

A Sinus tract that forms due to infection usually produces purulent drainage that is __

Hemovac, Jackson-Pratt

A __ and a __, also called J-P, both are active drains that operate on the suction principle

A stage I pressure ulcer

A __ pressure ulcer is indicated by erythema, generally over a bony prominence, that remains for at least 15 to 30 minutes after the pressure is relieved—and it will not blanch, or turn white, when you gently touch it with your fingertip. In a darker-skinned individual, the skin may appear darkened rather than red. The area may feel warm and firm, soft, or boggy.

A Stage II

A __ pressure ulcer occurs when there is a partial-thickness loss of dermis.

Puncture

A __ wound is an open wound that results when a sharp item, such as a needle, nail, or piece of wire, pierces the skin.

The Stage III pressure

This Pressure ulcer is a full-thickness loss involving damage to the epidermis, dermis, and subcutaneous tissue, but not involving muscle or bone. Undermining and tunneling may be seen in this stage. The depth of tissue loss is discernable even if slough is present. These wounds tend to be infected, may produce drainage, and take longer to heal than a stage I or II pressure ulcer because a great deal of granulation tissue must be produced to fill the wound and repair the damage.

Contusions, Abrasions, Puncture wounds, Penetrating wounds, Lacerations, or Pressure ulcers

In addition to being categorized as open or closed, wounds may be classified as __

2 to 3

In an individual with multiple risk factors for skin breakdown, it is possible for pressure ulcers to occur in __ to__ hours.

Irrigation

Nursing Responsibilities for Cleaning Wounds is the more gentle method of wound cleansing and is ordered when fragile granulation tissue is present.

8 hours, One-half to Two-thirds

Nursing Responsibilities for Drain Care Empty drains every _Hrs or when they become __to__ full

Penrose, 2 inches

Nursing Responsibilities for Drain Care If a __ drain is in use, change the dressings around the drain carefully to prevent dislodging the tube. The physician may order the drain to be shortened a specified length, for example, __

Must be emptied

Nursing Responsibilities for Drain Care If the bulb on the Jackson-Pratt drain or the round receptacle on the Hemovac drain is no longer compressed, the container is full and _.

Calibrated, Drainage

Nursing Responsibilities for Drain Care Measure drainage in a __ container and record the amount on the intake and output record. Note the type of __.

Purulent, Healing, Infection

Nursing Responsibilities for Drain Care Report a significant increase in the amount of drainage and the presence of __ drainage to the physician immediately because these could indicate impaired __ and __.

8 hours, Sutures and Staples

Nursing Responsibilities for Suture/Staple Care Assess incisions every __hours to detect changes that may occur. You also may be responsible for removing __and__ when the wound has healed

Loosening, Gaps, Redness

Nursing Responsibilities for Suture/Staple Care Note any sign of __ sutures, __ in the incision, or __ around the staples or sutures that indicates infection

Dressing change

Nursing Responsibilities for Suture/Staple Care Your responsibilities include assessment of the suture line each time you inspect an incision. This may be when you perform a __ or when you assess your patient at the beginning of your shift.

Contaminated

This can be a surgical wound or a wound caused by trauma that has been grossly contaminated by breaking asepsis.

Unstageable

These pressure ulcers also involve full-thickness tissue loss but are impossible to accurately stage due to the wound bed being completely obscured by eschar or excessive slough.