Wound care / Pressure Injuries

abdominal pads (ABD)

ABD dressings are used over other dressings to absorb excess drainage and should not be placed directly over a wound. This type of dressing can cause increased pain on removal when it is placed directly over an open wound

A nurse is caring for a client who has a heavy drainage from a moist red wound that is bleeding. Which of the following types of dressing should the nurse select to promote hemostasis?

Alginate Alginate dressings help establish hemostasis while providing a moist environment for healing and absorption of exudate. They do not adhere to the wound, so removal is unlikely to cause further

The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips?

Apply a skin protectant to the skin around the incision. Explanation: Before applying the wound closure strips, the nurse should apply a skin protectant to the skin surrounding the incision site. The skin barrier will help the closure strips adhere to the skin and helps prevent skin irritation and excoriation from tape, adhesives, and wound drainage. The skin protectant should not be placed on the incision itself. Nothing should be placed over the incision site itself before the closure strips are applied.

A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?

Apply oxygen at 2 L/min via nasal cannula Following an acute injury, the body responds best by increasing oxygen to improve perfusion, which is essential for healing. It is common to see a delay in the resolution of the inflammatory phase of chronic wounds in clients who have a lack of oxygen or poor perfusion

A nurse is caring for a client who has developed a stage 1 pressure injury in the area of the right ischial tuberosity. Which of the following should the nurse plan to apply to the client's pressure injury?

Barrier creams Barrier creams and ointments are used for clients that are prone to skin breakdown from pressure, shear, or incontinence. Therefore, the nurse should plan to apply barrier creams for a client who has a stage 1 pressure injury

A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development?

Braden scale Explanation: The Braden scale is an assessment tool used to assess the client's risk for pressure injury development. The Glasgow scale is used to assess a client's neurologic status quickly. This is typically used in emergency departments and critical care units. The FLACC scale is used to evaluate pain in clients. The Morse scale is used to assess the client's risk for falls.

A nurse is caring for a client who has multiple sclerosis and a chronic nonhealing wound. the nurse should recognize that which of the following types of medications is known to delay wound healing

Corticosteroids Corticosteroids suppress the immune system and can therefor delay wound healing

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?

Dehiscence of the wound Explanation: Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that "something has suddenly given way." If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the health care provider. Once dehiscence occurs, the wound is managed like any open wound. Manifestations of infection include redness, warmth, swelling, and heat. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents.

A nurse is obtaining a wound culture from a sacral pressure injury. After swabbing the area, the nurses determines that the wound was not cleaned. What is the priority action by the nurse?

Discard the swab, clean the wound with a nonantimicrobial cleanser, and obtain another swab Explanation: When the nurse has inserted the culture swab into the client's wound to obtain the specimen and realizes that the wound was not cleaned: Discard this swab. Obtain the additional supplies needed to clean the wound according to facility policy and a new culture swab. Cleaning the wound prior to obtaining a specimen for culture Cleaning the wound removes previous drainage and wound debris, which could introduce extraneous organisms into the collected specimen, resulting in inaccurate results. Clean the wound using a nonantimicrobial cleanser and then proceed to obtain the culture specimen.

A nurse is selecting dressings for a client who has a full-thickness pressure injury and is experiencing considerable pain during dressing changes, despite administration administration of the prescribed analgesic prior to wound care. Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes?

Hydrogel The nurse should select hydrogel for this client because hydrogel does not adhere to the wound bed and maintains moisture, which results in decreased pain

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action?

Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. Explanation: If sutures are crusted with dried blood or secretions, making them difficult to remove, the nurse should moisten sterile gauze with sterile saline and gently loosen crusts before removing the sutures; soap is not used for this purpose. Picking at the sutures could cause pain and bleeding. Crusting does not necessarily indicate inadequate wound healing.

A nurse is caring for a client who has stage 4 sacral pressure injury for which the provider has prescribed mechanical debridement. Which of the following is a form of mechanical debridement that the nurse should expect the client to receive?

Pulsating lavage Pulsating lavage or irrigations provides mechanical debridement by dislodging exudate, debris, and necrotic tissue in the wound bed

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?

Rotate the swab several times over the wound surface to obtain an adequate specimen. Explanation: The nurse should press and rotate the swab several times over the wound surface. The swab should be inserted into the culture tube at the bedside, immediately after collection. Saline or any other fluid is not added to the tube and anesthetics are not applied prior to collection.

nurse is documenting data about a healing wound on a clients lower leg. The predominant exudate is the wound is watery in consistency and light red in color. The nurse should document which of the following types of drainage?

Serosanguineous This exudate is serosanguineous, which is thin and watery in consistency and pink to light red in color

A nurse is documenting data about an deep necrotic wound on a clients left buttock. The nurse observes a yellowish tan, soft, stringy area of necrotic tissue formed in clumps and adhering firmly to the wound bed. Which of the following assessment findings should the nurse document?

Slough Slough is stringy necrotic tissue that appears whitish, yellowish, or tan in color and is firmly attached to the wound bed. The nurse should document this finding for the client

A nurse is teaching a pressure injury over clients right heel area. The pressure injury has no ask her or slow and exposed muscle or bone. The nurse should identify that this pressure injury is classified as which of the following?

Stage 3 The nurse should identify that this client has a stage 3 pressure injury indicated by full-thickness tissue loss appearing as a deep crater, without exposed muscle or bone. Stage 3 pressures can have slough, but it is not necessary

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples?

To splint the area when engaging in activity Explanation: To support the underlying tissues and decrease discomfort, the nurse should teach the client to splint the area when engaging in activities such as changing positions, coughing, or ambulating. Teaching the client to ambulate using a cane or walker may be necessary but is not done to support the underlying tissues or to decrease discomfort. It is done to ensure the client can use the ambulatory devices correctly. There is no indication that the client needs to stay in bed; in fact, ambulation should be encouraged. Teaching the client to turn the head away while coughing is done to aid in prevention of the infection

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces?

a client sitting in a chair who slides down Explanation: Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Clients who are pulled, rather than lifted, when being moved up in bed (or from bed to chair or stretcher) are at risk for injury from shearing forces. A client who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a client who sits in a chair but slides down. The client that is most likely to develop a pressure injury from shearing forces would be a client sitting in a chair who slides down.

stage 4

a stage 4 pressure injury has full-thickned tissue loss with destruction, tissue necrosis, and/or damage to muscle, bone, or supporting structures. There can be sinus tracts, deep pockets of infection, tunneling, undermining, and some eschar and slough

antifungal ointment

an antifungal agent is typically prescribed to treat rashes caused by fungus infections

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

an obese woman with a history of type 1 diabetes

Evisceration

complete separation of the wound, with protrusion of viscera through the incisional area.

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?

desiccation

dry gauze

dry gauze can disrupt angiogenesis, the development of the vascular bed in the wound, thereby causing further bleeding of the wound when removed. -gauze fibers can shed and adhere to the wound bed, causing painful removal

The nurse is performing an assessment of a client's full thickness pressure injury to the coccyx. The nurse observes that the wound bed is black and will consequently document what finding?

eschar

eschar

hard or soft necrotic tissue that is black, brown, or tan in color and is firmly attached to the wound bed.

hydrogel dressings

hydrogel dressings are used for clients who have a dry wound and minimal exudate

chemical debridement agent

is used to treat pressure injuries that have slough or eschar, or for infected wounds with poor wound edges

keloid

keloids are hypertrophic scar tissue resulting from excessive collagen formation following a wound injury

Maceration

localized wound overhydration or excessive moisture

A nurse is caring for a client with laceration wounds on the knee. The nurse notes that the client is in remodeling phase of wound repair. Which statement describes this phase of wound recovery?

period during which the wound undergoes changes and maturation

a suspected deep tissue injury

refers to the tissue that is discolored due to the underlying tissue damage, boggy, and warm to the tough. If the skin is intact, the injury appears as a blood-filled blister. If the skin is not intacted, the wound bed will appear very dark in color

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

The nurse in the long-term care facility observes that a client has developed a sacral pressure wound, which is very red and surrounded by blisters. Which stage of pressure injury does this client present?

stage 2

transparent film dressing

transparent film dressings are used for clients who have a stage 1 pressure injury with minimal drainage

unstageable

unstageable refers to the pressure injuries whose stage cannot be determined because eschar or slough obscures the wound.

antibiotic agent

used to treat infected wounds

necrosis

death of tissue in the wound

A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider as an indication of infection?

foul-smelling drainage that is grayish in color Explanation: Purulent drainage is frequently foul-smelling and may vary in color; such drainage is associated with infection and should be reported to the health care provider. Clear, watery (serous), blood-tinged (serosanguineous), and bloody (sanguineous) drainage are not commonly indicative of infection and may be seen in the drain during various stages of wound healing.