Chapter 14: Surgical Wound Care Part II
The health care provider has ordered the patient's wound be irrigated. What is the primary rationale for this procedure? 1.) To remove debris from the wound 2.) To decrease scar formation 3.) To improve circulation from the wound 4.) To decrease irritation from wound drainage
1
The nurse us preparing to remove the patient's staples, but after assessment, the nurse decides that the staple should not be removed. The decision was based on which finding? 1.) The wounds edges were partially separated 2.) Dried serous drainage was noted around the staple 3.) The patient was anxious about staple removal 4.) Early keloid formation was observed
1
The patient needs an abdominal binder. What is the most important consideration for the nurse when implementing this application? 1.) Respiratory function must not be restricted 2.) Vomiting and nausea are contraindication 3.) Binders cannot be used for patients who are obese 4.) Older patients have difficulty tolerating the binder
1
When providing care to a patient with a Hemovac drain, what actions are included in the plan of care? 1.) Record the appearance of the drainage in the nursing progress notes and include the amount in the intake and output calculations 2.) Clamp the tubing during patient ambulation and activity to prevent excess drainage during these times 3.) Empty the bulb drainage receptacle when it is one-fourth full 4.) Pin the bulb above the insertion site to assist in proper drainage of exudate
1
A patient has just returned from surgery. What is/are the initial assessment(s) that the nurse would make related to the surgical site? (Select all that apply) 1.) Inspect the protective dressing that was placed by the surgical team 2.) Look at the area around the dressing and record observations 3.) Check under the patient to make sure that exudate is not pooling 4.) Carefully remove the dressing and inspect the suture line for intactness 5.) Expect and note amount of serous drainage that is coming from the wound
1, 2, 3
What are the traditional purposes of a wet-to-dry dressings? (Select all that apply) 1.) Debridement 2.) Cooling 3.) Comfort 4.) Anti infection 5.) Maintenance of moisture at the wound bed
1, 5
A patient had surgery 4 days ago and now reports an increase in pain and has a temperature of 101.6 F (38.7 C). The incision site looks red compared to yesterday and a small amount of purulent drainage is seeping around the suture line. Which laboratory result will the nurse check before contacting the health care provider? 1.) Hemoglobin and hematocrit 2.) White blood cell count 3.) Platelet count 4.) Blood glucose level
2
During assessment of a patient after abdominal surgery, the nurse suspects internal hemorrhaging based on which finding? 1.) The dressing is saturated with bright red sanguineous drainage, and the patient has an increased urinary out put. 2.) The dressing us dry and intact, and the patient's blood pressure has decreased and pulse and respiration have increased 3.) The dressing is saturated with serosanguineous drainage, and the patient is diaphoretic with a decrease in pulse and respiration 4.) The dressing is dry and intact, and the patient reports shortness of breath and has an elevated temperature
2
The nurse is assessing the amount of drainage that the patient has from a surgical wound and finds that 650 mL has drained from 0900 to 1140. What should the nurse do first? 1.) Record the amount and appearance of the drainage and continue to observe 2.) Take the patient's vital signs, assess for other symptoms, and inform the provider 3.) Make sure that the patient's linens are clean and dry empty the drainage receptacle 4.) Apply a pressure dressing and place the patient in a supine position
2
The nurse is caring for a patient who has a large abdominal incision. The patient tells the nurse that she is afraid to sit up or even move because of the pain and the strain on the incision site. What instructions should the nurse give to the patient? 1.) Rest in bed util the incision sites is less tender and healing has progressed 2.) Roll to one side, use your elbow as a lever, and push to a sitting position 3.) Hold a pillow next to your abdomen and roll forward into a sitting position 4.) Call for assistance whenever needed and someone will help you sit up
2
The nurse is observing a new staff member perform a sterile dressing change. The nurse would intervene if the staff member performed which action? 1.) Loosens tap and gently pulls toward the incision 2.) Use sterile gloves to remove the old dressing 3.) Cleanses wound by starting at incision moving outward 4.) Allows anti septic cleansing solution to airdry
2
The patient has a T-tube in place following abdominal cholecystectomy . What is the exudate output of bile in the first 24 hours? 1.) 30 mL per hour 2.) 250-500 mL 3.) 10-50 mL 4.) 1-2 L
2
Which patient is more at risk for wound dehiscence? 1.) The patient who smokes 2.) The obese patient 3.) The patient with a history of peripheral vascular disease 4.) The patient who is immunocompromised
2
Which patient is most likely to benefit from the application of a triangular binder? 1.) Has a chronic pressure ulcer on the sacral area 2.) Has a possible fracture in forearm 3.) Has venous stasis ulcer on left ankle 4.) Has a surgical wound on the lateral chest area
2
The student nurse is changing a patient's dressing. What actions indicate the need for further education (Select all that apply). 1.) Enclose the soiled dressing within a latex glove. 2.) Clean the wound in circles toward the incision 3.) Free the tape by pulling it away from the incision 4.) Remove the soiled dressing with sterile gloves 5.) Apply the clean dressing with clean gloves
2, 3, 4, 5
What are the time frame and the characteristics of the reconstruction phase:
2-3 weeks, fibroblasts are present, collagen, formation begins, wound strength begins to increase
What is the time frame and the characteristics of the inflammatory phase?
24-48 hours, blood elements leak into the tissues, leukocytes appear
A nurse is supervising a nursing student who is doing a wet to dry dressing change. What does the nurse do when the student applies a dry dressing over the wet gauze? 1.) Directs the student to moisten all of the layers 2.) Hands the student to moisten all of the layers 3.) Tells the patient that the student is doing a great job 4.) Suggests removal of all layers and starting over
3
The health care provider has ordered an abdominal binder placed around a surgical patient with a new abdominal wound. What is the likely indication for this intervention? 1.) Collection of wound drainage 2.) Reduction of abdominal swelling 3.) Reduction of stress on the abdominal incision 4.) Stimulation of peristalsis from direct pressure
3
The nurse is applying a dressing over the insertion site of peripheral intravenous catheter. Which dressing is the best choice? 1.) Sterile tape with dry gauze 2.) Moistened gauze with paper tape 3.) Transparent dressing 4.) Sterile pad with chevron taping
3
The patient returned to the unit 3 hours ago after having surgery on the abdomen, and the dressing is now saturated with red, watery drainage. What should the nurse do first? 1.) Notify the charge nurse and the health care provider 2.) Take the patient's vital signs and assess for pain 3.) Securely reinforce the dressing with layers of gauze 4.) Remove the dressing and observe the wound site
3
What is the best indicator that a wound has become infected? 1.) Palpation of the wound reveals excess fluid under its edges 2.) Wound cultures are positive 3.) Purulent drainage is coming from the wound area 4.) The wound has a distinct
3
What is the first step when packing a wound? 1.) Assess its size, shape, and depth 2.) Prepare a sterile field 3.) Select gauze packing material 4.) Irrigate the wound
3
When emptying the drainage in a Hemovac reservoir, which nursing action is essential for reestablishing the negative pressure within this drainage device? 1.) Fill the reservoir with sterile normal saline solution 2.) Secure the reservoir to the skin near the wound 3.) Compress the reservoir and close the vent 4.) Open the vent, allowing the reservoir to fill with air.
3
Which lunch tray is best for providing protein, vitamin A and C, zinc, the nutrients required for wound healing? 1.) A peanut butter sandwich with a glass of milk 2.) A bowl of bean soup with crackers and iced tea 3.) Broiled seafood with spinach salad and tomato juice 4.) Stir-fried mixed vegetables with rice and hot tea
3
Which phrase best describes serous drainage? 1.) Fresh bleeding 2.) Thick and yellow 3.) Clear, watery plasma 4.) Beige to brown and foul smelling
3
Which wound drain is classified as providing gravity-assisted drainage? 1.) Jackson-Pratt 2.) Hemovac 3.) Penrose 4.) Wound VAC System
3
What equipment is needed for irrigation at the patient's bedside
35-mL syringe 19-gauge catheter sterile solution
After a total abdominal hysterectomy, a postoperative patient develops a wound evisceration. What should the nurse do first? 1.) Check patency of the intravenous (IV) site for delivery of fluids 2.) Place the patient in a supine position to reduce strain on the wound 3.) Prepare the patient for surgery and contact the health care provider 4.) Cover the wound with a sterile dressing moistened with a saline
4
The health care provider has ordered all sutures on a patient with an abdominal hysterectomy be removed on the 5th postoperative day and Steri-Strips applied. During suture removal, the nurse notices the incision edges are slightly separated. What is the best action by the nurse?
4
The nurse is preparing to change the patient's dry sterile dressing. Upon attempting the removal of the old dressing, it adheres to the site. What should the nurse do? 1.) Notify the health care provider 2.) Leave the dressing in place 3.) Pull the dressing off quickly 4.) Moisten the dressing with saline
4
The patient has just returned from the postanestheia care (PAC) unit. During report, the nurse is told that the patient has a Penrose drain in the left lower quadrant (LLQ). The patient asks why the drain is being used. What response by the nurse is most accurate? 1.) The drain allows for the postoperative instillation of wound irrigation fluid 2.) The drain is used to reduce infection in the postoperative period 3.) Penrose drains are used to drain body fluids from the area surrounding the wound by suction 4.) Gravity is used to drain fluid from the area around the wound with Penrose drain.
4
The patient has no contraindications for fluid intake; over a 24 hour period, he drank 16 oz of decaffeinated coffee, 10 oz of juice, 6 oz of milk and half a liter of soda. What instructions does the nurse give the patient to promote wound healing? 1.) Instructs the patient to continue drinking the same amount as he drank today 2.)Tells the patient that tomorrow he should try to drink twice as much as today 3.) Advises the patient that drinking excessive fluid is likely to decrease appetite for food 4.) Suggests that he drinks 2-3 additional 8 oz servings of his favorite fluid everyday
4
What actions can be implemented to reduce surgical wound infection? 1.) Adhering to the principles of hand hygiene 2.) Cleansing the incision from the least contaminated to the most contaminated area 3.) Leaving the incision open to the air 4.) Changing the dressing using sterile technique
4
What is the correct procedure for the wet-to-dry dressing method? 1.) Place dry gauze into the wound and remove it when it is wet 2.) Medicate the patient for patient for pain after you change the dressing 3.) Complete this type of dressing change just once a day 4.) Place moist gauze into the wound and remove it when it is dry
4
Which nursing entry is the most complete in its description of a wound? 1.) Wound appears to be healing well, dressing dray and intact 2.) Wound well approximately with minimal drainage 3.) Drainage size of quarter; wound pink; 4 X 4 applied 4.) Incision edges approximated without erythema or exudate
4
Which nursing intervention is most appropriate should the patient's abdominal wound eviscerate? 1.) Place the patient in high Fowler's position 2.) Give the patient fluids to prevent shock 3.) Replace dressings with sterile fluffy pads 4.) Apply warm, moist sterile dressings
4
Which statement is correct in regard to the use of an abdominal binder? 1.) It replaces the need to underlying dressings 2.) It should be kept loose for patient comfort 3.) The patient has to be sitting or standing when it is applied 4.) The patient must have adequate ventilatory capacity
4
What is the purpose of the transparent dressing?
Able to visualize wound, contains exudate, and decrease wound contamination
Cavity containing pus and surrounded by inflamed tissue
Abscess
Cavity containing pus and surrounding by inflamed tissue
Abscess
Band of scar tissue that binds together two anatomical surfaces that are normally separated
Adhesion
What are the time frame and the characteristics of the maturation phase?
After 3 weeks, fibroblasts exit, wound becomes stronger
What factors may impair wound healing?
Age Malnutrition Smoking Drugs Diabetes Mellitus
How is care determined for an open wound?
By the extent of the wound
Infection of the skin characterized by heat, pain, erythema, and edema
Cellulitis
What type of bandage turns should you use on the finger or wrist?
Circular
A drainage system requires close monitoring. In addition to noting:
Color Consistency Amount of Drainage Checking the tube patency is important
Separation of a surgical wound incision or rupture of a wound closure
Dehiscence
What is the direction of cleansing?
Direction of cleansing is from least to most contaminated
Protrusion of an internal organ through a wound or surgical incision
Evisceration
Passage or escape into the tissues; usually of blood, serum, or lymph
Extravasation
What type of bandage turns should you use for the joints?
Figure 8
Remove dressings ____ to prevent further injury to the wound. Dispose of used dressings appropriately to prevent cross contamination
Gently
Collection of extravasated blood trapped in the tissues, resulting from incomplete hemostasis after surgery or injury
Hematoma
What are the main complications of wound healing?
Hemorrhage Infection Dehiscence Evisceration
Describe tertiary intention wound healing
Infected wound left open, delayed suturing
The wet-to-dry dressing can be used to:
Mechanically debride a wound of necrotic tissue or wound exudate
Do not _____ the wet-to-dry dressing before moving it because this defeats the goal of debriding the wound
Moisten
What is the purpose of dry dressing?
Non draining wounds, protects wound from injury, prevents from bacteria, reduces discomfort, speeds healing
What are the two categories of wounds?
Open or Closed
What type of bandage turns should you use for the scalp?
Recurrent
What findings should immediately report to the health care provider?
Report fresh bleeding Sharp increase in pain Retention of irrigant Signs of Shock
What is included in proper wound assessment?
Size Description of appearance Amount and type of exudate Presence of Drains Integrity of wound closures Pain level
What type of bandage turns should you use on the calf or thigh?
Spiral reverse
Describe primary intention wound healing
Surgical wound, clean edges
How is the syringe positioned for the irrigation?
Syringe is held 1 inch above the wound for irrigation
What is the purpose of the gauze dressing?
To permit air to reach wound
What is the purpose of the semiocclusive dressing?
To permit oxygen to reach wound, but not the impurities in the air
What is the purpose of the occlusive dressing?
To prevent air or oxygen from reaching the wound to keep from the wound moist and promote healing
Wound drains remove secretions within tissue layers to promote:
Wound closure
Describe second intention wound healing
Wound edges not close together, may have purulent drainage
What is the purpose of wound irrigation
Wound irrigation is used to clean the wound and remove debris and eschar