NU 311: Exam 2

The student nurse is changing a dressing and is preparing to cleanse the intact suture line. The proper technique for cleaning an intact suture line includes:

cleaning the wound from an area of least contamination to an area of most contamination.

Steps to prepare and maintain a sterile field

maintain an area that is free from pathogenic organisms, serve to isolate an operative area from the unsterile environment,

serosanguineous drainage

mixture of serum and red blood cells

wound evisceration

protrusion of internal organs and tissues through incision

Nursing Process

(ADPIE) Assessment Diagnosis Planning Implementation Evaluation

Principles of sterile technique (surgical asepsis)

1. All items used within a sterile field must be sterile. 2. A sterile barrier that has been permeated by punctures, tears, or moisture must be considered contaminated. 3. Once a sterile package is opened, a 2.5-cm (1-inch) border around the edges is considered unsterile. 4. Tables draped as part of a sterile field are considered sterile only at table level. 5. If there is any question or doubt about the sterility of an item, the item is considered to be unsterile. 6. Sterile people or items contact only sterile areas; unsterile people or items contact only unsterile areas. 7. Movement around and in the sterile field must not compromise or contaminate the field. 8. A sterile object or field out of the range of vision or an object held below a person's waist is contaminated. 9. A sterile object or field becomes contaminated by prolonged exposure to air; stay organized and complete any procedure as soon as possible.

What are the parts of a nursing diagnosis?

1. Diagnostic Label (What is the problem; potential or actual?) 2. Etiology (What is the probable cause?) (Related to) 3.Defining Characteristics (What evidence leads you to 1 & 2?) (As evidenced by)

necrosis

Black or brown tissue is eschar, which represents full-thickness tissue destruction. Black is used to describe necrotic tissue or desiccated tissue such as tendon. It is also related to gangrenous lesions secondary to peripheral vascular disease. If the goal for a wound covered with eschar is debridement, sharp debridement is used to quickly remove the tissue, chemical debridement is used to soften the tissue for removal, or a moist dressing is also considered to loosen the tissue. The method of debridement depends on the overall goal for the patient.

provision 4 of the ANA Code of Ethics

The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care."

provision 1 of the ANA Code of Ethics

The nurse has compassion and respect for the inherent dignity, worth, and unique attributes of every person."

Which intervention is most beneficial in preventing pressure injury in the immobile client?

Reposition the client every 1-2 hours

A sterile dressing with no absorbent capacity that is impermeable to fluids and bacteria and is used as prophylaxis for high-risk intact skin (high risk friction areas), superficial wounds with minimal or no exudate best describes:

Transparent film

Use of the Electronic Health Record

Sign on to the electronic health record (EHR) using only your password. • Never share passwords and keep your password private. • Only open EHRs for patients for whom you are caring. • Review assessment data, problems identified (nursing diagnoses), goals and expected outcomes, and interventions and patient responses during contact with each patient before data entry. • Follow procedures for entering information in all appropriate program functions. • Review previously documented entries with those that you enter, noting if there is significant change in patient's status. Report changes to patient's health care provider. • The copy-and-paste features in EHRs should be used sparingly because of the potential for error. • Do not leave information about a patient displayed on a monitor where others can see it. Keep a log that accounts for every copy of a computerized file that you have generated from the system. • Follow agency confidentiality procedures for documenting sensitive material such as diagnosis of human immunodeficiency virus (HIV) infection. • Know and implement agency protocol to correct documentation errors. • Never create, change, or delete records unless your agency provides you with this authority. • Software systems have a system for backup files. If you inadvertently delete part of the permanent record, follow agency policy. It is necessary to type an explanation into the computer file with the date, time, and your initials and submit an explanation in writing to your manager. • Save information as documentation is completed. • Protect printouts from computerized records. Shredding printouts and logging in the number of copies generated by each caregiver minimize duplicate records and protect the confidentiality of patient information. • Workarounds can occur when EHRs are poorly designed; health care providers may fall back on paper charting. Medication errors may increase when nurses are working in a hybrid system. This system uses two formats—a paper and an electronic medical record for the same patient

Which statement/s is/are TRUE regarding wound irrigations? (Select all that apply)

Wound irrigations are useful for decreasing bacterial counts. Protective equipment such as a gown and eye wear should be used by the nurse.

Secondary intention

Wounds that are left open and allowed to heal by scar formation. There is tissue loss and open wound edges. Granulation tissue gradually fills in the area of the defect. This process is typical of severe laceration or massive surgical intervention with skin loss. there is a gap between the edges. Connective tissue develops, which supports new capillaries. This form of healing results in the formation of scar tissue to close the wound. The slowness of this process places a patient at greater risk for infection because there is no epidermal barrier until later in the healing process.

slough

Yellow tissue represents nonviable tissue and in some cases the presence of an infection. Slough tissue can be yellow; cream colored; or gray slough, which is usually accompanied by purulent drainage. For patients with a low infection risk, the use of moisture-retentive dressings enhances debridement of the yellow/slough tissue. Moisture-retentive dressings may include moist dressings, hydrocolloids, hydrogels, or alginates. If the wound is infected, topical antimicrobials are used.

pressure ulcer dark pigmentations

Patients with darkly pigmented skin cannot be assessed for pressure injury risk by examining only skin color. Changes in sensation, temperature, or tissue consistency may precede visual skin changes (WOCN, 2016). 1. Use natural lighting, but note that visual inspection techniques to identify pressure injuries are ineffective in darkly pigmented skin. Skin inspection techniques for individuals with darkly pigmented skin must include assessment of temperature, edema, and changes in tissue consistency as compared with the surrounding skin (WOCN, 2016). 2. Assess localized skin color changes. Any of the following may appear: • Color remains unchanged when pressure is applied. • Color changes occur at site of pressure, which differ from patient's usual skin color. • If patient previously had a pressure injury, that area of skin may be lighter than original color. • Localized area of skin may be purple/blue or violet instead of red. Purple or maroon discoloration may indicate deep tissue injury (WOCN, 2016). 3. Circumscribed area of intact skin may be warm to touch. As tissue changes color, intact skin will feel cool to touch. NOTE: Gloves may decrease sensitivity to changes in skin temperature. • Localized heat (inflammation) is detected by making comparisons to surrounding skin. Localized area of warmth eventually will be replaced by area of coolness, which is a sign of tissue devitalization. 4. Edema may occur with induration of more than 15 mm in diameter and may appear taut and shiny. 5. Palpate tissue consistency in surrounding tissues to identify any changes in tissue consistency between area of injury and normal tissue. 6. Patient complains of discomfort at a site that is predisposed to pressure injury development (e.g., bony prominence, under medical devices). redness in a dark-skinned patient is difficult to determine without the use of palpation and a comparison to other, nonaffected body parts

The RN is documenting on the electronic health record (EHR) at the client bedside. Which action/s by the RN requires intervention by the nurse manager? (Select all that apply)

The RN gives the personal password to the charge nurse and asks the charge nurse to complete documentation since he/she is taking care of a dying client. The RN leaves the computer monitor on in the ICU since valuable time is lost when logging in. The RN deletes the nurse's notes from the previous day since errors in spelling were noted. The RN re-wrote the notes today with correct spelling.

cleaning a draniage site

Clean around the drain using a circular strokes starting near the drain and moving outward and away from insertion site.

Select the most appropriate statement to be included in the electronic health record (EHR):

Client states, "I am dreading my surgery tomorrow because the last time I had surgery I got an infection in my wound." Client crying.

Part II Etiology or Contributing Factors

Connected to the Diagnostic Label by "Related to" or "R/T" nIt is best when nurses are able to do something about the etiology nWhat is causing the problem?

When repositioning an immobile client, the student nurse notices a deep red-maroon color over a bony prominence. When the area is further assessed, it does not blanch indicating:

Deep tissue injury

Which statement/s are true? (Select all that apply)

Fingernails of health care workers should be kept no longer than 1/4 inch in length. Health care workers having direct contact with clients should not wear artificial nails. Long nails increase the number of bacteria residing on the hands.

The RN is performing a pressure injury risk assessment using the Braden Scale. The Braden Scale predicts client risk for pressure injury by evaluating:

Friction and Shear, Nutrition, Mobility, Activity, Moisture, and Sensory Perception.

stage 3 pressure ulcer

Full-thickness loss of skin, in which adipose (fat) is visible in the injury and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury.

stage 4 pressure ulcer

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the injury. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an unstageable pressure injur

A surgical wound is expected to drain approximately 500 mL or more/24 hours. Which type of treatment does the RN anticipate?

Hemovac

Which statement made by the student nurse regarding moist-to-dry dressings will make Dr. Lynch happy?

I know that the purpose of moist-to-dry dressings is to mechanically debride the wound."

risk diagnosis

1. NANDA Diagnostic Label: n Risk for deficient fluid volume 2. Evidenced by risk factors of -increased intestinal losses (vomiting and diarrhea) and decreased fluid intake ex.) -Risk for deficient fluid volume as evidenced by risk factors of increased intestinal losses (vomiting and diarrhea) and decreased fluid intake

deep tissue injury

Intact or nonintact skin with localized area of persistent nonblanchable deep red, maroon, or purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full-thickness pressure injury (unstageable, stage 3 or 4). Do not use deep tissue pressure injury (DTPI) to describe vascular, traumatic, neuropathic, or dermatological conditions.

Stage 1 pressure ulcer

Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

The nurse assesses a Stage I pressure injury as:

Intact skin with nonblanchable redness.

The RN finds the post cardiac catheterization client with a large amount of bright red blood soaking the femoral dressing. What is the priority action of the nurse?

Look underneath the dressing and then apply pressure to the bleeding site.

Steps required to apply sterile gloves

a. Perform thorough hand hygiene. Place glove package near work area. b. Remove outer glove package wrapper by carefully separating and peeling apart sides. c. Grasp inner package and lay on clean, dry, flat surface at waist level. Open package, keeping gloves on inside surface of wrapper. d. Identify right and left glove. Each glove has a cuff approximately 5 cm (2 inches) wide. Glove dominant hand first. e. With thumb and first two fingers of nondominant hand, grasp glove for dominant hand by touching only inside surface of cuff. f. Carefully pull glove over dominant hand, leaving a cuff and being sure that cuff does not roll up wrist. Be sure that thumb and fingers are in proper spaces. g. With gloved dominant hand, slip fingers underneath cuff of second glove. h. Carefully pull second glove over fingers of nondominant hand. After second glove is on, interlock hands together and hold away from body above waist level until beginning procedure.

Pressure injuries occur: (Select all that apply)

because of tissue ischemia. from poorly positioned medical devices. on any area of skin subjected to pressure.

sanguineous drainage

bright red bloody drainage

How to pour a sterile solution into a container on a sterile field

a. Verify contents and expiration date of solution. b. Place receptacle for solution near table/work surface edge. Sterile kits have cups or plastic molded sections into which fluids can be poured. c. Remove sterile seal and cap from bottle in upward motion. d. With solution bottle held away from field and bottle lip 2.5 to 5 cm (1 to 2 inches) above inside of sterile receiving container, slowly pour needed amount of solution into container. Hold bottle with label facing palm of hand.

Wound irrigation PPE

clean gloves, gown, and goggles if splash/spray risk exists • Waterproof underpad if needed • Dressing supplies

Wound irrigation

cleans open surgical or chronic wounds such as pressure injuries. Typically the irrigation of an open wound involves the use of clean gloves. Review the health care provider's order to determine if a sterile solution is required. Sterile solutions may be necessary with new traumatic wounds. Irrigation involves introducing the cleaning solution directly into the wound with a syringe, syringe and catheter, pulsed lavage device, or a handheld shower. A proper wound cleaning solution is one that does not harm the tissue and uses an adequate force to agitate and wash away surface debris and devitalized tissue that contain bacteria Irrigant/cleaning solution (volume 1.5 to 2 times the estimated wound volume) • Irrigation delivery system (per order), depending on amount of pressure desired: • 35-mL syringe with a 19-gauge angiocatheter to facilitate optimum pressure for cleaning with minimal risk for tissue injury

serous drainage

clear, watery plasma

The postoperative client with a closed abdominal wound reports a sudden "pop" after coughing. The student nurse examines the surgical site and sees separation of the wound layers and internal organs protruding through the wound. The priority nursing action is to:

cover the wound with a moist sterile saline dressing, notify the surgeon immediately, prepare for emergent surgery.

When would the RN consider obtaining a wound culture?

if indicated by the presence of inflammation around the wound, purulent odor or drainage, new drainage, or a febrile patient.

Other risk factors that can contribute to the development of pressure injuries

include immobility, loss of sensory perception, decrease in activity, and malnutrition. • Immobility often restricts a patient's ability to change and control body position, thus increasing the pressure over bony prominences. • Loss of sensory perception decreases the individual's ability to respond to increased, prolonged pressure in an area of the body and change positions accordingly. • Level of activity refers to the person's normal physical movement. A person who is bed bound is at greater risk for skin breakdown than a person who is fully or partially mobile. • Research indicates that malnutrition contributes to the development of pressure injuries

tertiary intention

is sometimes called delayed primary intention or closure. It occurs when surgical wounds are not closed immediately but left open for 3 to 5 days to allow edema or infection to diminish. Then the wound edges are sutured or stapled closed

Hemovac or ConstaVac drainage system

is used for larger amounts of drainage (500 mL/24 h). The collection device is connected to a clear plastic drain with multiple perforations. Drainage collects in a closed reservoir or a suction bladder. The closed system collects fluid but operates only if the tubing is patent and a vacuum exists. If drainage device is half full, empty the chamber and measure the drainage. After measurement reestablish the vacuum and ensure that all drainage tubes are patent.

Scant drainage

minimal

primary intention

occurs when the edges of a clean surgical incision remain close together. The wound heals quickly, and tissue loss is minimal or absent. The skin cells regenerate quickly, and capillary walls stretch across under the suture line to form a smooth surface as they join.

Serosanguineous drainage from a wound may be described as:

pale red, watery drainage

Effects of warm therapy

decreasing joint stiffness; reducing pain; relieving muscle spasms; reducing inflammation, edema, and aids in the post acute phase of healing; and increasing blood flow.

copious drainage

drainage not contained by dressing; drainage obvious upon dressing removal and throughout treatment needing intervention

Moderate drainage

drainage visible on the dressing side next to the wound and on the other side; some visible in the wound bed; new drainage expressed during treatment

wound dehiscence

separation of the layers of a surgical wound; may be partial, or superficial only, or complete, with disruption of all layers

closed drainage system

such as the Jackson-Pratt (JP) drain or Hemovac drain relies on the presence of a vacuum to withdraw accumulated drainage from around the wound bed into the collection device. A JP drain collects fluid that is in the range of 100 to 200 mL/24 h

purulent drainage

thick green, yellow, or brown drainage

How to clean a wound

use a swab to clean in a circular motion around the would cleaning to the outside, use water, normal saline or cytotoxic wound cleanser, using a cold solution lowers wound temp which slows healing

objective data

what the health professional observes or measurement by inspecting, palpating, percussing, and auscultating during the physical examination

The client has an order for the application of an elastic bandage for compression. Which action by the nurse indicates proper understanding of the procedure?

wrapping the bandage from distal point to proximal point.

Part III Defining Characteristics

ØDefining Characteristics help to select the appropriate diagnosis ØDefining characteristics reflect causative or contributing factors ØSigns and symptoms (you will see on your data base highlighted in yellow)

Diagnostic label

ØSelf Care deficit ØDecreased cardiac output ØDeficient fluid volume ØIneffective Health Management ØHypothermia

The RN is caring for a client recovering from major abdominal surgery 2 days ago. The RN realizes factors affecting surgical wound healing include: (Select all that apply)

Nutritional status Wound infection Diabetes Advanced age Corticosteroid therapy

Patient reports sensation that "something has given way under the dressing."

Observe wound for increased drainage or dehiscence (partial or total separation of wound layers) or evisceration (total separation of wound layers and protrusion of viscera through wound opening). • If dehiscence or evisceration occurs, protect wound. Cover with sterile moist dressing. • Instruct patient to lie still. • Stay with patient to monitor vital signs. • Notify health care provider.

Dr. Swanzy is at the bedside with a clinical student preparing to perform a sterile procedure. The student makes an A in clinical for the day when he/she:

Opens the outermost flap of the sterile field away from the body, keeping arm outstretched and avoiding crossing the sterile field.

PRICE principle

• P—Protect from further injury • R—Restrict/Rest activity • I—Apply Ice • C—Apply Compression • E—Elevate injured area limit the amount of swelling

Safety Guidelines

• Quality documentation and reporting must have the following characteristics: it must be factual, accurate, complete, current, and organized. • Factual data contain descriptive, objective information about what a nurse sees, hears, feels, and smells. The only subjective data included in a record are what the patient actually verbalizes. Write subjective information with quotation marks, using the patient's exact words whenever possible. For example, record, "Patients states, 'My stomach hurts.' " • The use of exact measurements in documentation establishes accuracy. For example, charting that an abdominal wound is "5 cm (2 inches) in length without redness, edema, or drainage" is more descriptive than "large wound healing well." It is essential to avoid unnecessary words and irrelevant details. For example, the fact that a patient is watching television is only necessary when this activity is significant to the patient's status and plan of care. • The information within a recorded entry or a report must be complete, containing appropriate and essential information. Criteria for reporting and recoding information for health problems or nursing activities exist.

Adverse Event Reporting

An adverse event is any event not consistent with the routine operation of a health care unit or routine care of a patient. Examples include patient falls, needlestick injuries, medication errors, or a visitor becoming ill. The National Quality Forum (2015) identified a standardized list of preventable, serious adverse events that facilitate reporting of such events. Completion of an occurrence report happens when there is actual or potential patient injury (near miss) that is not part of the patient record. Document in the patient's record an objective description of what you observed and follow-up actions taken without reference to the incident report/occurrence report. Reporting helps to identify high-risk trends in nursing care or daily unit operations that warrant correction. You complete the report even if an injury does not occur or is not apparent. The information from the reports helps nursing staff find solutions to prevent repeated incidents. The reports are an important part of the quality improvement program of a unit. Adverse event reports are important sources of data for enhancing understanding of underlying causes of events that, when analyzed, can improve patient safety. Nurses are active participants in examining the cause of errors and redesigning systems to minimize the same type of errors in the future. By focusing on systems rather than individual failures, there is greater opportunity to improve patient safety. For example, a patient is administered the wrong medication by a nurse. A review of the event focuses primarily on the medication process as opposed to blaming the nurse for the error. Delegation and Collaboration The skill of adverse event reporting cannot be delegated to nursing assistive personnel (NAP). The nurse instructs the NAP to: • Report to the nurse any event such as a fall, incorrect treatment, or adverse reaction. • Report to the nurse any pertinent information about the event so a report can be completed

effects of cold therapy

Cold therapy treats localized inflammatory responses that lead to edema, hemorrhage, muscle spasm, or pain. Improvement to joint mobility following cold therapy is related to facilitating, relieving pain, inhibiting muscle spasm, and reducing muscle tension. physiological effect on the body, reducing inflammation caused by injuries to soft tissue and the musculoskeletal system

unstageable pressure ulcer

Obscured Full-Thickness Skin and Tissue Loss: full-thickness skin and tissue loss in which the extent of tissue damage within the injury cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.

The RN is caring for a client with a transparent film dressing (Tegaderm) over a wound that is showing a large amount of drainage. How should the nurse proceed?

Recommend another type of dressing for the wound.

stage 2 pressure ulcer

Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist and may also present as an intact or ruptured serum-filled blister. Adipose (fat) and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD), including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive-related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).

how to remove staples

Sutures and staples generally are removed within 7 to 14 days after surgery if healing is adequate. Retention sutures usually remain in place 14 to 21 days. a.) Place lower tips of staple extractor under first staple. As you close handles, upper tip of extractor depresses center of staple, causing both ends of staple to be bent upward and simultaneously exit their insertion sites in dermal layer b.) As soon as both ends of staple are visible, move it away from skin surface (see illustration) and continue until staple is over refuse bag. c.)Release handles of staple extractor, allowing staple to drop into refuse bag. d.) Repeat Steps a through d until all staples are removed. a. Place gauze few inches from suture line. Hold scissors in dominant hand and forceps (clamp) in nondominant hand. b. Grasp knot of suture with forceps and gently pull up knot while slipping tip of scissors under suture near skin Snip suture as close to skin as possible at end distal to knot. c.) ever pull exposed surface of any suture into tissue below epidermis. The exposed surface of any suture is considered contaminated. d. Repeat Steps a through d until you have removed every other suture. e. Observe healing level. Based on observations of wound response to suture removal and health care provider's original order, determine whether remaining sutures will be removed at this time. If so, repeat Steps a to d until you have removed all sutures. f. If any doubt, stop and notify health care provider.

As the RN, you administer Tylenol instead of Motrin. You understand when a medication error occurs:

The RN must assess the effects of the drug on the client.

subjective data

things a person tells you about that you cannot observe through your senses; symptoms

When aseptic procedures are performed, the nurse must have a sterile work area or sterile field. Which statement regarding maintenance of sterile fields is true?

Once a sterile field is outside of the vision of the nurse, the sterile field is considered contaminated.

Wound Assessment

1. Identify patient using at least two identifiers (e.g., name and birthday or name and medical record number), according to agency policy. 2. Assess patient's level of comfort on pain scale of 0 to 10. If patient is in pain, determine if prn pain medication has been ordered and administer. 3. Determine if patient has allergies to topical agents. 4. Review order for topical agent(s) and/or dressings. . Close room door or bedside curtains. Provides privacy. 6. Position patient to allow dressing removal and position plastic bag for dressing disposal. 7. Perform hand hygiene and apply clean gloves. Remove and discard old dressing. Reduces transmission of microorganisms and prevents accidental exposure to body fluids. 8. Assess patient's wounds using wound parameters and continue ongoing wound assessment per agency policy. NOTE: This may be done during wound care procedure a. Wound location: Describe body site where wound is located. b. Stage of wound: Describe extent of tissue destruction (see Box 39.1). c. Wound size: Length, width, and depth of wound are measured per agency protocol. Use disposable measuring guide for length and width. Use cotton-tipped applicator to assess depth. d. Presence of undermining, sinus tracts, or tunnels: Use sterile cotton-tipped applicator to measure depth and, if needed, a gloved finger to examine wound edges. e. Condition of wound bed: Describe type and percentage of tissue in wound bed. f. Volume of exudate: Describe amount, characteristics, odor, and color. g. Condition of periwound skin: Examine skin for breaks, dryness, and presence of rash, swelling, redness, or warmth. Modify assessment based on patient's skin color. h. Wound edges: Examine edges for condition of tissue. 9. Assess periwound skin; check for maceration, redness, denuded tissue. 10. Remove gloves and discard in appropriate receptacle. Perform hand hygiene. 11. Assess for factors affecting wound healing: poor perfusion, immunosuppression, or preexisting infection. 12. Assess patient's nutritional status (see Chapter 31). Clinically significant malnutrition is present if (1) serum albumin level is less than 3.5 g/dL, (2) lymphocyte count is less than 1800/mm3, or (3) body weight decreases more than 15%. Assess patient's and family caregiver's understanding of prevention, treatment, and factors contributing to recurrence of pressure injuries

Which statement/s regarding the application of ice, or cryotherapy is/are true? (Select all that apply)

Cryotherapy is one of the most widely used therapeutic modalities in the management of acute musculoskeletal injuries. Cold applications must be removed from areas that have turned red or blue during therapy related to the possibility of worsening ischemia.

The RN caring for a client following recent abdominal surgery finds the wound edges of the incision well approximated. The RN knows the wound is healing by:

Primary intentions

How to prioritize nursing diagnoses

Priorities are a moving target and change as the patient's condition changes Safety Airway Breathing Circulation Pain