Wound Management ( Sherpath)

Which statements indicate that the patient understands the role of inflammation in wound healing?

Inflammation is responsible for the redness, heat, and swelling of my wound." This statement indicates the patient understands that inflammation causes the redness, warmth, and swelling in the wound. "The inflammatory response works to clean the wound of organisms and debris." The patient stating the inflammatory response cleans the wound of organisms and debris indicates an understanding of the process.

A patient is scheduled to undergo a biopsy of a 4-cm deep wound to determine the source of the wound infection. The patient asks the nurse, "Why can't you just collect some of this stuff with a cotton swab?" What is the nurse's best response?

"Your wound is deeper and it is best to biopsy the tissue." A biopsy works best to determine the source of infection for deeper wounds.

The nurse is caring for a patient with a partial-thickness wound. The nurse understands which tissues are involved? Select all that apply.

Dermis A partial-thickness wound involves the dermis. Epidermis The epidermis is involved in a superficial and a partial-thickness wound.

The nurse is educating the patient about dietary changes needed to promote wound granulation. Which dietary choices would indicate the patient understands the instruction provided?

A ham and cheese sandwich with an orange and milk A ham and cheese sandwich with milk is a food choice that is high in protein. Protein-rich foods promote wound healing. An orange is a good dietary source of vitamin C, which is necessary to promote wound granulation.

The nurse is preparing to change the dressing to an ischial wound. The order has been changed from a wet-to-dry dressing to a wet-to-damp dressing. The patient asks the nurse why there is a change to a wet-to-damp dressing. What is the nurse's best response?

A wet-to-damp dressing protects the wound bed from trauma during dressing changes." Using a wet-to-damp dressing keeps the wound bed moist and protects it from trauma during dressing changes.

Which patients are at risk for abnormal wound healing?

An older adult An older patient is at risk for abnormal wound healing because re-epithelialization is slower as age increases. A patient with AIDS A patient with AIDS is at an increased risk for abnormal wound healing because the immune system is weakened in AIDS.

A registered nurse is supervising a student nurse performing a dressing change. Which action made by a student nurse requires intervention by the registered nurse?

Applying debridement enzyme ointment to the healthy tissue Enzyme debriding ointments should only be applied to necrotic or eschar tissue, not to healthy tissue. This ointment is used to eradicate the dead tissue.

The wound care nurse is preparing to dress a wound. The nurse notes increased granulation at the site. Which dressing should the nurse prepare to use?

Clear plastic dressing An occlusive, clear plastic dressing is used for wounds that are granulating.

The nurse is caring for a patient with an uninfected surgical wound. How would the nurse expect this wound to heal?

First intention A clean laceration or an uninfected surgical wound would heal by first intention.

Which wound-related task can the RN delegate to the unlicensed assistive personnel (UAP)?

Measure and empty a wound drainage container The UAP is able to measure the volume of fluid in a wound drainage container and empty its contents.

The nurse performing a focused wound assessment will document which findings?

Presence of exudate in the wound base The nurse would assess for the presence of exudate in the wound base as part of a focused wound assessment. Measurement of the greatest depth of the wound Taking the measurements of the greatest lengths, width, and depth of the wound is part of a focused wound assessment. Presence of erythema for 1 cm around the wound edges The nurse would assess for periwound erythema as part of the focused wound assessment.

A patient arrives at the emergency room after sustaining a cut to the arm a week ago that is "just not healing right." Which local manifestations would the nurse expect to observe if the wound is infected?

Redness Redness would be present around the wound if it is infected. Swelling of the arm Swelling is a common symptom of infection and is the result of fluid accumulation as blood rushes to the affected area to bring healing and clotting factors. Inability to move the arm A person with an infected arm wound may be unable to move their arm due to inflammation and pain.

A 24-year-old sustained a laceration to the lower leg and is having a difficult time healing. Which meal would be appropriate for the nurse to order for the patient?

Scrambled eggs and sausage with orange juice Scrambled eggs and sausage are high in protein sources that promote wound healing. Orange juice has vitamin C that also helps wounds heal.

A nurse is caring for a patient 2 days postoperative from appendectomy. The patient reports incisional pain of 4/10, and the nurse notes erythema at the margins of the wound, temperature of 100.4° F orally, and serosanguinous drainage on the dressing. Based on this assessment, what conclusion should the nurse make?

The incision is showing signs of infection and the surgeon should be notified. Erythema on the wound margins and an increased oral temperature are signs of a possible surgical wound infection. The surgeon should be notified of these findings.

A patient presents to the clinic with a full-thickness pressure ulcer to the sacrum. Which finding indicates this patient may likely require surgical intervention for the wound?

The patient is a paraplegic who sits in a wheelchair all day. A patient who is a paraplegic that sits in a wheelchair all day and has a full-thickness pressure ulcer to the sacrum. The patient's wound has a low probability for healing on its own. This patient would require surgical intervention to treat the wound.

A patient presents with a wound dehiscence requiring wet-to-dry dressing changes. The patient asks about trying that "wound vacuum thing" that someone else had. Which finding would make negative-pressure wound therapy (NPWT) contraindicated?

The patient is receiving anticoagulants for atrial fibrillation. The patient taking anticoagulants would not be a candidate for NPWT as it is contraindicated as the patient could begin bleeding into the wound vacuum canister.

The nurse is assessing a wound noted to have skin and some underlying tissue loss. Which is the appropriate frequency for the nurse to assess the size of this wound?

Weekly The nurse will measure the size of the wound weekly to determine granulation.

List the stages of wound healing in the order in which they occur.

When a person develops a cut or a wound, the initial response is momentary vasoconstriction to stop bleeding. After this, histamine is released allowing the vessels dilate to allow fluid, fibrin, and platelets to move into the tissues. Angiogenesis occurs, causing the formation of new blood vessels. Once the wound is stabilized, healing occurs leading to the formation of mature scar tissue.