Wounds adult health 2

Serous fluid

A clear, watery fluid secreted by the cells of a serous membrane. Seen in mild or early stages of injury. ex: blisters, pleural effusion

Serosanguineous

Pale, red, watery: mixture of clear and red fluid Found during the midpoint in healing after surgery. ex: surgical drain fluid

What is pus?

dead neutrophils, digested bacteria, and cell debris

What is the lifespan of macrophages?

long; weeks to months

A nurse is caring for a patient who has pressure ulcer that is treated with debridement, irrigations, and moist gauze dressings. How should the nurse anticipate the healing to occur? a. tertiary intention b. secondary intention c. regeneration of cells d. remodeling of cells

b. secondary intention

systemic response to inflammation

includes the manifestations of a shift to the left in the WBC count, malaise, nausea, anorexia, increased pulse and respiratory rate, and fever.

What is a "shift to the left"? when is it commonly found?

increase in number of bands or "baby" (immature) neutrophils in circulation. common in acute bacterial infections.

What happens in cases where particles are too large for a single macrophage to digest?

macrophages accumulate forming a "multinucleated giant cell"

Chemotaxis

migration of WBC to the site of injury

What is the second type of WBC to the site of injury?

monocytes (3-7 days after injury)

Catarrhal exudate

mucous. ex: runny nose, upper respiratory infections

The 1st leukocyte to arrive at the injury site? how many hrs?

neutrophils; within 6-12 hrs

Neutrophils function

phagocytosis to destroy bacteria

local response to inflammation

redness, heat, pain, swelling, loss of function

Neutrophils lifespan

short; 24-48 hours

leukotrienes

slow reacting substance of anaphylaxsis, constricts smooth muscles of bronchi, causing narrowing of the airway and increases capillary permeability l/t airway edema

Complement components (c3,c4,c5); source +MOA

source: Anaphylatoxic agents generated from complement pathway activation MOA: stimulates histamine release and chemotaxis

Kinins; source + MOA

source: from precursor kininogen as a result of activation of Hageman factor XII of clotting system MOA: cause contraction of smooth muscle and vasodilation. result in stimulation of pain

Prostaglandins: source + MOA

source: produced from arachidonic acid MOA: cause vasodilation, pain

Histamine; source + MOA

source: stored in granules of basophils, mast cells, + platelets MOA: causes vasodilation and increased capillary permeability

Serotonin; source + MOA

source: stored in platelets, mast cells, + enterochrromaffin cells of GI tract MOA: stimulates smooth muscle contraction

Acute inflammatory response

type of inflammation that heals in 2 to 3 weeks and usually leaves no residual damage.

thromboxane

vasoconstriction and platelet aggregation

4 major functions of the compliment system

1. enhanced phagocytosis 2. increased vascular permeability 3. chemotaxis 4. cellular lysis

What are monocytes?

2nd type of WBC to the site of injury -transform into macrophages when they reach injury site -assist with phagocyotosis and clean wound

When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing? a. The patient states that the ulcers are very painful. b. The patient has had the heel ulcers for the last 6 months. c. The patient has several old incisions that have formed keloids. d. The patient takes corticosteroids daily for rheumatoid arthritis.

ANS: D Chronic corticosteroid use will interfere with wound healing

A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is appropriate? a. Elevate the ankle above heart level. b. Remove the patients shoe and sock. c. Apply a warm moist pack to the ankle. d. Assess the ankles range of motion (ROM).

ANS: A Soft tissue injuries are treated with rest, ice, compression, and elevation (RICE). Elevation of the ankle will decrease tissue swelling.

To which patient should the nurse plan to administer round-the-clock antipyretic drugs? a. A 76-yr-old patient with bacterial meningitis and a temperature of 104.2°F b. An 82-yr-old patient after hip replacement surgery and a temperature of 100.4°F c. A 14-yr-old patient with infectious mononucleosis and a temperature of 101.6°F d. A 59-yr-old patient with an acute myocardial infarction and a temperature of 99.8°F

A. 76-yr-old patient with bacterial meningitis and a temperature of 104.2°F

Which nursing action will be included when the nurse is doing a wet-to-dry dressing change for a patients stage III sacral pressure ulcer? a. Administer the ordered PRN oral opioid 30 minutes before the dressing change. b. Soak the old dressings with sterile saline a few minutes before removing them. c. Pour sterile saline onto the new dry dressings after the wound has been packed. d. Apply antimicrobial ointment before repacking the wound with moist dressings.

ANS: A Mechanical debridement with wet-to-dry dressings is painful, and patients should receive pain medications before the dressing change begins.

A patient with an open abdominal wound has a complete blood cell (CBC) count and differential, which indicate an increase in white blood cells (WBCs) and a shift to the left. The nurse anticipates that the next action will be to a. obtain wound cultures. b. start antibiotic therapy. c. redress the wound with wet-to-dry dressings. d. continue to monitor the wound for purulent drainage.

ANS: A The shift to the left indicates that the patient probably has a bacterial infection, and the nurse will plan to obtain wound cultures. Antibiotic therapy and/or dressing changes may be started, but cultures should be done first. The nurse will continue to monitor the wound, but additional actions are needed as well.

A 76-year-old patient has an open surgical wound on the abdomen that contains a creamy exudate and small areas of deep pink granulation tissue. The nurse documents the wound as a a. red wound. b. yellow wound. c. full-thickness wound. d. stage III pressure wound.

ANS: B The description is consistent with a yellow wound. A stage III pressure wound would expose subcutaneous fat. A red wound would not have any creamy colored exudate. A full-thickness wound involves subcutaneous tissue, which is not indicated in the wound description.

The nurse assesses a surgical patient the morning of the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate? a. Obtain wound cultures. b. Document the assessment. c. Notify the health care provider. d. Assess the wound every 2 hours.

ANS: B The incisional redness and warmth are indicators of the normal initial (inflammatory) stage of wound healing by primary intention; the nurse should document the wound appearance and continue to monitor the wound.

A patient is admitted to the hospital with a pressure ulcer on the left buttock. The base of the wound is yellow and involves subcutaneous tissue. The nurse classifies the pressure ulcer as stage a. I. b. II. c. III. d. IV.

ANS: C A stage III pressure ulcer has full-thickness skin damage and extends into the subcutaneous tissue.

A patient with a systemic bacterial infection has goose pimples, feels cold, and has a shaking chill. At this stage of the febrile response, the nurse will plan to monitor for a. skin flushing. b. muscle cramps. c. rising body temperature. d. decreasing blood pressure.

ANS: C The patients complaints of feeling cold and shivering indicate that the hypothalamic set point for temperature has been increased and the temperature is increasing.

A patients 6 3-cm leg wound has a 2-mm black area surrounded by yellow-green semiliquid material. Which dressing will the nurse use for wound care? a. Dry gauze dressing (Kerlix) b. Nonadherent dressing (Xeroform) c. Hydrocolloid dressing (DuoDerm) d. Transparent film dressing (Tegaderm)

ANS: C The wound requires debridement of the necrotic areas and absorption of the yellow-green slough. A hydrocolloid dressing such as DuoDerm would accomplish these goals.

Which nursing action is most likely to detect early signs of infection in a patient who is taking immunosuppressive medications? a. Monitor white blood cell count. b. Check the skin for areas of redness. c. Check the temperature every 2 hours. d. Ask about fatigue or feelings of malaise.

ANS: D Common clinical manifestations of inflammation and infection are frequently not present when patients receive immunosuppressive medications. The earliest manifestation of an infection may be just not feeling well.

The nurse has just received change-of-shift report about the following four patients. Which patient will the nurse assess first? a. The patient who has multiple black wounds on the feet and ankles. b. The newly admitted patient with a stage IV pressure ulcer on the coccyx. c. The patient who needs to be medicated with multiple analgesics before a scheduled dressing change. d. The patient who has been receiving immunosuppressant medications and has a temperature of 102 F.

ANS: D Even a low fever in an immunosuppressed patient is a sign of serious infection and should be treated immediately with cultures and rapid initiation of antibiotic therapy.

Which of these four patients should the medical-surgical unit charge nurse assign to an LPN team member? a. The patient who has increased tenderness and swelling around a leg wound. b. The patient who has just arrived after suturing of a full-thickness arm wound. c. The patient who needs teaching about home care for a draining abdominal wound. d. The patient who requires a hydrocolloid dressing change for a Stage III sacral ulcer.

ANS: D LPN education and scope of practice include sterile dressing changes for stable patients. Initial wound assessments, patient teaching, and evaluation for possible poor wound healing or infection should be done by the RN.

A 24-year-old patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8 F (38.7 C). Which action by the nurse is most appropriate? a. Apply a cooling blanket. b. Notify the health care provider. c. Give the prescribed PRN aspirin (Ascriptin) 650 mg. d. Check the patients oral temperature again in 4 hours.

ANS: D Mild to moderate temperature elevations (less than 103 F) do not harm the young adult patient and may benefit host defense mechanisms. The nurse should continue to monitor the temperature.

The charge nurse observes a new graduate performing a dressing change on a stage II left heel pressure ulcer. Which action by the new graduate indicates a need for further education about pressure ulcer care? a. The new graduate uses a hydrocolloid dressing (DuoDerm) to cover the ulcer. b. The new graduate inserts a sterile cotton-tipped applicator into the pressure ulcer. c. The new graduate irrigates the pressure ulcer with a 30-ml syringe using sterile saline. d. The new graduate cleans the ulcer with a sterile dressing soaked in half-strength peroxide.

ANS: D Pressure ulcers should not be cleaned with solutions that are cytotoxic, such as hydrogen peroxide. The other actions are appropriate.

A patient who is confined to bed and who has a stage II pressure ulcer is being cared for in the home by family members. To prevent further tissue damage, the home care nurse instructs the family members that it is most important to a. change the patients bedding frequently. b. use a hydrocolloid dressing over the ulcer. c. record the size and appearance of the ulcer weekly. d. change the patients position at least every 2 hours.

ANS: D The most important intervention is to avoid prolonged pressure on bony prominences by frequent repositioning.

The nurse will plan to use wet-to-dry dressings when providing care for a patient with a a. pressure ulcer with pink granulation tissue. b. surgical incision with pink, approximated edges. c. full-thickness burn filled with dry, black material. d. wound with purulent drainage and dry brown areas.

ANS: D Wet-to-dry dressings are used when there is minimal eschar to be removed. A full-thickness wound filled with eschar will require interventions such as surgical debridement to remove the necrotic tissue. Wet-to-dry dressings are not needed on approximated surgical incisions. Wet-to-dry dressings are not used on uninfected granulating wounds because of the damage to the granulation tissue.

When caring for a diabetic patient who had abdominal surgery one week ago, the nurse obtains these data. Which finding should be reported immediately to the health care provider? a. Blood glucose 136 mg/dl b. Oral temperature 101 F (38.3 C) c. Patient complaint of increased incisional pain d. New 5-cm separation of the proximal wound edges

ANS: D Wound separation at a week postoperatively indicates possible wound dehiscence and should be immediately reported to the health care provider.

Lymphocytes

Arrive later at the site of injury. Primary role is r/t humoral and cell-mediated immunity

A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102°F. Which parameter would the nurse monitor, other than temperature, if the patient requires this medication? a. Pain level b. Intake and output c. Oxygen saturation d. Level of consciousness

B. intake and output Because fever can lead to excessive perspiration and evaporation of body fluid via the skin, the nurse should monitor the patient's overall intake and output to be sure that the patient remains in proper fluid balance.

The unlicensed assistive personnel (UAP) is assisting the patient with Crohn's disease with perineal care. The UAP tells the nurse that the patient had feces coming from the vagina. What is the priority action by the nurse? a. Notify the health care provider. b. Document the fistula formation. c. Assess the patient and vaginal drainage. d. Have the UAP apply a dressing to the vagina.

C. Assess the patient and vaginal drainage With Crohn's disease, a fistula may have formed between the bowel and the vagina. The nurse should first assess the patient and drainage from the vagina. Then the nurse should notify the health care provider, document the occurrence and care provided, describe interventions prescribed, and document the care and patient response.

Vascular response to inflammation

Cell injury-> transient vasoconstriction-> release of histamine and cytokines-> l/t vasodilation-> increased capillary permeability-> local edema-> inflammatory exudates

Which patient is most at risk for the development of a pressure ulcer? a. An older patient who is septic, bedridden, and incontinent b. An obese woman with leukemia who is receiving chemotherapy c. A middle-aged thin man in a halo cast after a motor vehicle accident d. An adult with type 1 diabetes mellitus admitted in diabetic ketoacidosis

a. An older patient who is septic, bedridden, and incontinent

fibrinous exudate

Thick, clotted, and sticky exudate. Happens with increasing vascular permeability and fibrin leaking into interstitial spaces. ex: adhesions, gelatinous ribbons seen in surgical drainage

An 85-year-old patient is assessed to have a score of 16 on the braden scale. Based on this information, how should the nurse plan for this patient's care? a. Implement a 1-hr turning schedule with skin assessment b. Place duo-derm on the patients sacrum to prevent breakdown c. Elevate the HOB to 90 degrees when the pt is suprine d. Continue with weekly skin assessments with no special precautions

a. Implement a 1-hr turning schedule with skin assessment

After the unlicensed assistive personnel (UAP) bathed the patient, she then told the nurse about a reddened area on the patient's coccyx. After assessing the area, what should be included in the plan of care? a. Reposition every 2 hours. b. Measure the size of the reddened area. c. Massage the area to increase blood flow. d. Evaluate the area later to see if it is better.

a. Reposition every 2 hours.

What is the precursor to prostaglandins?

arachidonic acid

Which intervention should the nurse include in the plan of care for a patient who is paraplegic with a stage III pressure ulcer? a. Keep the pressure ulcer clean and dry. b. Maintain protein intake of at least 1.25 g/kg/day. c. Use a 10-mL syringe to irrigate the pressure ulcer. d. Irrigate the pressure ulcer with hydrogen peroxide.

b. Maintain protein intake of at least 1.25 g/kg/day.

A patient had abdominal surgery last week and returns to the clinic for follow-up. The nurse assesses thick, white, malodorous drainage. How should the nurse document this drainage? a. Serous b. Purulent c. Fibrinous d. Catarrhal

b. Purulent

A patient is seen in the emergency department for a sprained ankle. What initial interventions should the nurse teach the patient for treatment of this soft tissue injury? a. Warm, moist heat and massage b. Rest, ice, compression, and elevation c. Antipyretic and antibiotic drug therapy d. Active movement and exercise to prevent stiffness

b. RICE

The patient has inflammation and reports feeling tired, nausea, and anorexia. The nurse explains to the patient that these manifestations are related to inflammation in what way? a. Local response b. Systemic response c. Infectious response d. Acute inflammatory response

b. Systemic response

A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5F temp. slight erythema at the incision margins, and 30mL serosanguineous drainage in the jackson-pratt drain. Based on this assessment, what conclusion would the nurse make? a. The abdominal incision shoes signs of an infection b. The patient is having a normal inflammatory response c. The abdominal incision shows signs of impending dehiscence d. The patient's physician must be notified about her condition

b. The patient is having a normal inflammatory response

The nurse assessing a patient with a chronic leg wound finds local signs of erythema and the patient complains of pain at the wound site. What would the nurse anticipate being ordered to assess the patient's systemic response? a. serum protein analysis b. WBC count and differential c. punch biopsy of center of wound d. culture and sensitivity of the wound

b. WBC count and differential

A patient with pneumonia has a fever of 103°F. What nursing actions will assist in managing the patient's febrile state? a. Administer aspirin on a scheduled basis around the clock. b. Provide acetaminophen every 4 hours to maintain consistent blood levels. c. Administer acetaminophen when the patient's oral temperature exceeds 103.5°F. d. Provide drug interventions if complementary and alternative therapies have failed.

b. acetaminophen ASA would not be the drug of choice because of its antiplatelet action and accompanying risk of bleeding.

A pt in the unit has a 103.7 F temp. Which intervention would be most effective in restoring normal body temp? a. use a cooling blanket while the pt is febrile b. administer antipyretics on an around-the-clock schedule c. provide increased fluids and have the UAP give sponge baths d. give prescribed antibiotics and provide warm blankets for comfort

b. administer antipyretics on an around-the-clock schedule

A postoperative patient is now able to eat and is requesting a snack. What snack should the nurse recommend for the patient that will facilitate wound healing? a. Apple b. Custard c. Popsicle d. Potato chips

b. custard Custard would be the best snack because it is made from milk, egg, sugar, and vanilla. Wound healing is facilitated by protein, carbohydrates, and B vitamins.

A nurse is teaching a patient how to promote healing following abdominal surgery. What should be included in the teaching (select all that apply.)? a. Take the antibiotic until the wound feels better. b. Take the analgesic every day to promote adequate rest for healing. c. Be sure to wash hands after changing the dressing to avoid infection. d. Take in more fluid, protein, and vitamins C, B, and A to facilitate healing.

c. Be sure to wash hands after changing the dressing to avoid infection. d. Take in more fluid, protein, and vitamins C, B, and A to facilitate healing.

A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment? a. Frequent examination of the character and quantity of exudate b. Monitoring for signs and symptoms of local or systemic infections c. Assessment of the patient's circulation distal to the location of the dressing d. Assessment of the range of motion of the ankle and the patient's activity tolerance

c. Assessment of the patient's circulation distal to the location of the dressing

An older adult patient is transferred from the nursing home with a black wound on her heel. What immediate wound therapy does the nurse anticipate providing to this patient? a. Dress it with an absorbent dressing for exudate. b. Handle the wound gently and let it dry out to heal. c. Debride the nonviable, eschar tissue to allow healing. d. Use negative-pressure wound (vacuum) therapy to facilitate healing.

c. Debride the nonviable, eschar tissue to allow healing.

A patient arrives in the emergency department reporting fever for 24 hours and lower right quadrant abdominal pain. After laboratory studies are performed, what does the nurse determine indicates the patient has a bacterial infection? a. Increased platelet count b. Increased blood urea nitrogen c. Increased number of band neutrophils d. Increased number of segmented myelocytes

c. Increased number of band neutrophils

The nurse is providing care to a patient with an open abdominal wound after surgery. What teaching should the nurse provide to the patient regarding the healing process? a. The wound will be stapled together until it heals. b. The healing will contract the area to close the wound. c. The wound will be left open and heal from the edges inward. d. The wound will be sutured after the current infection is controlled.

c. the wound will be left open and heal from the edges inward With secondary healing, the wound is left open and heals from the edges inward and from the bottom up. With primary intention, the wound edges are stapled or sutured,

An 82 year old man is being cared for at home by his family. A pressure ulcer on his right buttock measures 1x2x0.8 cm in depth, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form? a. Stage I b. Stage II c. Stage III d. Stage IV

c. Stage III

Which one of the orders should a nurse question in the plan of care for an elderly immobile stroke patient with a stage III pressure ulcer? a. pack the ulcer with foam dressing b. turn and position the patient every hour c. clean the ulcer every shift with Dakin's solution d. assess for pain and medicate before dressing change

c. clean the ulcer every shift with Dakin's solution

When assessing a patient who is receiving cefazolin for the treatment of a bacterial infection, which data suggest that treatment has been effective? a. White blood cell (WBC) count of 8000/ìL; temperature of 101.5 F b.White blood cell (WBC) count of 4000/ìL; temperature of 100.5 F c.White blood cell (WBC) count of 8500/ìL; temperature of 98.4 F d.White blood cell (WBC) count of 16,500/ìL; temperature of 98.8 F

c.White blood cell (WBC) count of 8500/ìL; temperature of 98.4 F

A patient is postoperative after a breast reduction and arrives for a follow-up appointment at the clinic. The nurse assesses excess soft pink tissue from the surgical incision site. What complication of wound healing does the nurse recognize this to be? a. Adhesion b. Contractions c. Keloid formation d. Excess granulation tissue

d. Excess granulation tissue

The nurse is caring for a patient who is immunocompromised while receiving chemotherapy for advanced breast cancer. What signs and symptoms will the nurse teach the patient to report that may indicate an infection? a. Fever and chills b. Increased blood pressure c. Increased respiratory rate d. General malaise and fatigue

d. General malaise and fatigue