ch 26 wound care

the nurse realizes that the pt with a shoulder incision needs more teaching when the pt says.

i will take these antibotics until the doctor removes the staples.

this includes pt who are paralyzed or having casts or splints, as well as those restricted to a bed or chair.

immobile

chronic metabolic conditions such as diabetes result in impairment of circulation, which can increase the risk of ischemic tissue

impaired circulation or chronic metabolic conditions

with incontience of bowel or bladder, the skin of the perineal area tends to be wet much of the time , leading it to become macerated, or softened.

incontinent of bowel or bladder

is one which the infectious process is already established, evidenced by high numbers or microorganisms .

infected

in what order do wounds heal?

inflammatory pahse, maturation phase. reconstruction pahse.

this phase occurs when the wound is fresh and includes both hemostasis and phagocytosis. during hemostasis the body stops the bleeding associated with the fresh wound.

inflammatory phase

phases of the healing process

inflammatory phase reconstruction phase maturation phase

signs of inflammation include

warmth, redness, pain, and edema

which of the following orders would you expect the physician to write after receiving lab result for ths pt i question above .

wound culture and sensitivity

life threatening situation. the exposure of abdominal contents can lead to necrosis of the intestines or overwhelming sepsis.. if pt tell you " i feel like something just split open " be ready to act quickly.

wound evisceration

related to impaired cirulation which is a major risk factor for skin breakdown

pallor

containing pus drainage

purulent

redness classic sign of infection

erythema

it is thick yellow or green drainage and is a sign of infection

purulent

assess incision every

8hours to detect changes that may occur.

accurate documentain wound .

describe the amount and color of drainage on the old dressing. document the length, width or diameter, and depth of the wound. document the type of dressing applied.how many gauze you used

which of these pt is most at risk for developing a pressure ulcer

a 78 year old with a feeding tube who is nonambulatory and is inocntient of bowels and bladder

a colonized wound is one in which?

a high number of microorganisms are present without signs and symptoms of infection

a pt has an injury on his arm where the skin has been scraped. this injury is an

abrasion

is a superficial open wound: abrasions include scrapes , scratches, or rub-type wounds where the skin is broken , such as a carpet burn or a skinned knee.

abrasion

classify the following wouns as either open or closed

abrasion -open laceration-open pressure ulcer-open contusion- closed

stat nursing response to wound evisceration.

act immediately do not attempt to replace the organs into the abdominal cavity. cover the exposed organs with sterile dressings soaked in normal saline. keep the dressing moist by adding sterile saline using the sterile syringe.position the pt in the low fowlers position with the knees flexed to reduce strain on the abdominal wound .npo.surgery will have to be performed.

if a pt had a stage 3 presure ulcer, you would expect tosee which of the following on assessment

an open area that reveals damage to the epidermis , dermis , subcutaneous, muscle, fascia, tendon, joint cap and bone

your pt has a large abdominal wound with copious drainae and may layers of gauze 4x4 in the dressing the pt develops a skin reaction to the tape due tp frequent dressing changes. what migh you recommend for this pt .

ask the charge nurse about using Montgomery straps or an abdominal binder instead of tape.

a pt is at risk for wound dehisence as result of nutritional issues an past history. which intervention should be included in the care plan?

assist the patient to splint the incsicion with a pillow when coughing . administer stool softeners and anit-nausea medicine promptly.

it is a dark greenish color and is often present in wound drainage after gallbladder surgery

bilious

many facilities use standardized scales of assessment, such as

braden scale

discolored areas; make notations of any such areas that are found, so it is easy to determine if new breakdwon occurs

bruising

during the inflammatory process, the following physiologyic responses occur

capillaries dialte, causing erythemia and increased warmth at the site of injury. leuckocytes move inot the intersitial space and attack microorganism. RBC deliver more oxygen and nutrients ato promote healing .edema causes pressure on nerve endings, resulting in discomfort and pain.

which one of the following interventions would you rate as the most important for care of his pressure ulcer/

change the wet-to -damp dressing on his right hip wound quid using sterile technique.

which of these factors affect wound healing

chronic illness, medication, diabetes mellitus , age

a wound that is not infected

clean

contamination of wounds fall into one of the following categories:

clean clean-contamineated contaminated infected colonized

a wound that was surgically made , is not infected but has direct contact with the normal flora in either the respiratory tract , urinary tract, or gastrointestinal tract. it has more potential to become infected.

clean-contaminated

types of wounds

close and open wound

a wound in which the skin reamins intact is considered a

close wound

differs from an infected wound in that it has a high number of microorganisms present but is without signs of infection

colonized

this can be surgical wound or a wound caused by trauma that has been grossly contaminated by breaking asepsis.

contaminated

is a closed discolored wound caused by blunt trauma, better known as a bruise.

contusion

skin assessment should be done on a

daily basis

usually begins with an area over a bony prominence that differs from the surrounding tissue in either temp, texture, firmness, or discomfort level. area may simply turn a dark burgundy , purple, or maroon color, like a bruise.

deep tissue injury

a pt ab wound starts to separte revealing the inner layers of muscle . this is called

dehiscaence

muscle intact, adipose tissue

dehiscence

the damaged cells release histamine and other chemicals, which cause the capillaries to

dilate, or widen, and increase permebility of the capillary walls.

while asesing the sking of a pt on bedrest you notice a pale area over the left hip with a small blistr in the center. what actions will yo take?

document your findings and assess again in 2hours

a pt returns from surgery with a left shoulder dressing. a 3in diametter spot of red drainage is visible onthe anterior portion of the dressing. the physician does not want the dressing disturbed for 24 hours. what wil you do.

draw a line on the dresing outlining the drainage, with the date, time, and your initials

is hard , dry , dead tissue that has a leathery appearance. it can be black, brown ,or tan.

echar

increased warmth, swelling, pain , odor, and drainage

edema

the skin of elderly individuals is thinner and less elastic making it more susceptible to friction and shearing

elderly

pt who are prone to development of pressure ulcers inlcude pt who are:

elderly emaciated or malnourished incontinent of bowel or bladder immobile impaired circulation or chronic metaboli conditions

is the state of being very lean or having very little muscle

emaciated or malnourished

indicates the increased capillary blood flow associated with inflammation

erythema

when you assess a pt skin you will pay specal attention to the color , notng.

erythema, pallor, bruising , jaudice

which one of the following assessment findings makes it impossible to stage a pressur ulcer?

eschar

a patients j-p drain shoul be emptied

every 8 hours , when one-half to two thirds full

when a pt tries to lift a piano shortly after sugery his ab incision separtes and his intestines protude through it . this is called

evisceration

protuding bowel, muscle separated, and adipose tissue

evisceration wound

some wounds contain dissolved necrotic tissue and pus; others may hold tissue fluid and blood

exudated

an appendectomy incision sutured closed

first intention

when the wound is clean with little tissues loss, such as a surgical incision, the edges are approximated and the wound is sutured closed.

first intention wound closers for healing

your pt with a stage 3 pressure ulcer infecte with MRSA is on contact precautions. you will obtain the following PPE when you enter his room

gloves and gown

the phase of healing during which granulation tissue forms in a wound is the

granulation phase

as new tissue begins to grow and fill in the wound , it looks red and semitransparent. this new tissue, called ____ is extremely fragile

granulation tissue

new tissue that looks red and semi-transparent taht grows to fil in a wound is called

granulation tissue

a pt with an open leg wound has the following lab results on his chart. wbc 15, 350mm with an elevated percentage of neutrophils. what does this tell you about the pt wound.

he most likely has an acute wound infection

tissues and capilaries are compressed , resulting in redued blood flow to the area, known as

ischemia

also known as yellwoing of the skin . it is a sign of an abnormally high serum level of bilirubin, which can make skin itch and be more sucesptible to loss of integrity.

jaundice

overproduction of collagen results in a thick, raised scar called

keloid

your sister accidentaly cut her finger while slicing tomatoes . this injury is an

laceration

is open wound made by the accidental cutting or tearing of tissue. common sources is knives and pieces of glass nad metal.

lacerations

thsi pahse , also known as the remodeling phase , occurs when the wound contracts and the scar strenghens . initially, a healing ridge develops just beneath the incision and approximately 1cm on either side.

maturation phase.

an elderly pt who lives alone and has a vascular stasis ulcer on his right leg is most at risk for infection bc he

may not see well enough to notice changes in the wound that indicated infection

you are callin a physician to report a possible wound infection. what information will you include in you report.

most recent vital signs. amount and type of wound drainage , observed signs of infection .pt ratin of his or herpain. lab results.

ischemia depries the involved tissues of adequate oxygen and nutrients and if this state persists, the cells will eventually

necrose(die)

dead tissue

necrotic

a wound in which the skin integrity has been breached is

open wound

is similar to a puncture wound , with the difference being that the offending object remains embedded in the tissue.

penetrating wounds

specialized white blood cells (macrophages )engluf and digest invading microorgansims and the remaining fragments of damaged cells

phagocytosis

how would tape a dressin to a pt elbow area

place the tape parallel to the bend of the joint, allowing movement without dislodging the dressing .

stat nursing response to hemorrhage

position the pt in the low fowlers position wiht the knees flexed. if you can see the source of the bleeding put on gloves and apply firm pressure over the area.

is a wound resulting from pressure and friction.

pressure ulcer

you are caring for a pt with severl risk factors for a pressure ulcer. which would you avoid when caring for this pt?

pulling the sheets from beneath the pt so she does not have to turn frequently

is a an open wound that results when a sharp item, such as a needle, nail or piece of wire, piereces the skin

puncture wound

stat nursing response to wound dehiscence

reassure you pt and assist him or her to a supine position. stay with your pt and notify the physician immediately.

this phase occurs when the wound begins to hel , lasting for about 21 days after the injury. it is also referred to as the proliferation phase.

reconstruction phase

the most common sites for development of pressue ulcers are over the bony prominences such as

sacrum buttocks greater trochanters elbows, heels, ankeles, occiput and scapulae

it refers to red, bloody drainage

sanguineous

the drainage in a pt jackson-pratt drain is red and appers bloody. this draingage is

sanguineous

a pressur ulcer being packed with moist gauze

second intention

when there is greater tissue loss and the wound edges are irregular, the edges cannot be brought together.examples of this would be a pressure ulcer or traumatic wound.

second intention wound closer for healing

both clear drainage anddrainage with pus are present

seropurulent

you observe pink drainage from a pt wound. you woud describe this as;

serosanguienous

both blood and clear drainage are present . combinded they turn dressing materials a pink color

serosanguineous

the drainage fro ma pt wound is pink in color this drianage is described as

serosanguineous

clear to plae yellow drainage that looks like serum

serous

the drainage on the dressing over a pt old iv site is clear and slightly yellow. this drainage is

serous

a___ is a channel or tunnel thatdevelops between tow cavities or between an infectd cavity and the surface of the skin

sinus tract

is a channel or tunnel that develops between two cavities or between an infected cavity and the surface of the skin, sometimes known as a fistula. a sinus tract that forms due to infection usually produces purulent drainage that is thick and yelow or green.

sinus tract

indicated by erthema, generaly over a bony prominence that reamins for at least 15 to 30 min after relieving the pressure and it will not blanch or turn white, when you gently touch it with your fingertip.

stage 1( avoid massaging the erythematous area as this may cause futher tissue damage.

partial thick ness loss of dermis. this would include intact serumfilled blisters and broken blisters taht reveal a shallow , pink or red ulceration that can be either shiny or dry.

stage 2

is a full thickness loss involving damage to the epidermis, dermis and subctaneous tissue but not involving muscle or . undermining and tunneling may be seen in this stage.

stage 3

is also full thickness tissue loss only it involves deep tissue necrosis of muscle , fascia, tendon, joint capsule and sometimes bone. ans in a stage 3 ulcer there may be tunneling and undermining.. can involve deeper tisues such as the bone , a condition known as osteomyelitis.

stage 4

the most common microbial pathogen associated with wound infections is

staphylococcus aureus.

develop when the venous blood flow is sluggish, generally in the lower extremities, allosing deoxygenated blood to pool in the veins.

stasis ulcers

intentionally made with sharp instruments are linear with more sharply defined edges than most wounds. the two edges of an incision be close together.

surgical incisions

wound treatment closure

sutures, staplesm surgical adhesive, and sterile adhesive strips, somethimes referred to by the brand name steri-strips

you are a nurse, and you are running behind schedule on a very busy work day. the UAP offers to chnge a pt ab dressing for you. she is a first semester nursing student. which is the most appropriae response?

thanks, but could you help Mr. Wu walk in the hall instead ? that way i can get that dressing changed.

all of the following are found during your assessment of a surgical wound. which ould concern you the most ?

the 2cm margin around the wound is red, warm, and swollen. the pt complains of increasing pain in the incisional area compared to yesterday.

a pt has had emergency surgery bc of a bowel obstruction . the wond becomes infected wih E,coil this likely occured bc

these bateria grow in the absence of oxygen, which is the case in the bowel.

a traumatic wound first left open to drain, then sutured closed

third intention

the wound is left open for a time to allwo granulation tissue to form; it is then sutured closed .and example of this wouuld be a draining woulnd which is left open until the drainage cease andthen is sutured closed.

third intention wound closer for healing

a pt comes to the clinic where you are working as nurse. he had surgery 2mth ago and is vey concerned. he asks you to feel the scar on his side. you feel a hard ridge beneath the incision scar extending about 1 cm on either side of the scar. which response is most appropriate?

this is a normal part of scar healing and strengthening. it will eventually thin out and become less hard.

why would you consider using Montogomery straps

to hold an abdominal dressing in place to prevent the need to remove tape with each dressing change.

a number of factors can delay the healing process , including the age and lifestyle of the pt , additional illness and wounds, nutritional status, osygenation, medications, andtension on the edges of the wound.

true

a surgical wound is closed from the inner layers to the outer layers of tissue

true

empty drains every 8 hour or when they become one-half to two-thirds full.

true

hemovac and jackson-pratt drains are active drainage devices. a t-tube drain is passive, draining via gravity

true

if the wound is open , asses the base or bed of the wound for color of tissue, texture of tissue, granulation tissue, eschar, sinus tracts, and undermining.

true

a pt has a black , hard , leathery scab on his left hel ,the stage of this ulcer is

unstageable

full thickness tussue loss but are impossible to accuraely stage due to the wound bed being compelety obscured by eschar or excessive slough.

unstageble

a pt has signs of infection in his left shoulder incision erythema, warmth, and a small amount of purulent drainage. you prepare to report this to the physician. which information will you have ready when you call?

vital signs,appropriate lab results ,pt rating of incisional pain, description of the wound and drainage,signs of infection you observe, name and dosage of antibiotics currtently ordered if any.

why is moisture necessary for wounds to heal?

when a wound is covered moisture is maintained within it, the epidermal cells can move freely through the mositure to promote healing .

is not a common complication of wound healing , but it is a extremely serious one . it occurs when there is partial or complete separation of the outer layers of a wound.

wound dehiscence