Chapter 32: Wound Care - N3632

The nurse is providing care for a client with a wound that has purulent drainage. Which interventions will the nurse provide when caring for this client?

1. give pain meds before changing dressing 2. don't change the dressing during mealtime! 3. apply a protective ointment to the surrounding tissue

Children under the age of _____ are at a risk of pressure ulcers.

2

Which stage(s) pressure ulcer would you want to use wet to dry dressing?

3 and 4 (heal the wound from inside to out)

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

assess their wound and their vitals

Pressure injuries usually occur over ________________________ where body weight is distributed over a small area without much subcutaneous tissue.

boney prominences

Your client recently had abdominal surgery. While checking on their stiches, you notice a stitch has come undone and the incision has opened slightly. What is this called?

dehiscence

_______________ occurs when the edges of a wound are kept dry. It's important to keep the edges wet to prevent scarring.

desiccation

Your patient is in pain, and when asked to point to where they are feeling pain, they wave their hand over their abdomen. What kind of pain would you document?

diffuse (over a large are)

You're helping a patient stand up after their abdominal surgery. They suddenly sneeze and you notice pink organs protruding from their incision. What is this called?

evisceration

What foods promote healing?

fish (salmon), greens; high in protein, vitamin B, and omega-3

During extreme instances of bowel obstruction, a ______________ will form. This is an opening/tunnel that leads to another opening.

fistula

Skin appendages include 3 things:

glands, hair, and nails

Healing by secondary intention involves the production of _________________ tissue. It fills the wound and is then covered by skin cells.

granulation

Your patient was admitted to the hospital with a stage 4 pressure ulcer. 3 weeks have passed and there is partial loss to the dermis. How would this wound be staged?

healing stage 4

What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing?

hydrocolloid

Why is someone who suffers from incontinence at a risk for injury?

impaired skin integrity

Arterial ulcers are due to injury or underlying ________________. These ulcers can result from underlying conditions, such as atherosclerosis or ________________.

ischemia, thrombosis

______________ occurs when the skin on the outside of a wound is kept wet/moist. Think of a bandaid over a wound and then you go swimming

maceration

The nurse is caring for a bedridden client who is at risk for the development of pressure injuries. In which position can the nurse place the client to relieve pressure on the trochanter area?

oblique

In patients with dark brown/black skin, what would pallor look like?

reduced darkness in palm creases, pale pink or white conjunctive (tissue under eye)

Venous ulcers are due to poor venous _______________ usually due to incompetent _____________ or an obstruction.

return, valves

A nurse is documenting a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a pale pink drainage on the dressing. Which drainage type should the nurse document?

serosanguinous

Your patient is in pain, and when you ask them to point to where they feel pain, they say they feel it in their lower abdomen and sometimes their stomach. What kind of pain are they feeling?

shifting (moves, doesn't stay in one place)

Your emaciated patient needs to be positioned, but you are concerned about pressure ulcers. Which position is NOT recommended for this patient?

side laying (all the weight on the trochanter/hip)

A nurse is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action?

stop removing staples and contact the surgeon/healthcare provider

While doing a skin assessment on a newly admitted patient, you notice a large area of very dark skin that is nonblanchable on their sacral area. What would you document?

suspected deep pressure ulcer

A nurse is cleaning the wound of a client who has been injured by a gunshot. In which direction would you clean the wound?

top to bottom, from center to outside

The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room?

transparent

When caring for an open wound, you want to keep the inside __________ and the outside skin ____________.

wet, dry