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