learning activity 5, 2nd semester Flashcards
1
Q
Surgical Asepsis
A
methods used to eliminate ALL microorganisms including spores, and to protect an area or object from these microorganisms
2
Q
Sterile Technique Guidelines/Principles
A
- A sterile object is sterile only when touched by another sterile object
- Only sterile objects may be placed on a sterile field
- Any sterile object out of your field of vision is contaminated. Any object held below the waist or above it is contaminated.
- A sterile object becomes contaminated by prolonged exposure to the air.
- A sterile field or object becomes contaminated by capillary action (wicking) when a sterile surface comes in contact with a wet contaminated surface.
- The edges of a sterile field or container are not considered sterile. The 1 inch border of a sterile field, towel or package is considered contaminated.
- When opening sterile kits or packages, we open away from us first, then the sides, and lastly, towards us.
3
Q
Factors that affect wound healing?
A
Protein – Vitamin C- Zinc Obesity Wound stress Diabetes Immunocompromised Age Extent of wound Oxygenation Smoking Radiation
4
Q
Types of Wounds
A
Abrasion
Laceration
Puncture wound
Ecchymosis (bluish discolouration of skin or mucous membrane caused by extravasation of blood into subcutaneous tissue)
5
Q
How Wounds Heal
Primary Intention
A
Staples and Sutures
Approximated
6
Q
How Wounds Heal
Secondary Intention
A
No sutures or staples
Wound left open- heals from inside out
Granulation tissue in wound bed
7
Q
How Wounds Heal
Delayed primary Intention( Tertiary Intention)
A
On occasion, surgical incisions are allowed to heal by delayed primary intention where non-viable tissue is removed and the wound is initially left open.
8
Q
Wound→ Inflammatory response
1st phase – Homeostasis
A
Bleeding stops →injured blood vessel constricts→
Platelets produce growth factor →thrombin acts on fibrinogen to form blood clot (fibrin) →stops bleeding
Blood flow ↑ causing redness and swelling
9
Q
Epidermal Repair
A
New skin cells form at edges of wound and move across wound – more efficient if wound bed is kept moist
New epidermis fragile and lighter in color than surrounding skin.
Gradually epidermis resumes normal function and color
Strength of scar 80% of skin that has never been wounded
10
Q
Complications of Wound Healing
A
Hemorrhage Nurses role: Monitor dressing Monitor drains Risk for is greater in 1st 24-48 hours after surgery
Hematoma
Hemorrhage under the skin
H and H ↓
↑ Pulse and BP ↓
Fistula
is an abnormal connection or passageway between two epithelium-lined organs or vessels that normally do not connect.
Dehiscence(a wound ruptures along surgical suture)
Occurs 3-11 days after surgery
Infected wounds more prone to dehiscence
Evisceration Most serious complication Wound opens and viscera are visible or loops of bowel seen in or hanging out of the wound Client feels “ giving way” ↑ bleeding at wound Emergency
11
Q
Nurse’s Role when Patient Eviscerates
A
Quickly place sterile saline soaked gauze or sterile towels on the wound to prevent viscera from drying out
Another nurse call Dr at the same time – client will have to go to Surgery
Keep client lying down in bed, often with knees bent
Keep warm to prevent shock and keep NPO
Take Vital signs and tell them their wound has opened and will need surgery to fix it
Keep it simple
Keep calm to prevent client from panic
12
Q
Wound Dressings
A
First surgical dressing change usually done by surgeon then nurse will continue to change dressings as ordered
Nurses reinforce the original dressing till Doctor says to change
Doctor may order specific type of wound dressing or leave up to the nurse
13
Q
Wound Assessment
REEDAS
A
Redness Edema Ecchymosis (superficial bleeding under the skin) Drainage Approximation of wound edges Sutures or staples are intact Also drains - condition of tissue
14
Q
Wound Drainage
A
Serous – liquid
Sanguinous – blood
Serosanguinous – liquid & blood
Purulent – pus
15
Q
Special Wound Drains
A
Purpose Held in place 2 main types *Gravity drains - Penrose *Suction drains - Jackson – Pratt or JP drain - Hemovac
16
Q
Nurse responsibilities with surgical drains
A
Ensure suction exerted All connection points intact Tubing not kinked Assess drainage Record on I & O sheet
17
Q
Contraindicated solutions
A
Hydrogen peroxide (H2O2) Betadine
18
Q
Types of Dressing Materials
A
Gauze Transparent Hydrocolloid Tape – Types Montgomery Straps/Ties
19
Q
Documenting –
2 parts
A
Observation of wound (REEDAS)
The dressing
20
Q
Heat and Cold Applications
A
Heat Dry or moist heat Dry – heating pad Moist Common uses – washcloth Soaks and sitz baths Aquathermia – K pad Tepid or lukewarm sponge bath
Cold Applications
Action
Compresses
Hypothermia Blanket
21
Q
Wound Classifications
A
Cause: intentional, unintentional
Skin integrity: open, closed, acute, chronic
Depth: partial thickness, full thickness
Cleanliness: clean, contaminated, infected
Duration: acute vs. chronic
Colour: red, yellow, black & mixed (applied to any wound healing by secondary intention)
22
Q
Pressure Ulcers: Pathogenesis
A
Pressure intensity
Pressure duration
Tissue tolerance
23
Q
Pressure Ulcers: Causes
A
Friction Shearing force Moisture (maceration) Impaired mobility Altered level of awareness Impaired sensory perception
24
Q
Stages of Pressure Ulcer Formation
A
Stage I: persistent red, blue, or purple tones; no open skin areas
Stage II: partial-thickness skin loss; presents as an abrasion or blister
Stage III: full-thickness skin loss with damage or necrosis of subcutaneous tissue; presents as a deep crater
Stage IV: full-thickness skin loss with extensive destruction, necrosis, or damage to muscle, bone, other structures
Unstageable: full-thickness tissue loss in which the base is covered by slough (dead tissue yellow, tan, grey, green or brown) or eschar (dead matter cast off the skin surface especially after a burn, crusty or scabbed tan, brown or black) or both, in the wound bed
25
The three phases of Wound Healing:
Inflammatory phase
Proliferative phase
Remodelling phase
26
Complications of Wound Healing
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Hemorrhage—shock
Infection
Dehiscence
Evisceration
Fistula formation
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27
Assessment
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Skin: colour, temperature, turgor, integrity
Risk for pressure ulcers: Braden scale
Mobility
Nutritional status
Exposure of skin to body fluids
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28
Assessment of Wounds
| Emergency Setting
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Abrasions
Lacerations
Punctures
Appearance
Amount of bleeding
Size
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29
Assessment of wounds
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Stable setting
Appearance: size, healing
Character of drainage: serous, sanguineous, serosanguineous, purulent
Tools
Drains
Closures: staples, sutures
Palpation of wound
Wound cultures: aerobic, anaerobic
Pain
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30
Nursing Diagnosis: Wounds
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Risk for infection
Imbalanced nutrition: less than body requirements
Pain
Impaired skin integrity
Impaired tissue integrity
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Goals and outcomes
Wound improvement within 2 weeks
No further skin breakdown
Increase in caloric intake by 10%
Setting priorities
Continuity of care
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Prevention of pressure ulcers
Topical skin care
Positioning
Therapeutic beds and mattresses
Education
31
Dressing Changes
* Administer required analgesic
* Explain steps of procedure to client
* Gather all necessary supplies
* Prepare sterile field, as indicated
* Remove old dressing, assess area, and provide necessary care using appropriate aseptic technique
* Answer client’s questions and document care provided
32
Wound Care
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Cleansing skin and drain sites
Wound irrigations
Suture/staple care and removal
Drainage evacuation
Comfort measures
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33
Application of Bandages and Binders
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Inspect underlying skin
Cover exposed wounds
Assess condition of dressings
Assess skin of areas distal to bandage
Use appropriate technique to apply
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34
Sterile gloves must be worn when touching sterile dressing supplies or the wounds inner surface. T or F
True
35
It is not necessary to wash your hands prior to putting on sterile gloves. T or F
False
36
Should dominant or non-dominant hand be gloved first?
Dominant
37
Once sterile gloves are on both hands, it is important to maintain "sterile to sterile technique". T or F
True
38
Sterile Gloves should be changed if:
a. sterile gloves touch a clean item
b. sterile gloves touch a contaminated item
c. glove tears
d. b and c
e. b only
f. all of the above
f. all of the above
39
When applying sterile gloves, it is important that the package of glove be placed on a surface that is:
a. eye level
b. waist level
c. flat
d. hip level
b. Waist level
40
Gloves should be removed and disposed of one at a time to avoid contamination. T or F
False
41
Wound infection is the second most common hospital related infection. T or F
True
42
When sterile gloves are worn, it is best to:
a. interlock the fingers and keep the gloved hands at eye level
b. interlock the fingers and keep the gloved hands at waist level
c. keep hands at sides
b. interlock the fingers and keep the gloved hands at waist level
43
List four signs of possible latex sensitivity.
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itching
hives
rhinitis
wheezing
changes in vitals
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44
List four factors that effect wound healing
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age
chronic disease
smoking
nutrition
obesity
medications
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45
When palpating the skin around the wound, assess for?
Pain
edema
skin temperature
46
Serous
clear, watery plasma
47
purulent
thick, yellow, green, or brown drainage with odour
48
sanguineous
bright red, indicates frank bleeding
49
serosanguineous
pale, red, watery drainage
50
What factors facilitate or inhibit wound healing?
(1) Adequate oxygenation
(2) Adequate rest or local immobilization
(3) Sufficient blood supply
(4) Proper nutrition
(a) Nutrients are needed for wound repair and prevention of infection
(b) Adequate wound healing is dependent upon the availability of essential nutrients
51
Factors that impair wound healing
(1)Age - causes slower regeneration of tissue
-Vascular changes impair circulation to wound site
-Formation of antibodies and lymphocytes is reduced
-Scar tissue is less elastic
(2) Malnutrition
Stress from burns or severe trauma increases nutritional requirements
Interventions - Provide balanced diet rich in protein, carbohydrates, lipids, vitamins A and C, and minerals
(3) Impaired oxygenation
-Low arterial oxygen tension alters synthesis of collagen and formation of epithelial cells
-If local circulating blood flow is poor, tissues fail to receive needed oxygen
( 4) Obesity
Fatty tissue lacks adequate blood supply to resist bacterial infection and deliver nutrients and cellular elements
(5) Smoking
-Reduces the amount of functional hemoglobin in blood, thus decreasing tissue oxygenation
-May increase platelet aggregation and cause hypercoagulability
-Interferes with normal cellular mechanisms that promote release of oxygen to tissue
(6) Presence of infection
(7) Drugs
-Steroids reduce inflammatory response
- Anti-inflammatory drugs suppress protein synthesis, wound contraction, epithelialization, and inflammation
-Prolonged antibiotic use may increase risk of superinfection
-Chemotherapeutic drugs can depress bone marrow function, number of leukocytes, and inflammatory response
(8) Diabetes mellitus
-Causes small blood vessel disease that impairs tissue perfusion
- Causes hemoglobin to have greater affinity for oxygen, so it fails to release oxygen to tissues
-Alters ability of leukocytes to perform phagocytosis and also supports overgrowth of fungal and yeast infection
52
What are the various categories of wounds?
Closed wound injury-
(1) Contusion - Hematoma beneath unbroken skin because of small vessel ruptures
(2) Crush injuries - Overlying skin may remain intact, injury to multiple tissues, muscle or bone
Open wound injury
(1) Abrasions - Partial thickness skin loss
(2) Lacerations - Break in skin of varying depth
(3) Avulsion - Full thickness skin loss, degloving or flap injuries are avulsions
(4) Amputations - A part of the body is partially or completely severed or torn from the body
(5) Punctures/ penetrations - Caused by a foreign object that enters the body, underlying damage can be extensive
(6) Bite - Breakage of the skin caused by animal or human teeth, all bites are considered contaminated
53
Primary intention
(a) Wounds that are closed surgically
(b) Little tissue loss
(c) Skin edges are close together and minimal scarring
(d) Healing begins during the inflammatory phase
54
Secondary intention (granulation)
(a) Healing occurs when skin edges are not close together (approximated) or when pus has formed
(b) If wound is producing or containing pus (purulent) a drainage system is established or the wound is packed with gauze
(c) Slowly the necrotized tissue decomposes and escapes
(d) The cavity begins to fill with soft, pink, fleshy projections consisting of capillaries surrounded by fibrous collagen (granulation tissue)
(e) The amount of granulation tissue required depends on the size of the wound
(f) Scarring is greater in a large wound
55
Tertiary (third) intention
(a) Delayed primary closer
(b) Two layers of granulation tissue are sutured together
(c) Occurs when:
(1) Contaminated wound is left open and sutured closed after the infection is controlled
(2) Delayed suturing of a wound
(3) Primary wound becomes infected, is opened, is allowed to granulate, and is then sutured
(d) Results in a larger and deeper scar than primary or secondary intention
56
Describe the stages of wound healing Inflammatory phase
• Proliferation phase
• Maturation phase
The inflammatory phase is the body’s natural response to injury. After initial wounding, the blood vessels in the wound bed contract and a clot is formed. Once haemostasis has been achieved, blood vessels then dilate to allow essential cells; antibodies, white blood cells,growth factors, enzymes and nutrients to reach the wounded area. This leads to a rise inexudate levels so the surrounding skin needs to be monitored for signs of maceration. It is at this stage that the characteristic signs of inflammation can be seen; erythema, heat, oedema, pain and functional disturbance. The predominant cells at work here are the phagocytic cells; ‘neutrophils and macrophages’; mounting a host response andautolysing any devitalised ‘necrotic / sloughy’ tissue.
During proliferation, the wound is ‘rebuilt’ with new granulation tissue which is comprised of collagen and extracellular matrix and into which a new network of blood vessels develop, a process known as ‘angiogenesis’. Healthy granulation tissue is dependent upon the fibroblast receiving sufficient levels of oxygen and nutrients supplied by the blood vessels. Healthy granulation tissue is granular and uneven in texture; it does not bleed easily and is pink / red in colour. The colour and condition of the granulation tissue is often an indicator of how the wound is healing. Dark granulation tissue can be indicative of poor perfusion, ischaemia and / or infection. Epithelial cells finally resurface the wound, a process known as ‘epithelialisation’.
Maturation is the final phase and occurs once the wound has closed. This phase involves remodelling of collagen from type III to type I. Cellular activity reduces and the number of blood vessels in the wounded area regress and decrease.
Other sections available:-
57
What is the “healing ridge”?
Healing ridge a normal occurring event, is a term used to describe the area of swelling and hardness beneath the incision after surgery. The healing ridge is a deposit of collagen palpated as an induration beneath the skin under the suture line extending about 1 cm on each side of the incision wound and is evident between day 5 and 9 post op. The size and duration of the 'ridge' is related to the size and complexity of the incision itself. The absence of the ridge post operatively is and should be considered a precursor of wound dehiscence(separation of the layers of a surgical wound.) and impaired wound healing.
58
What assessments are made pertaining to wounds?
1 assess your patient and the wound 2.treat underlining pathology and the wound
3 reassess the wound and determine affect of treatment if wound is healing continue care if not reassess.
Assessing and managing chronic wounds guide.
Patient assessment
Wound healing is determined by the general health of your patient, so a comprehensive assessment of your patient is crucial when planning and evaluating treatment.
Patient report
When assessing and reporting on the patient, note the following:
* full medical history such as diabetes, vascular diseases, compromised immune system, connective tissue disorders and allergies
* medication
* nutritional status
* lifestyle, for example tobacco and alcohol habits or impaired mobility
* psychological problems
* quality of life
59
Wound assessment
Diagnosing the underlying cause of a wound is an essential part of wound assessment – and you can only treat the wound once this has been determined. You’ll also need to assess the wound bed and the surrounding skin. After you’ve made these assessments, you can select the best dressing.
Wound report
When assessing and reporting on the wound, note the following:
• wound location, size and type
• characteristics of the wound bed, such as necrotic tissue, granulation tissue and infection
• odour and exudate (none, low, moderate, high)
• condition of the surrounding skin (normal, oedematous, white, shiny, warm, red, dry, scaling, thin)
• clinical signs of critical colonisation or local infection: delayed healing, odour, abnormal granulation tissue, increased wound pain and excessive exudate. (Further details can be found in our pocket guide on managing infected wounds)
• improved Patient Outcomes for Diabetic Foot Ulcers, Pocket guide.
• wound pain: location of the pain, pain duration, pain intensity (Pain scale.pdf), type of pain, nociceptive or neuropathic pain. (You can find further details in our pocket guide on managing painful wounds).
60
wound exudate?
An exudate is any fluid that filters from the circulatory system into lesions or areas of inflammation.
Exudate is derived from exude, “to ooze
Its composition varies but generally includes water and the dissolved solutes of the main circulatory fluid.
61
Serous exudate
* Contains: serum – no cells or clotting factors
* note: plasma differs from serum in that it contains no cells but contains clotting factors
* Consistency: watery
* Colour: clear
* Indicative of mild, acute inflammation
62
Purlent/suppurative exudate
* Contains: WBC, bacteria, fluid, proteins, fibrinogen and necrotic cellular debris
* Consistency: thick fluid
* Colour: white
* Indicative of severe infection and injury
63
Hemoragic exudate
* Contains: whole blood
* Consistency: fluid
* Colour: blood red
* Indicative of capilliary rupture
64
Fibrinous exudate
* Contains: High concentrations of Fibrinogen and Fibrin
* Consistency: Thick sticky meshwork
* Colour: yellowish, clear
* Indicative of severe injury
* Fibrinous inflammation is often difficult to resolve due to the fact that blood vessels grow into the exudate and fill the space that was occupied by fibrin. Often, large amounts of antibiotics are necessary for resolution.
65
What are the types of wound infection?
Wound infection is the second most common health
care–associated infection (nosocomial) (see Chapter 33). Accordingto the Centers for Disease Control and Prevention (CDC) (2001), a wound is infected if purulent material drains from it, even if a culture is not taken or has negative results. A sample of drainage from an infected wound does not always reveal bacteria, due to poor culture technique or administration of antibiotics. Positive culture findings do not always indicate an infection because many wounds contain colonies of noninfective resident bacteria. In fact, all chronic wounds are considered contaminated with bacteria. What differentiatescontaminated wounds from infected wounds is the amount of bacteria present. It is generally agreed that infected wounds have more than 100,000 (105) organisms per gram of tissue (Stotts, 2007b). The chances of wound infection are greater when the wound contains dead or necrotic tissue, when foreign bodies are in or near the wound, and when the blood supply and local tissue defenses are reduced.
Bacterial infection inhibits wound healing. Some contaminated or traumatic wounds show signs of infection early, within 2 to 3 days.
A surgical wound infection usually does not develop until day 4 or 5. The client has a fever, tenderness and pain at the wound site, and an elevated white blood cell count. The edges of the wound appear inflamed. If drainage is present, it is odorous and purulent, and is a yellow, green, or brown colour, depending on the causative organism
66
What is the difference between an aerobic an anaerobic culture?
Bacteria can be classified into aerobes and anaerobes. The main difference between the two is the fact that aerobic bacteria require oxygen to remain alive, while anaerobic bacteria do not rely on oxygen for metabolic processes and survival. While aerobes are able to thrive in habitats that have abundant oxygen, anaerobes may die in the presence of oxygen. This type of bacteria does have a growth advantage in areas of the body unexposed to oxygen, and they may become virulent pathogens. The difference in the capacity to utilize oxygen among aerobes and anaerobes is important in the treatment of bodily infections.
67
List the steps in collecting a wound culture specimen
* Clean the wound surface with a nonantiseptic (i.e., sterile water ornormal saline) solution.
* Use a sterile swab from a culturette tube.
* Rotate the swab in 1 cm2 of clean tissue in the open wound. Apply pressure to the swab to elicit tissue fluid. Insert the tip of the swab into the appropriate sterile container, and transport to the laboratory.
68
What is the purpose of a wet-to-dry dressing
several factors influence the choice of a wound dressing. When deciding which type of dressing to use the nurse must keep in mind that optimal healing takes place in a moist environment taking into account the wound, the drainage and the dressing. Necrotic tissue delays normal healing and must be debrided to promote wound healing. Wet to dry dressing can be used to help promote wound healing. Moist environments have been proven to aid in wound healing and shorten healing time. Open spots can take from days to weeks to heal. One way of treating this kind of a wound is to place a barrier against the newly forming skin and the wet gauze to help keep the area moist. Telfa pads are very gentle to open wounds without disturbing newly forming skin cells. Regular gauze dressing can pull off new skin cells at every dressing change and delay your healing since your body will have to make those skin cells again. This method can really make a difference and help the healing process.
69
. What is the purpose of wound packing? What precautions must be implemented?
serves three purposes: to debride the wound bed of dead tissue during healing, to absorb the Exudate and to keep the sides of the wound from touching and mending together. Pilonidal excision wounds are infamous for "bridging", which is the sides mending together before the bottom has filled in, this can leave dead space at the bottom of the wound and an abscess may form.
70
Dehiscence
separation of the layers of a surgical wound
71
Evisceration
he protrusion of an internal organ through a wound or surgical incision, especially in the abdominal wall.
72
Granulation tissue
: the newly formed vascular tissue normally produced in healing of wounds of soft tissue, ultimately forming the cicatrix.
73
Hemostasis
The stoppage of blood flow through a blood vessel or body part.
74
Keloid
an overgrowth of collagenous scar tissue at the site of a skin injury, particularly a wound or a surgical incision. The new tissue is elevated, rounded, and firm. Young women and African-Americans are particularly susceptible to keloid formation.
75
Eschar
a scab or dry crust that results from trauma, such as a thermal or chemical burn, infection, or excoriating skin disease.
76
Epithelialization :
the regrowth of skin over a wound.
77
Erythema
redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries. Examples of erythema are nervous blushes and mild sunburn.
78
Excoriation
an injury to a surface of the body caused by trauma, such as scratching, abrasion, or a chemical or thermal burn.
79
Exudate
fluid, cells, or other substances that have been slowly exuded, or discharged, from cells or blood vessels through small pores or breaks in cell membranes. Perspiration, pus, and serum are sometimes identified as exudates.
80
Serosanguineous drainage is normal immediatepostoperatively. T or F
True
81
Skin area around a wound should be assessed for
swelling
discolouration
redness
burning
82
A wound vac provides the following three functions:
removing drainage
improving tissue perfusion
mechanical debrieding of tissue
83
A wound vac is indicate for :
a. stage 3 and 4 pressure ulces
b. chronic open surgical wounds
c. primary intention healing
d. traumatic wounds
e. all of the above
f. a, b, and d
g. c only
f. a, b, and d
84
Documentation of a dressing should include:
integrity of suture line
change in skin colour
presence, amount, and character of drainage
85
To maintain adequate suction, a hemovac should be emptied:
a. when it is completely filled
b. when it is half full
c. every 2 hours
d. with each dressing change
b. when it is half full
86
A dressing saturated with blood is a potential sign of complication. T or F
True
87
List three functions of dressing changes
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control bleeding
maintain moist environment
protect from contaminates
prevent spreading of microorganisms
increase patient comfort
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88
Clean disposable gloves can be worn when removing the outer dressings of a wound. T or F
True
89
Wound cleansing should be done from most contaminated area to the least contaminated area. T or F
False
90
If a wet to dry dressing is saturated with too much solution, it could cause?
tissue maceration
bacterial growth
dressing not to dry adequately enough to remove necrotic tissue.
91
A wound vac is secured by a transparent self-adhering dressing. T or F
True
92
Wound vac foam strips should be inserted into the wound with moderate pressure. T or F
False
93
Wound vac documentation should include the amount of positive pressure userd
False. Negative pressure
94
Measuring the size of the wound is helpful when assessing healing. T or F
True
95
When repositioning an immobile client, the nurse notices redness over a bony prominence. When the area is assessed, the red spot blanches with fingertip touch, indicating which of the following?
A. A local skin infection requiring antibiotics
B. A stage III pressure ulcer needing the appropriate dressing
C. Sensitive skin that calls for the use of special bed linen
D. Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured area
D. Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured area
This observation is indicative of reactive hyperemia. This is not a local skin infection or a stage III pressure ulcer. Not enough information is given to determine whether the client has sensitive skin.
96
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Which type of pressure ulcer consists of an observable pressure-related alteration of intact skin that may show changes in skin temperature (warmth or coolness), tissue consistency (firm or beefy feel), or sensation (pain, itching) compared with an adjacent or opposite area on the body?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
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A. Stage I
97
When a wound specimen is obtained for culture to determine whether infection is present, the specimen should to be taken from which of the following?
A. Necrotic tissue
B. Wound drainage
C. Drainage on the dressing
D. The wound after it has first been cleansed with normal saline
D. The wound after it has first been cleansed with normal saline
The wound should be cleansed with saline, and then a culture specimen should be obtained from the cleanest (granulating) part of the wound. Necrotic tissue, drainage on the dressing, and old wound drainage can harbour old bacteria that may not necessarily be infecting the wound.
98
Postoperatively, a client with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the nurse sees that the sutures are open and that pieces of small bowel are visible at the bottom of the now opened wound. What is the correct intervention?
A. Allow the area to be exposed to air until all drainage has stopped.
B. Place several cold packs over the area, with care taken to protect the skin around the wound.
C. Cover the area with sterile saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration.
D. Cover the area with sterile gauze; place a tight binder over the areas; ask the client to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly
C. Cover the area with sterile saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration.
In wound evisceration, the bowel extrudes from the body. The nurse should cover the visible bowel with sterile saline-soaked towels and notify the surgical team. The area should not be allowed to be exposed or to dry out. Cold packs and binders are not acceptable options.
99
Serous drainage from a wound is defined as which of the following?
A. Fresh bleeding
B. Thick and yellow drainage
C. Clear, watery plasma
D. Beige to brown and foul-smelling drainage
C. Clear, watery plasma
100
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What item is not part of an assessment of skin regarding the risk of skin breakdown?
A. Nutritional status
B. Cognitive status
C. Hearing status
D. Mobility status
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C. Hearing status
101
Which of the following interventions is most appropriate in managing fecal and urinary incontinence in a client?
A. Keeping the buttocks exposed to air at all times
B. Applying a large absorbent diaper that is changed when completely saturated
C. Using an incontinence cleanser, followed by application of a moisture barrier ointment
D. Cleansing frequently, applying an ointment, and covering the areas with a thick, absorbent towel
C. Using an incontinence cleanser, followed by application of a moisture barrier ointment
The use of an incontinence cleanser followed by application of a moisture barrier helps to protect the skin when a client is incontinent. A diaper should be used to collect the feces and urine; however, the diaper should be changed as soon as it is wet—the nurse should not wait until the diaper is completely saturated. The client's dignity should be maintained by keeping the client covered.
102
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Which of the following is the most effective intervention for problems with skin integrity?
A. Sterile technique
B. Moist wound dressings
C. Thorough assessment
D. Prevention
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D. Prevention
Preventing skin breakdown is the best way to optimize skin integrity. Thorough assessment is important but must be acted upon. Moist wound dressings are useful tools when a wound has developed. Technique (clean or sterile) is relevant for wounds (chronic or surgical).
103
Placement of a binder around a surgical client with a new abdominal wound is indicated for which of the following?
A. Collection of wound drainage
B. Reduction of abdominal swelling
C. Reduction of stress on the abdominal incision
D. Stimulation of peristalsis (return of bowel function) from direct pressure
C. Reduction of stress on the abdominal incision
104
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When the skin and subcutaneous layers adhere to the surface of the bed, and the layers of muscle and the bones slide in the direction of body movement, this is known as which of the following?
A. Venous injury
B. Friction
C. Traction
D. Shear
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D. Shear
105
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Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, which results in tissue ischemia and, ultimately, tissue death. Pressure ulcer formation has four stages. The nurse observes partial-thickness skin loss involving the epidermis and possibly the dermis. What stage of ulcer will the nurse document?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
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B. Stage II
106
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Wound healing has three phases. The nurse observes granulation tissue in a client's pressure ulcer. What phase of wound healing is represented by granulation tissue?
A. Maturation phase
B. Hemostasis phase
C. Proliferative phase
D. Inflammatory phase
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C. Proliferative phase
Tissue granulation occurs in the proliferative phase. Maturation is the final stage of wound healing. Hemostasis occurs during the inflammatory phase.
107
A nurse observes all wounds closely. At what time is the risk of hemorrhage the greatest for surgical wounds?
A. Between 48 and 60 hours after surgery
B. Between 60 and 72 hours after surgery
C. During the first 24 to 48 hours after surgery
D. Seven days after surgery, when the client is more active
C. During the first 24 to 48 hours after surgery
The risk is highest during the first 24 to 48 hours after surgery because of the possibility of poor clot formation, slipped surgical suture, or trauma to a blood vessel by a foreign object. The more time that passes after surgery, the greater the amount of healing, which lessens the risk of hemorrhage.
108
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The autolytic, mechanical, chemical, and surgical methods that are often used during wound management are all methods of accomplishing what?
A. Wound dressing
B. Wound cleansing
C. Wound debridement
D. Stimulation of growth factors
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C. Wound debridement
All of these methods share the common objective of removing nonviable, necrotic tissue. Dressing, cleansing, and stimulation of growth factors are not part of debridement.
109
Several instruments are available for assessing clients who are at high risk for developing a pressure ulcer. The Braden Scale is the most commonly used. What risk factors are assessed using the Braden Scale?
A. Infection, hemorrhage, dehiscence, evisceration, and fistulas
B. Physical condition, mental condition, activity, mobility, and incontinence
C. Sensory perception, moisture, activity, mobility, nutrition, friction, and shear
D. Nutrition, tissue perfusion, infection, age, shear force and friction, and moisture
D. Nutrition, tissue perfusion, infection, age, shear force and friction, and moisture
The Braden Scale measures the following risk factors: sensory perception, moisture, activity, mobility, nutrition, friction, and shear. The Norton Scale measures five risk factors: physical condition, mental condition, activity, mobility, and incontinence. Infection, hemorrhage, dehiscence, evisceration, and fistulas are the complications of wound healing. The factors that influence pressure ulcer formation and wound healing are nutrition, tissue perfusion, infection, age, shear force and friction, and moisture.
110
A 40-year-old client recently became paraplegic. The client is about to be discharged from the rehabilitation centre. Prevention of pressure ulcers has been an important part of the client's education. In providing this education, the nurse should have included which of the following guidelines?
A. The client should sit in a chair for no longer than three hours.
B. The client should use a donut-shaped chair cushion.
C. The client should use a rigid cushion for full support.
D. The client should shift the weight in a chair every 15 minutes.
D. The client should shift the weight in a chair every 15 minutes.
Shifting weight frequently prevents prolonged pressure that may lead to pressure ulcer formation. The guideline for sitting up in a chair is to sit for two hours or less, but it is only a guideline. You should individualize activity for each client. Sitting on rigid or donut-shaped cushions is contraindicated because they reduce blood supply to the area, which increases the area of ischemia.
111
During the skin assessment of an older adult client who had a stroke, the nurse noted a reddened area over the coccyx. The nurse's next action for this client should include which of the following?
A. Massaging the reddened area and repositioning the client
B. Placing the client in the Fowler’s position and returning in two hours
C. Inserting a urinary catheter to prevent accumulation of moisture from urinary incontinence
D. Repositioning the client off the coccygeal area and reassessing the area in one hour
D. Repositioning the client off the coccygeal area and reassessing the area in one hour
Repositioning the client and reassessing the area in one hour are the most appropriate actions. When pressure is relieved from an area, the blood flow returns and the redness will disappear if no damage has occurred. This is the appropriate assessment. Placement in the Fowler's position would only increase pressure on the coccyx. Massaging of a reddened area is not recommended because it could cause further injury if the tissue is already compromised. Insertion of a urinary catheter will not relieve pressure on the coccyx.
112
Which of the following applies to an infected wound?
A. It requires systemic antibiotics
B. It will have increased drainage, pain, periwound erythema
C. It should be covered with an occlusive dressing
D. It always requires a swab for a culture specimen
B. It will have increased drainage, pain, periwound erythema
Signs and symptoms of wound infection include increased drainage, pain, and periwound erythema. Infected wounds ONLY require swab for culture to determine the virulence and type of bacteria present in the wound bed, in order to provide appropriate systemic antibiotic coverage. Superficial wound infections do not require systemic antibiotics as topical treatment will suffice. Occlusive dressings should not be used on infected wounds because they promote bacterial proliferation.
113
Which of the following is typical of venous stasis ulcers?
A. They are located on the arms and trunk.
B. They are shallow, irregularly shaped wounds on the lower legs.
C. They are deep and “punched out,” with a pale wound bed.
D. They are easy to heal.
B. They are shallow, irregularly shaped wounds on the lower legs.
Venous stasis wounds are characteristically located on the lower legs. They appear as superficial and irregularly shaped and are difficult to heal because of the underlying circulatory issues of edema and poor tissue perfusion. Deep, "punched-out," pale wound bed ulcers are arterial.
114
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Diabetic ulcers occur most commonly over bony prominences located on the plantar surface of the foot, over the metatarsal heads, and beneath the heels due to which of the following?
A. Neuropathic changes
B. Nutritional deficits
C. Reflex vasodilation
D. The aging process
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D. The aging process
Neuropathic changes affect microcirculation, decrease sensation, and decrease moisture in skin. Clients with diabetes often cannot feel pressure to the feet; hence, too tight footwear or abrasions within footwear cannot be felt. Dry skin is prone to calluses that create more pressure to the foot. Although nutritional deficits and the aging process have some impact on wound development, they are not the primary cause of diabetic ulcers. Reflex vasodilation occurs when an application of cold is left on too long.
115
Types of Bandage(Circular turns.)
Bandage turn overlapping previous turn completely
Purpose or Use Anchors bandage at the first and final turn; covers
small part (finger, toe)
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Types of Bandage(Spiral turns.)
Bandage ascending body part with each turn overlapping
previous one by one-half or two-thirds width of
bandage
Purpose or Use Covers cylindrical body parts such as wrist or upper
Arm
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Types of Bandage(Spiral-reverse turns.)
Turn requiring twist (reversal) of bandage halfway
through each turn
Purpose or Use Covers cone-shaped body parts such as the forearm,
thigh, or calf; useful with nonstretching
bandages such as gauze or flannel
118
Types of Bandage(Figure-eight turns)
Oblique overlapping turns alternately ascending and
descending over bandaged part; each turn crossing
previous one to form figure eight
Purpose or Use Covers joints, applies low-grade pressure for
venous return; snug fit provides excellent
immobilization
119
Types of Bandage(Recurrent turns.)
Bandage fi rst secured with two circular turns around
proximal end of body part; half turn made perpendicular
up from bandage edge; body of bandage brought over
distal end of body part to be covered with each turn
folded back over on itself
Purpose or Use Covers uneven body parts such as head or stump
120
Binders are bandages
made of large pieces of material specially
designed to fi t a specifi c body part. Most binders are made of elastic
or cotton. The most common type of binders are the abdominal
binder and breast binder. An abdominal binder supports large abdominal
incisions (e.g., following hernia repair) that are vulnerable
to tension or stress as a patient moves or coughs
121
Binders are bandages(Delegation Considerations)
The skill of applying a binder can be delegated to NAP. A nurse
assesses the condition of any incision, the skin, and patient’s ability
to breathe before binder application. The nurse directs the NAP
about:
• How to modify the skill, such as special wrapping or manner of
securing the binder.
• Reporting patient’s complaint of pain, numbness, tingling, or
diffi culty breathing after applying abdominal binder, or any
changes in patient’s skin color or temperature.
122
Binders are bandages(ASSESSMENT)
1 Observe patient who needs support of thorax or abdomen; observe ability to breathe deeply, cough effectively, and turn or move independently.
2 Review medical record for order for binder.
3 Inspect skin for actual or potential alterations in integrity. Observe for irritation, abrasion, and skin surfaces that rub against each other
4 Inspect any surgical dressing for intactness, presence of drainage, and coverage of incision. Change any soiled dressing before applying binder.
5 Determine patient’s level of comfort using a scale of 0 to 10. Administer prescribed analgesic 30 minutes before dressing change.
6 Gather necessary data regarding size of patient and appropriate binder to use (see manufacturer’s guidelines).
7 Determine patient’s knowledge of purpose of binder.
123
Principles for Packing a Wound
• Use the wound characteristics to decide what type of packing
is appropriate.
• Make sure the packing material can be safely used to pack a
wound.
• Moisten the packing material with a noncytotoxic solution such
as normal saline. Never use cytotoxic solutions (e.g., povidoneiodine)
to pack a wound.
• If using woven gauze, fl uff it before packing it into the wound.
• Loosely pack the wound.
• Do not let the packing material drag or touch the surrounding
wound tissue before you put it into the wound.
• Fill all the wound dead space with the packing material.
• Pack the wound until you reach the wound surface; never pack
the wound higher than the wound surface.
124
CULTURAL CONSIDERATIONS
Different cultures and religious practices attribute different meanings
to wounds and trauma. It is important to assess and try to
understand the different meaning of blood and wounds and how it
affects patients and their families
125
Gauze
| Dressings
A cotton or synthetic material of woven or nonwoven construction.
Indications for Use--
• Protection of surgical incisions
• Mechanical debridement (moist to dry)
• Secondary dressing for many other wound products
• Packing wounds
126
Transparent Films
Adhesive membrane dressings that are waterproof, impermeable to fluids and bacteria and allow oxygen and moisture vapor exchange.
Indications for Use--
• Shallow wounds with minimal exudate
• Skin protection from friction and shear
• Promotes autolytic debridement
• Stage I or II pressure ulcers
127
Hydrocolloids
Adhesive dressings composed of elastomeric, adhesive, and gelling agents. Considered semiocclusive dressings.
Indications for Use--
• Minimal to moderate exudating wounds
• Stage I to IV pressure ulcers
• Can be used in combination with absorbent powder or alginate
128
Hydrogel
Glycerin- or water-based dressings that are designed to hydrate a wound. They may also absorb a small amount of exudate.
Indications for Use--
• Dry to minimally invasive wound with or without a clean granular wound base
• Shallow or deep wounds
• Wounds with undermining
• Necrotic wounds
129
Alginates
Highly absorbent, nonwoven material that forms a gel when exposed to wound drainage; fibrous product derived from brown seaweed.
Indications for Use--
• Moderate to heavily exudating wounds with or without depth
• Full-thickness, tunneling wounds
• Partial- and fullthickness wounds
• Leg ulcers, donor sites, traumatic wounds
130
Foam
| Dressings
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An absorbent, nonadherent polyurethane pad used to protect wounds and maintain a moist healing environment.
Indications for Use--
Moderate or heavily exudating wounds
• Partial- and fullthickness wounds
• Stages II, II, and IV pressure ulcers
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