Surgical Wound Care ( ch 14 foundations) Flashcards
The nurse instructs a patient who has a drain in a surgical wound that the wound will heal by:
tertiary intention.
To assist the postoperative patient to cough, the nurse:
splints the abdomen with a pillow.
-is helpful to relieve stress on the suture line.
The day following surgery, the nurse notes bloody drainage on the dressing. The nurse will record this drainage as:
sanguineous.
-The term sanguineous means bloody. It is indicative of active bleeding.
The nurse explains that the advantage of an occlusive dressing is that it:
keeps the incision moist and increase epithelialization.
When the nurse discovers that the gauze dressing has adhered to the wound, the nurse should:
moisten the dressing with sterile water.
The nurse instructs the patient in home wound irrigation to hold the hand-held showerhead approximately ______ inches from the wound .
12
The nurse follows the basic concept of wound irrigation when directing the flow of the irrigant:
from the area of least contamination to the area of most contamination.
- to prevent microorganisms from entering the wound.
The nurse observes a loop of bowel protruding from the surgical incision. The nurse’s initial intervention should be to:
cover the bowel with a sterile saline dressing.
*Although the RN must be notified, covering the loop of bowel takes priority. The patient may be raised to a semi-Fowler’s position to relieve strain on the suture line.
The nurse is removing every other staple from a surgical wound, which has been closed with 15 staples. If the wound begins to separate after removal of 3 of the 15 staples, the nurse should:
leave the 12 staples in place and record the separation.
Because the physician has not ordered a dressing change for a draining wound, the nurse should assess the amount of drainage by:
circling and dating the outline of the exudate on the dressing.
The Centers for Disease Control (CDC) classifies wounds according to the amount of contamination. An uninfected surgical wound with less than a 5% chance of becoming infected postoperatively is classified as a:
clean wound.
Hemostasis begins as soon as the injury occurs and a clot begins to form. The substance in the clot that holds the wound together is:
fibrin.
When blood and fluid flow into the vascular space and produce edema, erythema, heat, and pain, the nurse knows that the wound is in which phase?
Inflammatory
Primary intention has a marked advantage over other phases of wound healing because:
minimal scarring results.
For the first 24 hours following surgery, the nurse assesses for bleeding by observing the dressing and the area under the patient every:
2 to 4 hours.
To keep the patient comfortable during a dressing change, the nurse may administer an analgesic:
at least 30 minutes before the dressing change.
The nurse informs a patient that a wet-to-dry dressing is applied wet and allowed to dry. This drying process causes it to adhere to the wound, which when removed results in:
mechanical debridement.
During assessment of a postoperative patient, the nurse discovers that the pulse is rapid, blood pressure has decreased, urinary output has decreased, and the dressing is dry. The nurse recognizes these findings as indicative of:
internal hemorrhage.
The usual length of time before suture removal is:
7 to 10 days.
The nurse carefully measures drainage during the first 24 hours after surgery on a patient with a Jackson-Pratt drain. It is considered abnormal if the drainage exceeds:
300 mL.
The nurse recognizes that the Jackson-Pratt drainage removal system is classified as a(n):
closed drainage system.
The nurse caring for a patient with a surgical wound promotes healing by:
encouraging the consumption of small frequent meals.
The nurse instructing a patient about the effects of smoking informs the patient that smoking:
interferes with normal cellular mechanisms that promote release of oxygen.
*Smoking reduces the amount of functional hemoglobin in blood, thus decreasing tissue oxygenation. Smoking may increase platelet aggregation and hypercoagulability. Smoking interferes with normal cellular mechanisms that promote release of oxygen to tissues.
The nurse instructing a patient about the effects of diabetes mellitus informs the patient that diabetes mellitus:
causes hemoglobin to have a greater affinity for oxygen.
*Diabetes mellitus is a chronic disease that causes small blood vessel disease that impairs tissue perfusion. It also causes hemoglobin to have greater affinity for oxygen, so it fails to release oxygen to tissues.
The nurse assessing a patient’s wound notes a clear watery drainage. The nurse documents this finding as:
serous drainage.
- has the appearance of clear, watery plasma.
The nurse assessing a patient’s wound notes thick, yellow drainage. The nurse documents this finding as:
purulent drainage.
- has the appearance of thick, yellow, green, tan, or brown drainage
The nurse assessing a patient’s wound notes pale red watery drainage. The nurse documents this finding as:
serosanguineous drainage.
- is pale, red, and watery and is a mixture of serous and sanguineous drainage.
The nurse assessing a patient’s wound notes bright red drainage. The nurse documents this finding as:
sanguineous drainage.-
- is bright red and indicates active bleeding.
The nurse is assisting a patient to a sitting position when the patient suddenly complains of feeling that his surgical incision has separated. The nurse recognizes this as an indication of:
dehiscence.
Which are the phases of wound healing? (Select all that apply.)
a. Reconstruction
b. Hemostasis
c. Inflammatory
d. Maturation
Which solution(s) can be used on a wet-to-dry dressing? (Select all that apply.)
a. Normal saline
b. Lactated Ringer’s
c. Acetic acid
d. Dakin’s
The nurse assures a patient that the purple, raised, immature scar of his surgical wound is normal and caused by _______ formation.
collagen
The nurse encourages a patient recovering from a hysterectomy to drink at least _______ mL of fluid a day.
2000
When preparing to remove a dressing, the nurse should don __________ gloves.
clean
A transparent dressing has which advantages? (Select all that apply.)
a. Adheres to undamaged skin
b. Contains the exudate
c. Reduces wound contamination
d. Serves as a barrier to external bacteria
e. Speeds epithelial growth
Clean Wound
Is an uninfected surgical wound with closure
Inflammatory phase
initial increase in blood elements and fluid leaking out of the blood vessels into the vascular space
healing process lasts about 4-6 days; Leukocytes and Macrophages move to clean up debris.
- cells in the injured tissue migrate, divide and form new cells
Inflammatory Phase
Causes Cardinal signs and symptoms of inflammation: erythema, heat, edema, pain, and tissue dysfunction
Reconstruction Phase
- collagen formation occurs-a gluelike protein substance that adds tensile strength to the wound and tissue;
- appearance changes to an irregular, raised, purplish, immature scar, wound dehiscence most frequently occurs during this phase
- this phase begins on the 3rd or 4th day after injury and lasts 2-3 weeks
Maturation Phase
healing starts at week 3, can last months, closed by connective tissue and resurfaced epithelial cells
Keloids (hypertropic scar) may form during this phase
Primary Intention
- Wound in which skin edges are close together and little tissue is lost such as those made surgically
- Minimal scarring results
- healing begins during the inflammatory phase of healing; in surgery this is usually during closure of the wound
Hemostasis
Termination of bleeding
Begins as soon as the injury occurs
Fibrin in the clot begins to hold the wound together and bleeding subsides
Secondary Intention
- when a wound must granulate during healing
- skin edges are not close together or when pus has
formed
-scarring is greater in a larger wound
Tertiary Intention
delayed suturing of a wound in which two layers of granulation tissue are sutured together
-occurs when a contaminated wound is left open and sutured closed after the infection is controlled or a primary wound becomes infected, is opened, allowed to granulate and then sutured
The inflammatory response
tissue reaction to injury
Depends on the level of injury inflicted, size of the area involved, and physical condition of the patient
Phagocytosis
Occurs when exudate from the injured cell is surrounded, engulfed, and digested by leukocytes
Gauze
Permits air to reach the wound
Semiocclusive
Permits oxygne but not air impurities to pass
Occlusive
Permits neither air nor oxygen to pass
Keep the incision moist and increase epithelialization
Dry Dressing
-may be chosen for management of a wound with little exudate/drainage
-Protects wounds from:
-injury
-Prevents introduction of bacteria
-reduces discomfort
speeds healing
-most commonly used for abrasions and non-draining postoperative incisions
Wet-to-Dry
- primary purpose is to mechanically debride a wound (remove dead skin)
- The moistened contact layer of the dressing increases the absorptive ability of the dressing to collect exudate and wound debris.
- as the dressing dries, it adheres to the wound and debrides it when the dressing is removed
- commonly used wetting agents are:
- normal saline
- povidone-iodine
- antibiotic solutions
Irrigations
Fluid retention is avoided by positioing the patient on his/her side to encourage the flow of the irrigant away from the wound
Internal hemorrhage
Rapid pulse, decrease blood pressure, decreased urinary output, and the dressing is dry
If internal hemorrhage occurs The dressing may be dry while the abdominal cavity collects blood
Evisceration
Abdominal organs protrude through an opened incision
Patient is to remain in bed, Wound and contents should be coverd with warm, sterile saline dressings
Surgeon is notified immediately, Medical Emergency
wound infection
Infected wound displays a fever, tenderness, and pain at the wound, edema. and elevated WBC count
Staple and Suture Removal
Time of removal is based on the stage of healing
Usually removed 7 to 10 days after surgery
If wound separates during removal of staples, cease removal, cover with dry dressing and record separation
Serous
thin, watery exudate composing the serum portion of blood
Sanguineous
Fluid that contains blood
Serosanguineous
thin and red; composed both of serum and blood
Jackson-pratt
removal system Closed drainage system
Closed drainage
System of tubing and other apparatus attached to the body to remove fluid in airtight circuit that prevent environmental contaminants from entering the wound or cavity
binder
bandages made of large pieces of material to fit a specific part of the body
granulation
soft, pink, fleshy projection consisting of capillaries surrounded by fibrosis collagen that slowly fills the incision during process of healing
T-tube
After surgical removal of gallbladder ( an open cholecystectomy)
to drain bile from common duct until edema has subsided
- drains by gravity into a closed drainage system
vacuum-assisted closure
A device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together
clean-contaminated wound
a surgical incision made into the respiratory, the gastrointestinal. or the genitourinary tract after special presurgical preparation
contaminated wound
results from the presence of GI products from an acute, nonpurulent inflammation; or when aseptic technique is broken during surgery
dirty/infected wound
wound infected before surgery
Wounds are classified
according to: Cause: -incision or puncture Severity of injury: Amount of contamination: -clean, clean contaminated, contaminated, and dirty or infected Skin integrity:
Transparent dressings
-self adhesive transparent film is a synthetic permeable membrane that acts as a temporary secondary skin.
Advantages:
- adheres to undamaged skin to contain exudates and minimize wound contamination
- serves as a barrier to external fluids and bacteria yet still allows the wound to breathe
- Promotes a moist environment that speeds epithelial cell growth
- Permits visualization of the wound
Wound bleeding
bleeding may indicate:
- a slipped suture
- dislodged clot
- coagulation problem
- trauma to blood vessels or tissue
- if internal hemorrhage occurs, the dressing may be dry while the abdominal cavity collects blood.
Wound infection
-surgical wound becomes contaminated
-CDC labels a wound “infected” when it contains purulent drainage
-A patient with infected wound displays:
-cardinal symptoms
-Elevated WBC count
-Purulent drainage has an odor and is brown, yellow, or green depending on the pathogen
Culturing a wound Bacterial wound contamination:
-one of the most common causes of altered wound healing
Clinical infection may become apparent 2 to 11 days postoperatively
Important step in wound healing:
-Identifying infectious agent in wound
Exudate/Drainage
- the type and amount produced depend on the tissue and organs involved
- More than 300 mL in the first 24 hours should be treated as abnormal
- when patients first ambulate, a slight increase may occur
- Assess (color, amount, consistency and odor)
Staple and suture removal -
physicians written order is always obtained before implementing either skill
- Removal is based on the stage of healing and extent of surgery
- Sutures and staples are generally removed within 7 - 10 days after surgery
- the physician determines and orders removal of:
- sutures or staples one at a time
- removal of every other suture or staple
- Replaced with a steri-strip
Sutures -
threads of wire or other materials )silk, steel, cotton, linen, nylon and dacron) used to sew together body tissues
- Placed within:
- tissue layers in deep wounds
- superficially as the final means of wound closure
Open drainage
Passes through an open ended tube into a receptacle or out onto the dressing
