Podcast
Questions and Answers
A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient’s pain?
A patient complains of pain during a dressing change. What would be the most effective intervention the nurse could initiate at the next dressing change in order to reduce the patient’s pain?
Which action reduces the nurse’s risk for infection when changing the dressing of an infected abdominal wound?
Which action reduces the nurse’s risk for infection when changing the dressing of an infected abdominal wound?
What is the nurse’s best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago?
What is the nurse’s best response when additional bloody drainage appears on the initial abdominal dressing of a patient who had surgery 7 hours ago?
When changing a patient’s surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves?
When changing a patient’s surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves?
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Which action would minimize the risk for cross-contamination while cleansing an infected abdominal surgical wound?
Which action would minimize the risk for cross-contamination while cleansing an infected abdominal surgical wound?
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A patient who had surgery yesterday has the initial dressing covering the surgical site. What is the nurse’s responsibility in assessing this patient’s wound?
A patient who had surgery yesterday has the initial dressing covering the surgical site. What is the nurse’s responsibility in assessing this patient’s wound?
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Which wound would be allowed to heal by secondary intention?
Which wound would be allowed to heal by secondary intention?
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Before performing a wound assessment, which nursing action would reduce the patient’s risk for infection?
Before performing a wound assessment, which nursing action would reduce the patient’s risk for infection?
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Which intervention can the nurse delegate to nursing assistive personnel (NAP) in caring for a patient with a wound?
Which intervention can the nurse delegate to nursing assistive personnel (NAP) in caring for a patient with a wound?
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The nurse notes that a patient’s surgical wound is healing slowly. Which health problem would contribute to slow wound healing?
The nurse notes that a patient’s surgical wound is healing slowly. Which health problem would contribute to slow wound healing?
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What is the proper method for cleansing the evacuation port of a wound drainage system?
What is the proper method for cleansing the evacuation port of a wound drainage system?
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What is the nursing action to set up suction for a Hemovac drainage system?
What is the nursing action to set up suction for a Hemovac drainage system?
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When emptying a Jackson-Pratt drain, which issue should nursing assistive personnel (NAP) report immediately to the nurse as a potential abnormality?
When emptying a Jackson-Pratt drain, which issue should nursing assistive personnel (NAP) report immediately to the nurse as a potential abnormality?
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Which action might the nurse perform to ensure that the wound drainage tubing does not pull on the insertion site?
Which action might the nurse perform to ensure that the wound drainage tubing does not pull on the insertion site?
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Which action would maximize the suction produced by the Jackson-Pratt drainage system after the system has been emptied?
Which action would maximize the suction produced by the Jackson-Pratt drainage system after the system has been emptied?
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What is the preferred location for collecting a wound culture sample?
What is the preferred location for collecting a wound culture sample?
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What indicates a wound may have become infected?
What indicates a wound may have become infected?
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What should a nurse avoid when collecting a wound culture sample?
What should a nurse avoid when collecting a wound culture sample?
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Which practice should be followed for transporting wound culture specimens?
Which practice should be followed for transporting wound culture specimens?
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What could indicate trauma to a wound during assessment?
What could indicate trauma to a wound during assessment?
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What is the correct method for obtaining an anaerobic culture from a wound?
What is the correct method for obtaining an anaerobic culture from a wound?
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Which action should be taken before collecting a wound culture sample?
Which action should be taken before collecting a wound culture sample?
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What is an indication of wound trauma during assessment?
What is an indication of wound trauma during assessment?
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The health care provider writes an order for a culture specimen to be collected from a patient with a dog bite wound. What would the nurse do first?
The health care provider writes an order for a culture specimen to be collected from a patient with a dog bite wound. What would the nurse do first?
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Which action would the nurse take to reduce the risk for wound infection when collecting a specimen for culture?
Which action would the nurse take to reduce the risk for wound infection when collecting a specimen for culture?
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Which question might the nurse ask the patient when an aerobic wound culture has been ordered?
Which question might the nurse ask the patient when an aerobic wound culture has been ordered?
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Which instruction might the nurse give to the NAP to help ensure that a wound culture specimen will be transported properly?
Which instruction might the nurse give to the NAP to help ensure that a wound culture specimen will be transported properly?
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Which nursing action demonstrates proper procedure in the collection of a wound culture specimen?
Which nursing action demonstrates proper procedure in the collection of a wound culture specimen?
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Alexander Brooks is a 20-year-old caucasian male with paraplegia as the result of a spinal cord injury received in a motorcycle accident. He lives at home with his parents who assist with his care. Alexander is attending college and has a strong social support system. He visits the health clinic on campus for a regularly scheduled skin assessment, where the nurse observes a reddish area on his sacrum. the nurse observes that the reddish area is round and directly over the pt sacrum. The skin is intact. In addition to measuring the length of time the redness last which assessment measures should the nurse perfom
Alexander Brooks is a 20-year-old caucasian male with paraplegia as the result of a spinal cord injury received in a motorcycle accident. He lives at home with his parents who assist with his care. Alexander is attending college and has a strong social support system. He visits the health clinic on campus for a regularly scheduled skin assessment, where the nurse observes a reddish area on his sacrum. the nurse observes that the reddish area is round and directly over the pt sacrum. The skin is intact. In addition to measuring the length of time the redness last which assessment measures should the nurse perfom
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Alexander Brooks is a 20-year-old caucasian male with paraplegia as the result of a spinal cord injury received in a motorcycle accident. He lives at home with his parents who assist with his care. Alexander is attending college and has a strong social support system. He visits the health clinic on campus for a regularly scheduled skin assessment, where the nurse observes a reddish area on his sacrum. the nurse observes that the reddish area is round and directly over the pt sacrum. The aural area has remained red for 2 hours and does not blanch when tested. which is the best description for the nurse to document
Alexander Brooks is a 20-year-old caucasian male with paraplegia as the result of a spinal cord injury received in a motorcycle accident. He lives at home with his parents who assist with his care. Alexander is attending college and has a strong social support system. He visits the health clinic on campus for a regularly scheduled skin assessment, where the nurse observes a reddish area on his sacrum. the nurse observes that the reddish area is round and directly over the pt sacrum. The aural area has remained red for 2 hours and does not blanch when tested. which is the best description for the nurse to document
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Alexander Brooks is a 20-year-old caucasian male with paraplegia as the result of a spinal cord injury received in a motorcycle accident. He lives at home with his parents who assist with his care. Alexander is attending college and has a strong social support system. He visits the health clinic on campus for a regularly scheduled skin assessment, where the nurse observes a reddish area on his sacrum. the nurse observes that the reddish area is round and directly over the pt sacrum. Nurse identifies pt has stage 1 pressure ulcer. What areas are most important for the nurse to observe for additional ulcers
Alexander Brooks is a 20-year-old caucasian male with paraplegia as the result of a spinal cord injury received in a motorcycle accident. He lives at home with his parents who assist with his care. Alexander is attending college and has a strong social support system. He visits the health clinic on campus for a regularly scheduled skin assessment, where the nurse observes a reddish area on his sacrum. the nurse observes that the reddish area is round and directly over the pt sacrum. Nurse identifies pt has stage 1 pressure ulcer. What areas are most important for the nurse to observe for additional ulcers
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Alexander Brooks is a 20-year-old caucasian male with paraplegia as the result of a spinal cord injury received in a motorcycle accident. He lives at home with his parents who assist with his care. Alexander is attending college and has a strong social support system. He visits the health clinic on campus for a regularly scheduled skin assessment, where the nurse observes a reddish area on his sacrum. the nurse observes that the reddish area is round and directly over the pt sacrum. During assessment of high risk areas the nurse find no redness by underlying tissues feels spongy
Alexander Brooks is a 20-year-old caucasian male with paraplegia as the result of a spinal cord injury received in a motorcycle accident. He lives at home with his parents who assist with his care. Alexander is attending college and has a strong social support system. He visits the health clinic on campus for a regularly scheduled skin assessment, where the nurse observes a reddish area on his sacrum. the nurse observes that the reddish area is round and directly over the pt sacrum. During assessment of high risk areas the nurse find no redness by underlying tissues feels spongy
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Which type of dressing is most likely to be used over a stage 1 pressure ulcer
Which type of dressing is most likely to be used over a stage 1 pressure ulcer
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A month later Alexander arrives in the emergency department at the local hospital he reports that he has had the flu and has spent most of his time in bed for the last several days. He has been experiencing vomiting and diarrhea. The nurse observes that his sacral ulcer is open, has a crate like appearance and the draining is a large amount of thick yellow tan fluid with an unpleasant odor a small amount of eschar is present Alexander is admitted to the hospital with a fever fluid volume deficiency and possible substance which documentation best describes the drainage from Alexander's wound?
A month later Alexander arrives in the emergency department at the local hospital he reports that he has had the flu and has spent most of his time in bed for the last several days. He has been experiencing vomiting and diarrhea. The nurse observes that his sacral ulcer is open, has a crate like appearance and the draining is a large amount of thick yellow tan fluid with an unpleasant odor a small amount of eschar is present Alexander is admitted to the hospital with a fever fluid volume deficiency and possible substance which documentation best describes the drainage from Alexander's wound?
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a month later Alexander arrives in the emergency department at the local hospital he reports that he has had the flu and has spent most of his time in bed for the last several days. He has been experiencing vomiting and diarrhea. The nurse observes that his sacral ulcer is open, has a crate like appearance and the draining is a large amount of thick yellow tan fluid with an unpleasant odor a small amount of eschar is present Alexander is admitted to the hospital with a fever fluid volume deficiency and possible sepsis. Which intervention is important to reduce the effect of diarrhea on Alexander's skin
a month later Alexander arrives in the emergency department at the local hospital he reports that he has had the flu and has spent most of his time in bed for the last several days. He has been experiencing vomiting and diarrhea. The nurse observes that his sacral ulcer is open, has a crate like appearance and the draining is a large amount of thick yellow tan fluid with an unpleasant odor a small amount of eschar is present Alexander is admitted to the hospital with a fever fluid volume deficiency and possible sepsis. Which intervention is important to reduce the effect of diarrhea on Alexander's skin
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When preparing to discharge a patient who had an indwelling urinary catheter removed 24 hours ago the nurse would offer patient education regarding which common complication
When preparing to discharge a patient who had an indwelling urinary catheter removed 24 hours ago the nurse would offer patient education regarding which common complication
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Which action would best minimize a patient’s risk for infection during removal of an indwelling urinary catheter?
Which action would best minimize a patient’s risk for infection during removal of an indwelling urinary catheter?
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Which statement might the nurse make to nursing assistive personnel (NAP) caring for a patient who has just had an indwelling urinary catheter removed?
Which statement might the nurse make to nursing assistive personnel (NAP) caring for a patient who has just had an indwelling urinary catheter removed?
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Which nursing action minimizes a patient’s risk for injury during removal of an indwelling urinary catheter?
Which nursing action minimizes a patient’s risk for injury during removal of an indwelling urinary catheter?
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Which is not an expected outcome on a first voiding after catheter removal?
Which is not an expected outcome on a first voiding after catheter removal?
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While performing an intermittent straight urinary catheterization of a female patient, the nurse inadvertently inserts the catheter into the patient’s vagina. Which action would the nurse take next?
While performing an intermittent straight urinary catheterization of a female patient, the nurse inadvertently inserts the catheter into the patient’s vagina. Which action would the nurse take next?
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While attempting to perform a straight catheterization for a male patient, the nurse advances the catheter 3 to 4 inches into the meatus but observes no urine flow. Which action would the nurse take at this time?
While attempting to perform a straight catheterization for a male patient, the nurse advances the catheter 3 to 4 inches into the meatus but observes no urine flow. Which action would the nurse take at this time?
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The nurse instructs nursing assistive personnel (NAP) regarding proper technique for intermittent straight catheterization of a male patient. Which statement made by NAP indicates that the instruction was effective?
The nurse instructs nursing assistive personnel (NAP) regarding proper technique for intermittent straight catheterization of a male patient. Which statement made by NAP indicates that the instruction was effective?
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Why does the nurse cleanse a female patient’s perineum before inserting an intermittent urinary catheter?
Why does the nurse cleanse a female patient’s perineum before inserting an intermittent urinary catheter?
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The nurse has completed an intermittent straight urinary catheterization of a female patient. Which action would the nurse delegate to nursing assistive personnel (NAP)?
The nurse has completed an intermittent straight urinary catheterization of a female patient. Which action would the nurse delegate to nursing assistive personnel (NAP)?
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Why does the nurse need to keep the urine sterile while obtaining a sample from an indwelling urinary catheter?
Why does the nurse need to keep the urine sterile while obtaining a sample from an indwelling urinary catheter?
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Which action will ensure that a sterile urine specimen is handled properly in order to help obtain reliable results?
Which action will ensure that a sterile urine specimen is handled properly in order to help obtain reliable results?
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Which statement might the nurse make to nursing assistive personnel (NAP) before delegating the collection of a routine urine sample from a patient with an indwelling urinary catheter?
Which statement might the nurse make to nursing assistive personnel (NAP) before delegating the collection of a routine urine sample from a patient with an indwelling urinary catheter?
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Which measure may be taken to minimize the staff’s risk for infection from a urine specimen?
Which measure may be taken to minimize the staff’s risk for infection from a urine specimen?
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When collecting a urine specimen from an indwelling urinary catheter, which action is most likely to ensure that sufficient urine is collected?
When collecting a urine specimen from an indwelling urinary catheter, which action is most likely to ensure that sufficient urine is collected?
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What is the best reason for the nurse to instruct a male patient to take slow, deep breaths during insertion of an indwelling urinary catheter?
What is the best reason for the nurse to instruct a male patient to take slow, deep breaths during insertion of an indwelling urinary catheter?
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When preparing to insert an indwelling urinary catheter in a male patient, it is important for the nurse to do what?
When preparing to insert an indwelling urinary catheter in a male patient, it is important for the nurse to do what?
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Which observation indicates that instruction given to nursing assistive personnel (NAP) in caring for a patient with an indwelling urinary catheter has been effective?
Which observation indicates that instruction given to nursing assistive personnel (NAP) in caring for a patient with an indwelling urinary catheter has been effective?
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Which action will the nurse implement to reduce the risk of catheter-associated urinary tract infection (CAUTI) in a male patient with an indwelling urinary catheter?
Which action will the nurse implement to reduce the risk of catheter-associated urinary tract infection (CAUTI) in a male patient with an indwelling urinary catheter?
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While setting up the sterile field in preparation for inserting an indwelling urinary catheter, a male patient is incontinent of urine over most of the supplies. What action would the nurse take to reduce the patient’s risk for infection?
While setting up the sterile field in preparation for inserting an indwelling urinary catheter, a male patient is incontinent of urine over most of the supplies. What action would the nurse take to reduce the patient’s risk for infection?
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. Which action would the nurse take to reduce the risk for a catheter-associated urinary tract infection (CAUTI) in a patient with an indwelling urinary catheter?
. Which action would the nurse take to reduce the risk for a catheter-associated urinary tract infection (CAUTI) in a patient with an indwelling urinary catheter?
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Which action(s) would minimize the patient’s risk for injury during insertion of an indwelling urinary catheter?
Which action(s) would minimize the patient’s risk for injury during insertion of an indwelling urinary catheter?
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Which statement best illustrates the nurse’s understanding of the role of nursing assistive personnel (NAP) when inserting an indwelling urinary catheter in a female patient?
Which statement best illustrates the nurse’s understanding of the role of nursing assistive personnel (NAP) when inserting an indwelling urinary catheter in a female patient?
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The nurse has completed the initial inspection of the patient’s perineum and is preparing to insert an indwelling urinary catheter. Which action would the nurse complete next?
The nurse has completed the initial inspection of the patient’s perineum and is preparing to insert an indwelling urinary catheter. Which action would the nurse complete next?
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A female patient placed in the dorsal recumbent position for the insertion of an indwelling urinary catheter tells the nurse that she “doesn’t feel comfortable in this position” and that her “back really hurts.” What is the nurse’s best response?
A female patient placed in the dorsal recumbent position for the insertion of an indwelling urinary catheter tells the nurse that she “doesn’t feel comfortable in this position” and that her “back really hurts.” What is the nurse’s best response?
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Which of the following is an example of healing by secondary intention? (Select all that apply.)
Which of the following is an example of healing by secondary intention? (Select all that apply.)
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The nurse is assigned to care for a patient with a deep wound infection. Which action would result in the contamination of sterile gloves?
The nurse is assigned to care for a patient with a deep wound infection. Which action would result in the contamination of sterile gloves?
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The nurse may use clean gloves for changing the dressing on which of the following?
The nurse may use clean gloves for changing the dressing on which of the following?
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Which of the following patients is at greatest risk for developing a wound infection?
Which of the following patients is at greatest risk for developing a wound infection?
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- A package of gauze that is wet is safe to use provided that the gauze on the inside is not wet
- A package of gauze that is wet is safe to use provided that the gauze on the inside is not wet
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Edges of wrappers hanging down over the edge of a sterile field are considered sterile
Edges of wrappers hanging down over the edge of a sterile field are considered sterile
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The one half inch area at the edge of the sterile field is considered contaminated
The one half inch area at the edge of the sterile field is considered contaminated
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. Always hold sterile objects in front of you and below the waist
. Always hold sterile objects in front of you and below the waist
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The nurse is performing a dressing change on a patient who is postoperative from a laparotomy. The patient coughs and the nurse see a few loops of intestine uncoiling from the wound. What is the nurse’s best action at this time?
The nurse is performing a dressing change on a patient who is postoperative from a laparotomy. The patient coughs and the nurse see a few loops of intestine uncoiling from the wound. What is the nurse’s best action at this time?
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When teaching a patient about wound healing, which of the following should the nurse tell the patient?
When teaching a patient about wound healing, which of the following should the nurse tell the patient?
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Serous drainage from a wound is defined as which of the following
Serous drainage from a wound is defined as which of the following
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How is the vacuum re established after emptying a drain such as the Jackson Pratt drain or hemovac
How is the vacuum re established after emptying a drain such as the Jackson Pratt drain or hemovac
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The nurse is collaborating with the dietitian in treatment of a patient with stage 3 pressure injury. After the collaboration the nurse the nurse orders a meal plan that includes increased levels of what?
The nurse is collaborating with the dietitian in treatment of a patient with stage 3 pressure injury. After the collaboration the nurse the nurse orders a meal plan that includes increased levels of what?
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Which of the following is correct for wound irrigation to avoid damaging fragile granulation tissue
Which of the following is correct for wound irrigation to avoid damaging fragile granulation tissue
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Wound healing has three phases. The nurse observes granulation tissue in a patient's pressure ulcer. What phase of wound healing is represented by granulation tissue
Wound healing has three phases. The nurse observes granulation tissue in a patient's pressure ulcer. What phase of wound healing is represented by granulation tissue
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when repositioning an immobile patient the nurse notices redness over a Bony prominence. When the area is assessed the red spot blanches with fingertip touch indicating:
when repositioning an immobile patient the nurse notices redness over a Bony prominence. When the area is assessed the red spot blanches with fingertip touch indicating:
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A client is to go home with a Jackson Pratt drain. Which of the following statements if made by a client indicates further teaching is required
A client is to go home with a Jackson Pratt drain. Which of the following statements if made by a client indicates further teaching is required
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The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by wish process
The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by wish process
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Why does a wound bed need to stay moist
Why does a wound bed need to stay moist
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A family member calls the nurse to ask for advice regarding their mother who has developed a bed sore on her right heel. The family member describes the pressure injury as a blister that has now popped and you can see redness. Based on this description at what stage would the nurse classify this pressure injury??
A family member calls the nurse to ask for advice regarding their mother who has developed a bed sore on her right heel. The family member describes the pressure injury as a blister that has now popped and you can see redness. Based on this description at what stage would the nurse classify this pressure injury??
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What is the primary goal of medical asepsis?
What is the primary goal of medical asepsis?
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In which scenario is surgical asepsis most appropriately utilized?
In which scenario is surgical asepsis most appropriately utilized?
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What happens if a sterile object touches a non-sterile object?
What happens if a sterile object touches a non-sterile object?
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Which action is vital for ensuring surgical asepsis during a procedure?
Which action is vital for ensuring surgical asepsis during a procedure?
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How often should handwashing be emphasized in medical asepsis practices?
How often should handwashing be emphasized in medical asepsis practices?
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What happens to a sterile object that touches a clean or contaminated object?
What happens to a sterile object that touches a clean or contaminated object?
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When is the sterile field considered contaminated?
When is the sterile field considered contaminated?
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Which of the following practices helps maintain the sterility of a surgical field?
Which of the following practices helps maintain the sterility of a surgical field?
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What should be done if a sterile package is found to be wet or punctured?
What should be done if a sterile package is found to be wet or punctured?
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How does gravity affect sterile objects during surgical procedures?
How does gravity affect sterile objects during surgical procedures?
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What is a common indicator of a pressure injury developing due to inadequate blood flow?
What is a common indicator of a pressure injury developing due to inadequate blood flow?
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Which of the following factors does NOT affect tissue tolerance to pressure injuries?
Which of the following factors does NOT affect tissue tolerance to pressure injuries?
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What could result from prolonged pressure applied to a capillary beyond its normal capacity?
What could result from prolonged pressure applied to a capillary beyond its normal capacity?
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Which pressure-related factor is most associated with the duration of pressure on the skin?
Which pressure-related factor is most associated with the duration of pressure on the skin?
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What is the significance of hyperemia in evaluating a pressure injury?
What is the significance of hyperemia in evaluating a pressure injury?
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What is the correct direction to clean a wound during irrigation?
What is the correct direction to clean a wound during irrigation?
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Which solution is appropriate for cleaning a wound without harming healing tissues?
Which solution is appropriate for cleaning a wound without harming healing tissues?
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What is the recommended pressure for irrigating a wound?
What is the recommended pressure for irrigating a wound?
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What type of gauge catheter should be used for wound irrigation with a syringe?
What type of gauge catheter should be used for wound irrigation with a syringe?
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What action should be avoided when cleaning a wound to minimize trauma?
What action should be avoided when cleaning a wound to minimize trauma?
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What characterizes chronic wounds compared to acute wounds?
What characterizes chronic wounds compared to acute wounds?
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Which type of wound healing involves the greatest loss of tissue?
Which type of wound healing involves the greatest loss of tissue?
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In what scenario would tertiary intention healing typically occur?
In what scenario would tertiary intention healing typically occur?
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Which of the following best describes primary intention healing?
Which of the following best describes primary intention healing?
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What type of wounds typically heal by secondary intention?
What type of wounds typically heal by secondary intention?
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What is the typical time frame during which dehiscence is most likely to occur after an injury or surgery?
What is the typical time frame during which dehiscence is most likely to occur after an injury or surgery?
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Which sign is NOT typically associated with wound infection?
Which sign is NOT typically associated with wound infection?
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What is the proper action to take in the event of evisceration of abdominal organs through the wound opening?
What is the proper action to take in the event of evisceration of abdominal organs through the wound opening?
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Which of the following strategies is effective in preventing dehiscence during patient coughing?
Which of the following strategies is effective in preventing dehiscence during patient coughing?
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Which of the following symptoms is least likely to be associated with delayed healing of a wound?
Which of the following symptoms is least likely to be associated with delayed healing of a wound?
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What is the primary characteristic of serous drainage?
What is the primary characteristic of serous drainage?
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Which type of drainage is indicated by a light red or pink tint and is thin in consistency?
Which type of drainage is indicated by a light red or pink tint and is thin in consistency?
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Purulent drainage can vary in color. Which of the following is not a typical color associated with purulent drainage?
Purulent drainage can vary in color. Which of the following is not a typical color associated with purulent drainage?
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In assessing wound drainage, what would sanguineous drainage most likely indicate?
In assessing wound drainage, what would sanguineous drainage most likely indicate?
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Which description best matches the appearance and consistency of purulent drainage?
Which description best matches the appearance and consistency of purulent drainage?
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What is the primary function of neutrophils during the inflammatory phase of wound healing?
What is the primary function of neutrophils during the inflammatory phase of wound healing?
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Which process occurs first in the phases of wound healing?
Which process occurs first in the phases of wound healing?
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During which phase of wound healing does scar tissue begin to form?
During which phase of wound healing does scar tissue begin to form?
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What crucial role does collagen play in the wound healing process?
What crucial role does collagen play in the wound healing process?
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What characteristic of scar tissue differentiates it from normal skin?
What characteristic of scar tissue differentiates it from normal skin?
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What does a red color in a wound generally indicate?
What does a red color in a wound generally indicate?
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Which characteristic describes a wound that is classified as partial thickness?
Which characteristic describes a wound that is classified as partial thickness?
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What does a black or brown color in a wound tissue indicate?
What does a black or brown color in a wound tissue indicate?
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How is a chronic wound defined in terms of age?
How is a chronic wound defined in terms of age?
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What does a yellow color in a wound indicate regarding its cleanup need?
What does a yellow color in a wound indicate regarding its cleanup need?
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What characterizes a Stage 1 pressure ulcer?
What characterizes a Stage 1 pressure ulcer?
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Which of the following describes a Stage 2 pressure ulcer?
Which of the following describes a Stage 2 pressure ulcer?
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Which statement is true for a Stage 3 pressure ulcer?
Which statement is true for a Stage 3 pressure ulcer?
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What is a defining feature of a Stage 4 pressure ulcer?
What is a defining feature of a Stage 4 pressure ulcer?
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What does Stage 5 pressure ulcer indicate?
What does Stage 5 pressure ulcer indicate?
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Which description best fits a Stage 3 pressure ulcer?
Which description best fits a Stage 3 pressure ulcer?
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Which factor is not used to classify a pressure ulcer stage?
Which factor is not used to classify a pressure ulcer stage?
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Study Notes
Wound Culture Collection
- Collect wound culture samples from viable granulation tissue near the center of the wound.
- Cleanse or irrigate the wound with sterile 0.9% sodium chloride solution before sampling.
- Avoid touching the periskin with the culture swab to prevent wound contamination from normal skin flora.
- Consult agency policies regarding infection control practices and specimen transport procedures.
- Watch for localized inflammation, tenderness, and warmth at the wound site, potentially indicating infection.
- Observe for redness and bleeding around wound edges, which may indicate trauma.
- Deliver the specimen to the laboratory within the appropriate timeframe for accurate results.
Wound Culture Samples
- Wound culture samples should be collected from viable granulation tissue near the center of the wound.
- Cleanse or irrigate the wound with sterile 0.9% sodium chloride solution before collecting the sample.
Signs of Infection
- Look for localized inflammation, tenderness, and warmth at a wound site with purulent drainage, indicating infection.
Wound Trauma
- Observe for redness and bleeding around the edges of a wound, which may indicate wound trauma.
Aerobic Culture
- Use a swab from a culture tube and gently rotate it in the wound's fresh drainage area.
- Return the swab to the culture tube.
Anaerobic Culture
- Use a swab from a special anaerobic culture tube.
- Insert the swab deeply into the draining body cavity and gently rotate it.
- Withdraw the swab and return it to the culture tube.
Alternative Anaerobic Collection
- Insert a syringe without a needle into the wound and aspirate 5 to 10 mL of exudate.
- Attach a transfer device to the syringe, expel all air, and inject the drainage into an anaerobic culture tube.
Medical Asepsis
- Referred to as "clean techniques"
- Reduces the number of pathogens
- Used in procedures such as medication administration, enemas, tube feedings, and daily washing.
- Handwashing is considered the number one factor in preventing infections.
- An object or area is considered contaminated if it contains or is suspected of containing microorganisms.
- Examples of contaminated objects include used bedpans, the floor, and used dressings.
Surgical Asepsis
- Referred to as "sterile technique"
- Eliminates all pathogens, including spores.
- Includes procedures used to eliminate pathogens from an object or area.
- Used for procedures such as dressing changes, cauterizations, and surgical procedures.
- Used in procedures where the client's skin is punctured, such as IV insertion or injections.
- Also used for non-intact skin due to injury or surgery, and insertions of catheters or surgical instruments into sterile body cavities, like urinary catheterization, peritoneal dialysis catheters.
- An object or area is considered contaminated if touched by anything that is not sterile.
- The slightest break in technique results in contamination.
- Commonly practiced in operating rooms, labor and delivery areas, and diagnostic areas.
- Surgical asepsis is also used at the bedside.
- Proper preparation of the patient is essential to avoid contaminated sterile items.
- Surgical asepsis takes time, so nurses may need to administer analgesics to the patient no more than half an hour before sterile procedures begin.
- Patients should be given the opportunity to void before a sterile procedure.
Principles of Surgical Asepsis
- Sterile objects remain sterile only when touched by other sterile objects.
- Touching a sterile object with a contaminated object contaminates the sterile object.
- Only sterile items should be placed on a sterile field.
- Tears, wetness, or punctures in packaging before opening contaminate the contents.
- A sterile object or field out of sight or below the waist is contaminated.
- Prolonged exposure to air contaminates a sterile object or field as microorganisms can fall on it from the air. Nurses should avoid activities that create air currents while a sterile field or object is exposed.
- A sterile surface that comes into contact with a wet, contaminated surface becomes contaminated. Wet sterile pouches and packages require re-sterilization.
- Fluids flow with gravity which can contaminate objects.
- To maintain sterility, nurses should hold their hands above the elbow as this prevents contaminated fluids from flowing down the arm.
- The edges of a sterile field or container are considered contaminated. The border of contamination is about 1 inch (2.5 cm).
### Pressure Injuries
- Pressure injuries are localized damage to the skin and underlying tissue, often occurring over bony prominences.
- The primary causes are pressure, shear, and friction, exacerbated by factors like moisture, nutrition, perfusion, and co-morbidities.
-
Pressure intensity is crucial:
- Excessive pressure surpasses normal capillary pressure, obstructing blood flow for extended periods, leading to tissue ischemia.
- Clinical evaluation includes observing skin color changes:
- Hyperemia (redness) indicates potential blood flow obstruction.
- Blanching (turning lighter when pressed) followed by color return suggests reversible tissue damage.
- Non-blanching after pressure application suggests deeper tissue damage.
- Assessment difficulties arise in individuals with darker skin pigmentation.
-
Pressure duration impacts tissue damage:
- Both prolonged low pressure and short-term high pressure can cause injury.
- Extended pressure occludes blood flow and nutrients, contributing to cell death.
-
Tissue tolerance is influenced by factors like:
- Shear and friction: Increase susceptibility to damage.
- Moisture: Aggravates tissue vulnerability.
- Underlying tissue integrity: Weak support structures reduce pressure redistribution capacity.
-
Systemic factors impacting tolerance include:
- Poor nutrition: Compromises tissue health and repair.
- Age: Older individuals have thinner skin, leading to reduced tolerance.
- Low blood pressure: Reduces blood flow and oxygen delivery to tissues.
Wound Cleansing
- Never use the same gauze to clean across an incision or wound.
- Clean wounds from the least contaminated area to the most contaminated area.
- Use gentle friction when applying solutions to the skin.
- When irrigating, solutions should flow from the least contaminated area to the most contaminated area.
- Only noncytotoxic wound cleaners, like normal saline or commercial wound cleaners, should be used.
- Cytotoxic solutions are not recommended for healing wounds.
- When irrigating, pressure should be within 8-15 psi.
- Use a 30-50 cc syringe with an 18–19-gauge Angio catheter or 100 ml saline squeeze bottle for irrigation.
Wound Definition
- A wound is defined as a disruption to the structure and function of tissues within the body.
Wound Types
- There are two main types of wounds: acute and chronic.
- Acute wounds, such as surgical wounds, heal predictably and quickly following a normal healing process.
- Chronic wounds, such as pressure injuries, experience interruptions in the normal repair process and healing is difficult.
Wound Healing: Primary Intention
- Occurs when wounds have minimal tissue loss.
- Examples include clean surgical wounds and paper cuts.
- Wound edges are closely approximated and healing is rapid.
Wound Healing: Secondary Intention
- Occurs when wounds involve tissue loss.
- Examples include second and third-degree burns, or pressure injuries.
- Wound edges are not approximated, making healing slower.
- Healing proceeds from the edges inward and from the base of the wound upwards through granulation tissue development.
Wound Healing: Tertiary Intention
- Also known as delayed primary intention.
- Occurs when suturing is delayed to allow infection resolution.
- The wound is left open until infection is resolved and then sutured.
- Two layers of granulated tissue are then sutured together.
Wound Healing Complications
-
Hemorrhage: Bleeding from a wound can occur externally or internally.
-
Wound Infection:
- Second most common hospital-acquired infection (HAI).
- Signs include:
- Pain and tenderness at the wound site
- Erythema (redness)
- Edema (swelling)
- Inflammation of wound edges
- Purulent drainage (pus)
- Warmth of tissues at the site
- Fever or chills
- Elevated white blood cell (WBC) count
- Delayed healing
-
Dehiscence:
- Partial or total separation of wound layers.
- Typically occurs 3 to 11 days after injury or surgery.
- Most common in abdominal surgical wounds.
- Can occur after vigorous coughing or straining.
- Prevention strategies:
- Support the area with pillows or splints during coughing.
-
Evisceration:
- Protrusion of abdominal organs through the wound opening.
- Medical emergency requiring immediate surgical intervention.
- Nursing interventions:
- Cover organs with sterile saline-soaked towels.
- Keep the client NPO (nothing by mouth).
- Monitor for signs and symptoms of shock.
Wound Drainage Types
-
Serous Drainage:
- Clear or slightly yellow
- Thin plasma
- Slightly thicker than water
-
Sanguineous Drainage:
- Bloody drainage
- Bright red color
- Somewhat thick consistency (like syrup)
- May indicate:
- Fresh trauma to the wound
- Excessive activity after surgery
- Stress on the wound site
-
Serosanguineous Drainage:
- Thin, like water
- Light red or pink tinge
- Appearance influenced by the amount of clotted red blood mixed with serum
-
Purulent Drainage:
- Thick consistency
- Color variation: grayish, yellow, green, tan, brown
Wound Healing
- Wound healing: A natural process involving a complex cascade of cellular events to restore injured skin.
Stages of Wound Healing
-
Hemostasis: Begins immediately after injury.
- Vasoconstriction to minimize blood loss via mediators (epinephrine, norepinephrine, prostaglandins, serotonin & thromboxane)
- Platelet aggregation results in clot formation.
-
Inflammation: Body's response to injury, lasting ~3 days.
- Neutrophils are the primary white blood cells, ingesting bacteria & debris.
- Monocytes transform into macrophages (phagocytes).
-
Proliferation: lasts 3-24 days.
- New blood vessels form.
- Wound fills with granulated tissue.
- Wound contraction reduces the healing area.
- Epithelialization resurfaces the wound.
- Collagen provides structural integrity.
-
Remodeling/Maturation: Can take up to 2 years.
- Scar tissue forms, lighter in color due to fewer pigment cells.
- Healed wounds are susceptible to pressure injuries due to reduced tensile strength.
Wound Classification
- Wound classification helps nurses assess wound risk and healing potential.
- Age classifies wounds as acute (recent injury) or chronic (long-lasting).
- Wound depth is categorized as partial thickness (affecting the epidermis and dermis) or full thickness (extending to the subcutaneous tissue or deeper).
-
Wound Colour indicates the stage of healing:
- Red signifies a protective phase, where new tissue is forming.
- Yellow indicates a cleaning phase is needed, with presence of slough or exudate.
- Black/Brown suggests debridement, where necrotic tissue needs to be removed.
Stage 1 Pressure Ulcer
- Skin remains intact
- Non-blanchable erythema present: Redness that does not disappear when pressure is applied
- Erythema does not fade within minutes of pressure relief
- Individuals with darker skin may exhibit purplish or bluish discoloration
- Typically located over bony prominences
Stage 2 Pressure Ulcer
- Partial-thickness ulceration involving loss of the dermis
- Superficial wound appearance
- Shallow, open ulcer with a pink base
- No slough present
- Examples include abrasions, blisters, and shallow craters
Stage 3 Pressure Ulcer
- Full-thickness tissue loss
- May affect subcutaneous tissue (SC)
- Does not extend beyond the fascia
- Deep crater with varying depth
- Slough may be present
Stage 4 Pressure Ulcer
- Full-thickness tissue loss with exposed bone, tendon, or muscle
- Extends through SC tissue and into the fascia
- Extensive destruction, often with undermining and tunneling
- Examples include exposed muscle, bone, tendons, and joints
Stage 5 Pressure Ulcer
- Stage unknown due to obscured wound bed
- Wound bed may be covered with eschar
- Unable to accurately stage due to lack of visibility
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Explore effective interventions for managing patient pain during dressing changes. This quiz focuses on nursing techniques aimed at reducing discomfort while providing care. Test your knowledge on patient-centered approaches to pain management.
