Practice lab II midterm

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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?

Premedicate the patient with a prescribed analgesic 30 minutes before the intervention. (correct)

Use a distraction technique to divert the patient’s attention during the procedure.

Position the patient comfortably before the intervention.

Thoroughly explain the procedure to the patient.

Which action reduces the nurse’s risk for infection when changing the dressing of an infected abdominal wound?

Begin antibiotic therapy before the dressing change.

Use appropriate personal protective equipment (PPE). (correct)

Adhere to sterile technique during the intervention.

Complete the dressing change in an effective, timely way.

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?

Notify the surgeon of the bleeding.

Remove the dressing, and assess the wound.

Assess the patient for signs of shock.

Further assess the patient and the wound. (correct)

When changing a patient’s surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves?

After removing the original dressing materials and performing hand hygiene a second time Signup and view all the answers

Which action would minimize the risk for cross-contamination while cleansing an infected abdominal surgical wound?

Using a new gauze pad for each stroke while cleansing the wound Signup and view all the answers

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?

Wait until the health care provider orders the removal of the surgical dressing. Signup and view all the answers

Which wound would be allowed to heal by secondary intention?

Infected hysterectomy incision Signup and view all the answers

Before performing a wound assessment, which nursing action would reduce the patient’s risk for infection?

Applying clean gloves Signup and view all the answers

Which intervention can the nurse delegate to nursing assistive personnel (NAP) in caring for a patient with a wound?

Reporting the presence of wound odor Signup and view all the answers

The nurse notes that a patient’s surgical wound is healing slowly. Which health problem would contribute to slow wound healing?

Diabetes mellitus Signup and view all the answers

What is the proper method for cleansing the evacuation port of a wound drainage system?

Wipe it with an alcohol sponge. Signup and view all the answers

What is the nursing action to set up suction for a Hemovac drainage system?

Compress the hemovac, creating suctio Signup and view all the answers

When emptying a Jackson-Pratt drain, which issue should nursing assistive personnel (NAP) report immediately to the nurse as a potential abnormality?

The amount of drainage was greater today than yesterday. Signup and view all the answers

Which action might the nurse perform to ensure that the wound drainage tubing does not pull on the insertion site?

Attach the tubing to the patient’s gown with a safety pin. Signup and view all the answers

Which action would maximize the suction produced by the Jackson-Pratt drainage system after the system has been emptied?

Compressing the bulb while replacing the port cap Signup and view all the answers

What is the preferred location for collecting a wound culture sample?

From the center of the wound using viable granulation tissue Signup and view all the answers

What indicates a wound may have become infected?

Increased warmth and tenderness at the site Signup and view all the answers

What should a nurse avoid when collecting a wound culture sample?

Contact with periskin unless a skin culture is ordered Signup and view all the answers

Which practice should be followed for transporting wound culture specimens?

Know and adhere to agency policies on infection control for body substances Signup and view all the answers

What could indicate trauma to a wound during assessment?

Redness and bleeding around the edges of the wound Signup and view all the answers

What is the correct method for obtaining an anaerobic culture from a wound?

Aspirate exudate and inject it into a special anaerobic culture tube Signup and view all the answers

Which action should be taken before collecting a wound culture sample?

Irrigate the wound with sterile saline Signup and view all the answers

What is an indication of wound trauma during assessment?

Redness and bleeding around the edges of the wound Signup and view all the answers

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?

Review the order to determine the type of specimen to be collected. Signup and view all the answers

Which action would the nurse take to reduce the risk for wound infection when collecting a specimen for culture?

Collect the specimen while wearing sterile gloves. Signup and view all the answers

Which question might the nurse ask the patient when an aerobic wound culture has been ordered?

Do you have any pain at the wound site?” Signup and view all the answers

Which instruction might the nurse give to the NAP to help ensure that a wound culture specimen will be transported properly?

“Take this specimen to the lab immediately.” Signup and view all the answers

Which nursing action demonstrates proper procedure in the collection of a wound culture specimen?

Wearing clean gloves to remove soiled dressings Signup and view all the answers

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

Apply light pressure to the area with the fingertips Signup and view all the answers

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

Reactive Hyperemia Signup and view all the answers

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

Heels and ankles Signup and view all the answers

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

Identify these area as sites where pressure damage has occurred. Signup and view all the answers

Which type of dressing is most likely to be used over a stage 1 pressure ulcer

Transparent film dressing Signup and view all the answers

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?

Purulent Signup and view all the answers

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

Apply a moisture repellent ointment to intact skin areas Signup and view all the answers

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

UTI Signup and view all the answers

Which action would best minimize a patient’s risk for infection during removal of an indwelling urinary catheter?

The nurse or nursing assistive personnel (NAP) removing the catheter must employ clean technique. Signup and view all the answers

Which statement might the nurse make to nursing assistive personnel (NAP) caring for a patient who has just had an indwelling urinary catheter removed?

“Tell me when and how much the patient first voids.” Signup and view all the answers

Which nursing action minimizes a patient’s risk for injury during removal of an indwelling urinary catheter?

Checking the documentation for the volume of fluid used to inflate the balloon Signup and view all the answers

Which is not an expected outcome on a first voiding after catheter removal?

Fever and back pain Signup and view all the answers

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?

Keep the catheter in place, and begin again with a new sterile catheter. Signup and view all the answers

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?

Continue to advance the catheter until 5 to 7 inches of the catheter tube has been introduced into the urethra. Signup and view all the answers

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?

“I’ll help keep his legs away from the sterile field.” Signup and view all the answers

Why does the nurse cleanse a female patient’s perineum before inserting an intermittent urinary catheter?

To reduce the patient’s risk of urinary tract infection Signup and view all the answers

The nurse has completed an intermittent straight urinary catheterization of a female patient. Which action would the nurse delegate to nursing assistive personnel (NAP)?

Measure and empty the urine. Signup and view all the answers

Why does the nurse need to keep the urine sterile while obtaining a sample from an indwelling urinary catheter?

Sterile technique ensures that microorganisms in the specimen are from the urine, and not the result of contamination. Signup and view all the answers

Which action will ensure that a sterile urine specimen is handled properly in order to help obtain reliable results?

Having someone take the specimen to the lab immediately Signup and view all the answers

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?

“Let me know if the urine contains blood or sediment, or appears cloudy.” Signup and view all the answers

Which measure may be taken to minimize the staff’s risk for infection from a urine specimen?

. Firmly securing the lid of the urine specimen container Signup and view all the answers

When collecting a urine specimen from an indwelling urinary catheter, which action is most likely to ensure that sufficient urine is collected?

Clamping the catheter tubing for 15 minutes before collection Signup and view all the answers

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?

To promote relaxation Signup and view all the answers

When preparing to insert an indwelling urinary catheter in a male patient, it is important for the nurse to do what?

Lubricate the first 5 to 7 inches of the catheter. Signup and view all the answers

Which observation indicates that instruction given to nursing assistive personnel (NAP) in caring for a patient with an indwelling urinary catheter has been effective?

The excess catheter tubing has been coiled beside the patient’s inner thigh. Signup and view all the answers

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?

Clean the urinary meatus daily. Signup and view all the answers

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?

Replace all contaminated supplies, and begin the process again. Signup and view all the answers

. 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?

Use the smallest-size catheter possible. Signup and view all the answers

Which action(s) would minimize the patient’s risk for injury during insertion of an indwelling urinary catheter?

Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances Signup and view all the answers

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?

“Please direct the light to better illuminate the patient’s perineal area.” Signup and view all the answers

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?

Remove soiled gloves, and perform hand hygiene. Signup and view all the answers

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?

Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip. Signup and view all the answers

Which of the following is an example of healing by secondary intention? (Select all that apply.)

A full-thickness pressure injury Signup and view all the answers

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 takes a gauze pad in hand and places it in the wound. Signup and view all the answers

The nurse may use clean gloves for changing the dressing on which of the following?

Chronic pressure injury Signup and view all the answers

Which of the following patients is at greatest risk for developing a wound infection?

An obese patient with diabetes who smokes Signup and view all the answers

A package of gauze that is wet is safe to use provided that the gauze on the inside is not wet

False Signup and view all the answers

Edges of wrappers hanging down over the edge of a sterile field are considered sterile

False Signup and view all the answers

The one half inch area at the edge of the sterile field is considered contaminated

False Signup and view all the answers

. Always hold sterile objects in front of you and below the waist

False Signup and view all the answers

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?

Apply sterile saline-soaked towels to the area. Signup and view all the answers

When teaching a patient about wound healing, which of the following should the nurse tell the patient?

Inadequate nutrition delays wound healing and increases risk of infection. Signup and view all the answers

Serous drainage from a wound is defined as which of the following

clear, watery plasma Signup and view all the answers

How is the vacuum re established after emptying a drain such as the Jackson Pratt drain or hemovac

By compressing the drain reservoir Signup and view all the answers

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?

Protein Signup and view all the answers

Which of the following is correct for wound irrigation to avoid damaging fragile granulation tissue

Room temperature or body temperature and 4-15 psi of pressure Signup and view all the answers

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

proliferative Signup and view all the answers

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:

Reactive hyperaemia, a reaction that causes the blood vessels to dilate I the injured area Signup and view all the answers

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

If drainage suddenly stops it means the drain is ready to be removed. Signup and view all the answers

The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by wish process

Secondary intention Signup and view all the answers

Why does a wound bed need to stay moist

To support healing by enabling granulation tissue Signup and view all the answers

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??

Stage 2 Signup and view all the answers

What is the primary goal of medical asepsis?

Reducing the number of pathogens Signup and view all the answers

In which scenario is surgical asepsis most appropriately utilized?

Insertion of a urinary catheter Signup and view all the answers

What happens if a sterile object touches a non-sterile object?

The sterile object is considered contaminated Signup and view all the answers

Which action is vital for ensuring surgical asepsis during a procedure?

Maintaining a sterile field and technique Signup and view all the answers

How often should handwashing be emphasized in medical asepsis practices?

As the number one factor in infection control Signup and view all the answers

What happens to a sterile object that touches a clean or contaminated object?

The sterile object becomes contaminated. Signup and view all the answers

When is the sterile field considered contaminated?

When it is out of sight or below the waist. Signup and view all the answers

Which of the following practices helps maintain the sterility of a surgical field?

Ensuring air currents are minimized. Signup and view all the answers

What should be done if a sterile package is found to be wet or punctured?

It is considered contaminated and should not be used. Signup and view all the answers

How does gravity affect sterile objects during surgical procedures?

Fluid flows downwards and can contaminate the objects. Signup and view all the answers

What is a common indicator of a pressure injury developing due to inadequate blood flow?

The skin remains red and becomes more elevated than surrounding tissue. Signup and view all the answers

Which of the following factors does NOT affect tissue tolerance to pressure injuries?

Hydration level Signup and view all the answers

What could result from prolonged pressure applied to a capillary beyond its normal capacity?

Tissue ischemia or reduced blood flow. Signup and view all the answers

Which pressure-related factor is most associated with the duration of pressure on the skin?

Pressure duration Signup and view all the answers

What is the significance of hyperemia in evaluating a pressure injury?

It signifies potential deeper tissue damage if blanching does not occur. Signup and view all the answers

What is the correct direction to clean a wound during irrigation?

From the least contaminated area to the most contaminated area Signup and view all the answers

Which solution is appropriate for cleaning a wound without harming healing tissues?

Commercial wound cleaners Signup and view all the answers

What is the recommended pressure for irrigating a wound?

8-15 psi Signup and view all the answers

What type of gauge catheter should be used for wound irrigation with a syringe?

18–19-gauge Angio catheter Signup and view all the answers

What action should be avoided when cleaning a wound to minimize trauma?

Applying solutions at a high pressure Signup and view all the answers

What characterizes chronic wounds compared to acute wounds?

They do not heal easily and the normal healing process is interrupted. Signup and view all the answers

Which type of wound healing involves the greatest loss of tissue?

Secondary Intention Signup and view all the answers

In what scenario would tertiary intention healing typically occur?

When a wound becomes infected before it is sutured. Signup and view all the answers

Which of the following best describes primary intention healing?

It is characterized by rapid healing of well-approximated edges. Signup and view all the answers

What type of wounds typically heal by secondary intention?

Second and third degree burns. Signup and view all the answers

What is the typical time frame during which dehiscence is most likely to occur after an injury or surgery?

3-11 days Signup and view all the answers

Which sign is NOT typically associated with wound infection?

Bleeding at the wound site Signup and view all the answers

What is the proper action to take in the event of evisceration of abdominal organs through the wound opening?

Cover the organs with sterile saline soaked towels Signup and view all the answers

Which of the following strategies is effective in preventing dehiscence during patient coughing?

Using a pillow as a splint for support Signup and view all the answers

Which of the following symptoms is least likely to be associated with delayed healing of a wound?

Normal white blood cell count Signup and view all the answers

What is the primary characteristic of serous drainage?

Clear or slightly yellow and thin Signup and view all the answers

Which type of drainage is indicated by a light red or pink tint and is thin in consistency?

Serosanguineous drainage Signup and view all the answers

Purulent drainage can vary in color. Which of the following is not a typical color associated with purulent drainage?

Bright red Signup and view all the answers

In assessing wound drainage, what would sanguineous drainage most likely indicate?

Presence of fresh trauma or activity stress on the wound site Signup and view all the answers

Which description best matches the appearance and consistency of purulent drainage?

Thick and yellow to brown Signup and view all the answers

What is the primary function of neutrophils during the inflammatory phase of wound healing?

To ingest bacteria and debris Signup and view all the answers

Which process occurs first in the phases of wound healing?

Hemostasis Signup and view all the answers

During which phase of wound healing does scar tissue begin to form?

Remodeling/Maturation Signup and view all the answers

What crucial role does collagen play in the wound healing process?

It acts as a framework for cellular repair Signup and view all the answers

What characteristic of scar tissue differentiates it from normal skin?

Contains fewer pigmented cells Signup and view all the answers

What does a red color in a wound generally indicate?

Healing process is underway Signup and view all the answers

Which characteristic describes a wound that is classified as partial thickness?

It extends through the epidermis and part of the dermis Signup and view all the answers

What does a black or brown color in a wound tissue indicate?

Necrotic tissue that requires debridement Signup and view all the answers

How is a chronic wound defined in terms of age?

Wounds that have not healed in adequate time Signup and view all the answers

What does a yellow color in a wound indicate regarding its cleanup need?

The wound needs cleaning to aid healing Signup and view all the answers

What characterizes a Stage 1 pressure ulcer?

Intact skin with non-blanchable erythema Signup and view all the answers

Which of the following describes a Stage 2 pressure ulcer?

Shallow, open ulcer with loss of dermis Signup and view all the answers

Which statement is true for a Stage 3 pressure ulcer?

Does not extend beyond the fascia Signup and view all the answers

What is a defining feature of a Stage 4 pressure ulcer?

Exposed bone, tendon, or muscle Signup and view all the answers

What does Stage 5 pressure ulcer indicate?

Unstageable due to obscured wound bed Signup and view all the answers

Which description best fits a Stage 3 pressure ulcer?

Full thickness tissue loss with possible slough Signup and view all the answers

Which factor is not used to classify a pressure ulcer stage?

Presence of infection Signup and view all the answers

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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Description

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.