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Questions and Answers

What is the primary goal in managing pain related to surgical wounds?

Maintain strict bed rest

Promote wound drainage

Decrease medication use

Increase mobility (correct)

Which type of drainage is characterized by a mixture of clear and red fluid?

Serous

Purulent

Sanguineous

Serosanguineous (correct)

What is one of the key assessments of a wound that can indicate potential infection?

Wound size

Wound color

Patient pain levels

Wound drainage consistency (correct)

Which nursing diagnosis is commonly associated with wounds and injuries?

Risk for Infection Signup and view all the answers

What is the primary purpose of using drains like Hemovac or Jackson Pratt?

To facilitate fluid removal Signup and view all the answers

What is the significance of assessing the color and odor of a wound's drainage?

To evaluate potential complications such as infection Signup and view all the answers

Which of the following is a type of wound closure method?

Sutures Signup and view all the answers

What is a commonly used method for cleaning a wound effectively?

Starting from the least contaminated area Signup and view all the answers

Why is proper nutrition important in wound management?

It enhances the body's healing process Signup and view all the answers

Which dressing type is most appropriate for a heavily draining wound?

Foam dressings Signup and view all the answers

Which layer of the skin is responsible for providing structural integrity and elasticity?

Dermis Signup and view all the answers

What type of wound is classified as having full-thickness skin loss with exposed dermis?

Stage 2 Pressure Injury Signup and view all the answers

Which factor is NOT associated with the development of pressure ulcers?

Balanced nutrition Signup and view all the answers

Which of the following describes the inflammatory phase of wound healing?

Response to injury with redness and swelling Signup and view all the answers

What is the primary intention of wound healing?

Surgical closure of a wound Signup and view all the answers

In the context of wound classifications, which term describes a wound with damage to both the dermis and epidermis?

Open wound Signup and view all the answers

What complication may occur if a surgical wound opens up along the incision line?

Dehiscence Signup and view all the answers

Which classification of pressure injury is characterized by full-thickness skin loss obscured by slough or eschar?

Unstageable Pressure Injury Signup and view all the answers

Which of the following is an example of a descriptive quality of wounds?

Contusion Signup and view all the answers

Which assessment tool is most widely used to predict the risk of developing pressure injuries?

Braden Scale Signup and view all the answers

In secondary intention healing, which phase plays a crucial role in filling the wound with new tissue?

Proliferative phase Signup and view all the answers

Moisture on the skin can contribute to pressure ulcer development by causing which of the following?

Skin maceration Signup and view all the answers

What is a common cause of evisceration in wound healing?

Improper surgical closure Signup and view all the answers

Which combination of factors can interfere with wound healing?

Age, Infection, Nutrition Signup and view all the answers

What is a complication associated with the use of nasogastric tubes for long-term feeding?

Electrolyte imbalance Signup and view all the answers

Which category of nasogastric tubes is specifically designed for gastric decompression?

Large-bore Tube Signup and view all the answers

What common sign indicates a paralytic ileus is present?

Abdominal distention Signup and view all the answers

Which suction type is NOT typically used for facilitating tube drainage?

Reverse Suction Signup and view all the answers

What can be a direct effect of maintaining an NG tube improperly?

Oral inflammations Signup and view all the answers

Which of the following is a primary function of the Sengstaken-Blakemore tube?

Internal application of pressure Signup and view all the answers

What specific electrolyte imbalance is a common cause of paralytic ileus?

Hypokalemia Signup and view all the answers

Which intervention is essential for preventing reflux and aspiration in patients with an NG tube?

Maintaining a high Fowler's position Signup and view all the answers

What is a primary nursing diagnosis for a patient requiring long-term management of incompetent bladders?

Risk for impaired urinary elimination Signup and view all the answers

Which of the following indications necessitates intermittent catheterization?

Need for sterile urine specimen Signup and view all the answers

What essential patient education should be provided regarding Kegel exercises?

Consistency in practice is key for effectiveness. Signup and view all the answers

Which of the following is a key technique in ensuring proper catheter insertion?

Verifying and confirming the provider's orders Signup and view all the answers

Which statement is true regarding care for patients with indwelling catheters to prevent urinary tract infections (UTIs)?

Appropriate peri care is a significant nursing measure. Signup and view all the answers

Which nursing diagnosis is commonly associated with urinary elimination problems, indicating the patient’s difficulty in managing their urinary hygiene?

Self-care deficit, toileting Signup and view all the answers

Which laboratory test is primarily used to assess the presence of bacteria and other pathogens in the urine?

Urinalysis Signup and view all the answers

What is the main purpose of patient education regarding fluid intake in urinary health promotion?

To maintain adequate hydration and promote normal urination Signup and view all the answers

In catheterization techniques, what is the most important nursing responsibility prior to performing a cystoscopy?

Ensure the patient has signed consent and assess for allergies Signup and view all the answers

Which factor can contribute to urinary retention in patients post-surgery?

Anesthesia affecting bladder function Signup and view all the answers

When assessing the characteristics of urine, which of the following is typically NOT a normal finding?

Foul odor Signup and view all the answers

Which approach best helps to prevent catheter-associated urinary tract infections (CAUTI)?

Strict adherence to hygiene protocols Signup and view all the answers

In the context of urinary diversion, what procedure involves the diversion of urine to an external source to bypass the bladder?

Ureterostomy Signup and view all the answers

Which aspect of patient care is essential after urinary diagnostic examinations?

Assessing intake and output (I&O) Signup and view all the answers

What is the main goal of using anticholinergic medications in urinary management?

To enhance bladder relaxation Signup and view all the answers

Which urinary elimination problem is characterized by the involuntary leakage of urine?

Urinary incontinence Signup and view all the answers

What is an important psychological consideration for patients with urinary elimination issues?

Feelings of anxiety regarding hygiene and embarrassment Signup and view all the answers

What characteristic of urine is typically NOT used to assess renal function?

Odor Signup and view all the answers

Which urinary catheter size is commonly associated with long-term use in managing urinary retention?

14 Fr Signup and view all the answers

Study Notes

Skin Layers

Epidermis: Outermost skin layer.
Dermis: Inner skin layer containing collagen.
Dermal-epidermal junction: Separates dermis and epidermis.

Wound Severity

Superficial
Penetrating
Perforating

Wound Descriptors

Laceration
Incision
Abrasion
Contusion
Pressure wounds

Pressure Injuries

Also known as pressure ulcers, decubitus ulcers, or bedsores.
Pathogenesis involves pressure intensity causing tissue ischemia and blanching, pressure duration, and tissue tolerance.

Pressure Injury Risk Factors

Impaired sensory perception
Impaired mobility
Altered level of consciousness (LOC)
Shear
Friction
Moisture

Pressure Injury Classification

Stage 1: Non-blanchable erythema of intact skin.
Stage 2: Partial-thickness skin loss with exposed dermis.
Stage 3: Full-thickness skin loss.
Stage 4: Full-thickness skin and tissue loss.
Unstageable: Full-thickness loss obscured by slough or eschar.
Deep tissue pressure injury: Non-blanchable dark discoloration or epidermal separation with a dark wound bed or blood-filled blister.

Wound Classification by Skin Integrity and Cause

Open or closed wound
Intentional or unintentional wound

Information found in Table 48.1 (page 1324).
Medical adhesive-related skin injury.

Wound Healing Onset and Duration

Information found in Table 48.2 (page 1325).

Wound Repair

Partial-thickness wound repair.
Full-thickness wound repair.

Wound Healing Process

Primary intention
Secondary intention
Tertiary intention/Delayed closure

Wound Assessment by Color

Details on page 1326.

Full-Thickness Wound Repair Stages

Hemostasis: Minimizing blood loss.
Inflammatory phase.
Proliferative and new tissue formation phase.
Remodeling and maturation.

Complications of Wound Healing

Hemorrhage
Infection (types of wound drainage detailed in Table 48.3, page 1327)
Dehiscence
Evisceration

Pressure Injury Prediction and Prevention

Risk assessment using tools like the Braden Scale (Table 48.5, page 1329).
Economic consequences of pressure injuries.
Factors influencing pressure injury formation and wound healing: Nutrition (Table 48.6, page 1330), tissue perfusion, infection, age, and psychosocial impact.

Nursing Assessment

Environment contributing factors.
Skin assessment (minimum once per shift).
Wounds and pressure injuries.
Risk assessment using predictive measures.
Mobility assessment.
Nutritional status screening (within 24 hours), including weight and oral health.
Body fluids (urine, bile, stool, purulent drainage, gastric and pancreatic drainage).
Pain assessment (decreased pain increases mobility).

Surgical and Traumatic Wound Assessment

Emergency setting assessment.
Stable setting assessment.
Wound appearance.
Character of wound drainage.
Palpation of the wound.
Drains.
Wound closures.
Wound cultures.
Psychosocial assessment.

Characteristics of Wound Drainage

Amount, color, odor, and consistency.
Serous
Sanguineous
Serosanguineous
Purulent

Drains

Penrose drain (Figure 48.10).
Evacuator units: Jackson-Pratt drains (Figure 48.11) and Hemovac drains.

Wound Closures

Staples
Sutures
Wound adhesives

Nursing Diagnoses/Patient Problems

Risk for infection.
Acute or chronic pain.
Impaired mobility.
Impaired peripheral tissue perfusion.

Implementation: Nutrition and Pressure Injury Prevention

Nutritional support.
Topical skin care and incontinence management.
Positioning.
Support surfaces (therapeutic beds and mattresses; Table 48.9, pages 1343-1344).

Implementation: Acute Care (Wound Management)

First aid for wounds (hemostasis and cleaning).
Pressure injury management.
Wound management (debridement, protection, and nutritional support).

Implementation: Dressings

Purposes of dressings.
Types of dressings.
Changing dressings.
Packing a wound.
Negative-pressure wound therapy.
Securing dressings.

Wound Cleaning

Comfort measures.
Cleaning skin and drain sites (least contaminated first, page 1352).
Irrigation.
Skin closures (binders, slings, roll bandage application).

Heat and Cold Therapy

Review handout in syllabus.
Additional reading on pages 1354-1358 (Tables 48.11 and 48.12).
Physiological effects and appropriate uses of heat and cold therapies.

Nasogastric (NG) Intubation

Purposes: Decompression, enteral feeding, compression, lavage.
NG Tube Categories: Fine/small-bore (medication, feedings); large-bore (≥12 French; decompression, secretion removal).
Technique: Clean technique used for insertion and maintenance. Patency must be maintained.

Paralytic Ileus

Etiology: Cessation of peristalsis due to infection (bacterial/viral), irritation (surgery), electrolyte imbalances (e.g., low potassium), decreased intestinal blood supply, kidney/lung disease, or medications (especially narcotics).
Pathophysiology: Peristalsis stops; stomach or small intestine distends with air and fluid.
Signs & Symptoms: Abdominal distention, absence of bowel movements (BMs), absent bowel sounds, vomiting.

Types of NG Tubes

Nasogastric Tubes: Primarily for stomach decompression.
Specific Tube Types: Levin, Salem Sump, Dobhoff, Duo.

Measuring and Inserting an NG Tube

Procedure: Detailed procedure not provided in this excerpt.

Facilitating Tube Drainage

Suction Types: Low, high, intermittent, constant suction required to overcome gravity.

Proper NG Tube Functioning

Details: Not specified in this excerpt.

Preventing Injury

Anchoring: Secure the tube to prevent dislodgement. Use of a pin is mentioned.
Oral Inflammation Prevention: Keep oral membranes moist (ice chips, hard candy).
Reflux/Aspiration Prevention: Strategies not detailed.

Promoting Comfort

Secretions: Remove excess secretions.
Lubrication: Use water-soluble lubricant.
Sore Throat Relief: Warm saline gargles, ice bag to neck, throat lozenges, position changes.

Specialty Tube: Sengstaken-Blakemore Tube

Purpose: Internal pressure application via inflated balloon (to prevent esophageal bleeding - text is incomplete).

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