25 Questions
Which intervention should the nurse take if the client's surgical wound after colon resection has intestinal contents protruding?
Apply saline solution moistened gauze over the protruding area
What should the nurse do first if a client reports acute pain while negative pressure wound therapy is in place?
Administer the prescribed analgesic
Which medication is commonly used to reduce inflammation in various conditions?
Corticosteroid
What is the purpose of negative pressure wound therapy?
To promote wound healing by removing excess fluid and debris
Which book provides information on clinical nursing skills?
Taylor’s clinical nursing skills: A nursing process approach (5th ed.)
What action should the nurse take if a client's wound is bleeding profusely?
Apply pressure to the wound with a sterile dressing
What is the purpose of packing a wound with gauze pads?
To promote wound healing by absorbing excess fluid
Which intervention should the nurse prioritize if a client's wound shows signs of infection?
Administering antibiotics as prescribed
What is the purpose of administering a potassium supplement?
To replace potassium lost through diuretic use
Which step in the nursing process involves assessing the patient's past medical history?
Assessment
What type of assessment involves evaluating the wound's size and location?
Wound assessment
Which of the following is NOT a component of the wound assessment?
Undermining
What should be noted during the wound assessment?
Tunneling
Which of the following is used to describe the wound's edges?
Approximated or not approximated
What is the purpose of wound measurement in wound care?
To evaluate the wound's size and location
Which of the following is NOT used to measure a wound?
Tunneling
What is undermining in wound care?
The erosion of tissue beneath the wound's edges
Which type of drainage from a wound can be managed with an open drain like a Penrose?
Serosanguinous drainage
What should be included in wound documentation?
Type, location, size, edges, wound bed, drainage, periwound, pain, and signs of infection
Which nursing diagnosis is related to risk for impaired skin integrity?
Risk for infection
What is an important function of dressings in wound care?
All of the above
What are some factors to consider when selecting a dressing?
All of the above
What are some nursing interventions for wound care?
All of the above
What are some techniques used in pressure injury prevention?
All of the above
What contraindications should be considered before using negative pressure wound therapy (NPWT)?
All of the above
Study Notes
Wound Assessment and Care Techniques
- Wound assessment includes evaluating the tissue present in the wound bed, such as necrotic tissue, slough, granulation tissue, and newly formed epithelial tissue.
- Drainage from the wound can be serous, serosanguinous, sanguinous, or purulent, and can be managed with different types of drains, including open drains (Penrose) and closed drains (Chest tube, Jackson-Pratt, Hemovac).
- Periwound assessment involves noting the color, palpating for pain, and looking for signs of infection around the wound.
- Wound documentation should include information about the type, location, size, edges, wound bed, drainage, periwound, pain, and signs of infection.
- Nursing diagnoses related to wound care include risk for impaired skin integrity, risk for infection, impaired skin integrity, disturbed body image, and deficient knowledge related to wound care.
- Outcome identification and planning for wound care involve maintaining skin integrity, demonstrating self-care measures, showing evidence of wound healing, remaining infection-free, and demonstrating appropriate wound care measures before discharge.
- Nursing interventions for wound care include preventing infection and further injury, promoting wound healing, promoting physical and emotional comfort, and consulting specialists if necessary.
- Pressure injury prevention techniques include skin assessment, assessing risk using the Braden scale, vigilant monitoring, applying protective barriers, alleviating pressure through early mobility and appropriate surfaces, managing incontinence, and promoting nutrition and hydration.
- Wound care nursing interventions involve preventing infection and further injury, promoting wound healing, ensuring adequate nutrition and hydration, managing comorbid health conditions, consulting specialists if necessary, and performing wound care as ordered.
- Dressings are an important part of wound care and serve functions such as absorbing drainage, maintaining moisture, preventing infection, and protecting the wound and surrounding skin.
- Factors to consider when selecting a dressing include the wound condition, amount of drainage, need for debridement, availability within the facility, ease of use, and cost and insurance coverage.
- Performing a dressing change involves preparing for the change, verifying the order, explaining the procedure to the patient, gathering supplies, removing the old dressing carefully, cleansing the wound, and applying a new dressing.
Additional Techniques in Wound Care
- Negative pressure wound therapy (NPWT) can stimulate cell proliferation, improve blood flow, remove excess fluid, and prevent infection, but it has contraindications such as active bleeding, necrotic tissue, fistulas, and malignant wounds.
- Hyperbaric oxygen therapy, which involves pressurized chambers and 100% oxygen, can be used for hard-to-heal wounds as well as for carbon monoxide poisoning, decompression sickness, and severe anemia.
- Hot and cold therapy can be used to promote healing and reduce edema and muscle spasms, but care must be taken to prevent injury and avoid exceeding the maximum therapeutic effect time.
- Devices to apply
Test your knowledge on wound assessment and care techniques with this quiz! Learn about different types of wound drainage, periwound assessment, nursing interventions, pressure injury prevention, dressing selection, and more. Plus, explore additional techniques such as negative pressure wound therapy, hyperbaric oxygen therapy, and hot/cold therapy. Challenge yourself and enhance your wound care skills today!
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