Mosby’s nursing skills – wound care – Flashcards
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what *cannot* be delegated
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The skill of wound assessment may not be delegated The skill of sterile wound irrigation may not be delegated As the nurse, you are responsible for wound assessment and may not delegate this skill you may not delegate the skill of caring for acute new wounds or any skills that require sterile technique or a moist-to-dry dressing change The assessment of wound drainage, the maintenance of drains, and the maintenance of drainage systems may not be delegated The skill of changing a pressure ulcer dressing may not be delegated
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what *can* be delegated
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You may delegate the application of a dry dressing or a change of the top dressing the task of emptying a closed drainage container or pouch, measuring the amount of drainage, and recording the amount on the patient's intake and output (I&O) record may be delegated
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additional assessment steps for wound care
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Ask the patient to rate pain on a scale of 0 to 10. Note whether the patient appears anxious as you explain the wound assessment procedure.
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primary intention - Observe for the presence of drainage. Look for evidence of infection, such as the presence of erythema, odor, or wound drainage. A closed incision should have ________.
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no drainage
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primary intention - Lightly palpate along the incision to feel for a healing ridge. The ridge will appear as an accumulation of new tissue presenting as firmness beneath the skin extending to about 1 cm (½ inch) on each side of the wound. It appears ________ after surgery. This is an expected positive sign
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5 to 9 days
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secondary intention - In this process, ______ forms and the wound edges contract healing quickly but leaving behind a more obvious scar.
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granulation tissue
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Assess the wound dimensions. Measure the size of the wound, including length, width and depth, using a centimeter measuring guide:
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a. Measure the length by placing a ruler over the wound at the point of greatest length (or head to foot). b. Measure the width from side to side. c. Measure the depth by inserting a sterile cotton-tipped applicator into the area of greatest depth and placing a mark on the applicator at skin level.
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If necrotic tissue does not allow you to visualize the base of the wound, the stage
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cannot be determined
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Note if any of the wound edges are rounded toward the wound bed. This may indicate _____ wound healing. Describe the presence of epithelialization at the wound edges, if present, since this indicates movement ______ healing.
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delayed toward
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information to include in description of exudate
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consistency color odor amount (expressed as a proportion of the dressing or in descriptive terms)
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what info do you include on a dressing?
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time date initials
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1. 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? Remove the dressing, inspect the wound, and reapply a new dressing. Inspect the wound and reapply the surgical dressing every 2 hours. Inspect the wound, and keep the dressing off until the health care provider arrives. Wait until the health care provider orders the removal of the surgical dressing.
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Remove the dressing, inspect the wound, and reapply a new dressing. Inspect the wound and reapply the surgical dressing every 2 hours. Inspect the wound, and keep the dressing off until the health care provider arrives. *Wait until the health care provider orders the removal of the surgical dressing.* CORRECT. The nurse would want to wait until the provider orders the dressing to be removed to ensure that the initial dressing is ready to come off.
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2. Which wound would be allowed to heal by secondary intention? Cleft lip repair Infected hysterectomy incision Exploratory laparoscopy incision Facial laceration caused by a pocket knife
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Cleft lip repair *Infected hysterectomy incision* Exploratory laparoscopy incision Facial laceration caused by a pocket knife CORRECT. This wound would heal by secondary intention because it is an infected surgical wound.
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3. Before performing a wound assessment, which nursing action would reduce the patient's risk for infection? Taking the patient's temperature Applying clean gloves Assessing the wound for drainage Assessing the dressing for drainage
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Taking the patient's temperature *Applying clean gloves* Assessing the wound for drainage Assessing the dressing for drainage CORRECT. Wearing clean gloves would reduce the risk for infection when removing an old dressing.
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4. Which intervention can the nurse delegate to nursing assistive personnel (NAP) in caring for a patient with a wound? Assessing the site for signs of redness or swelling Reporting the presence of wound odor Removing a soiled outer dressing Opening sterile dressings during the dressing change
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Assessing the site for signs of redness or swelling *Reporting the presence of wound odor* Removing a soiled outer dressing Opening sterile dressings during the dressing change CORRECT. The task of reporting the presence of odor in the area of the wound may be delegated to NAP.
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5. The nurse notes that a patient's surgical wound is healing slowly. Which health problem would contribute to slow wound healing? Osteoarthritis Glaucoma Deafness Diabetes mellitus
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Osteoarthritis Glaucoma Deafness *Diabetes mellitus* CORRECT. Diabetes decreases tissue perfusion, impairing the supply of oxygen to the tissues. This slows wound healing.
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1. When irrigating a wound, how would the nurse know the right amount of pressure to apply? Calculate the wound size. Follow the general rule of keeping the pressure between 4 and 15 psi. Keep the pressure strong enough to cause moderate pain. Gentle enough that it does not create a splash off of the wound.
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Calculate the wound size. *Follow the general rule of keeping the pressure between 4 and 15 psi.* Keep the pressure strong enough to cause moderate pain. Gentle enough that it does not create a splash off of the wound. CORRECT. Less than 4 psi would not be effective. More than 15 psi is likely to cause tissue damage.
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2. Which action should the nurse avoid before irrigating a patient's foot wound? Assess the patient for a history of allergies to tape and irrigating solution. Review the provider's orders for the type of irrigating solution to be used. Assess the patient's pain on a scale of 0 to 10. Warm the irrigant to body temperature in the microwave.
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Assess the patient for a history of allergies to tape and irrigating solution. Review the provider's orders for the type of irrigating solution to be used. Assess the patient's pain on a scale of 0 to 10. * Warm the irrigant to body temperature in the microwave.* CORRECT. Although the nurse must warm the solution before irrigating the wound, using the microwave can create hotspots and make the fluid unsafe.
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3. Which device is used for wound irrigation? 19-gauge needle attached to a 10-mL syringe 19-gauge needle attached to a 35-mL syringe Sterile container held 30.5 cm (12 inches) above the wound Foley irrigating syringe
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19-gauge needle attached to a 10-mL syringe *19-gauge needle attached to a 35-mL syringe* Sterile container held 30.5 cm (12 inches) above the wound Foley irrigating syringe CORRECT. A 19-gauge needle attached to a 35-mL syringe will release a sufficient quantity of solution at the correct pressure for wound irrigation.
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4. Which imaging study or diagnostic test would the nurse review to determine if the pressure ulcer on a patient's left heel is infected? White blood cell count Complete blood count X-ray of left foot Culture and sensitivity test
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White blood cell count Complete blood count X-ray of left foot * Culture and sensitivity test* CORRECT. A wound culture and sensitivity test will indicate whether the pressure ulcer is infected, identify the pathogen responsible (if any), and determine which antibiotic the pathogen is most vulnerable to.
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5. A nurse is irrigating a patient's abdominal wound 2 days postoperatively. Which finding would need to be reported to the health care provider? Drainage that was not present previously Redness at the abdominal suture line Granulation tissue in the wound bed The patient reports less pain
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* Drainage that was not present previously* Redness at the abdominal suture line Granulation tissue in the wound bed The patient reports less pain CORRECT. The appearance of new drainage indicates possible wound infection.
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Identify any risk factors for wound healing problems, including the following:
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Advanced age Prematurity Obesity Diabetes Compromised circulation Poor nutritional state Immunosuppressive drugs Irradiation of wound area High stress level Use of steroid medications
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1. 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. 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.
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*Premedicate the patient with a prescribed analgesic 30 minutes before the intervention.* 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. CORRECT. Administration of a prescribed analgesic would directly control the patient's pain level during the dressing change. This intervention is more likely to be effective than the other options listed.
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2. 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). Adhere to sterile technique during the intervention. Complete the dressing change in an effective, timely way.
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Begin antibiotic therapy before the dressing change. *Use appropriate personal protective equipment (PPE).* Adhere to sterile technique during the intervention. Complete the dressing change in an effective, timely way. CORRECT. Using appropriate PPE minimizes the nurse's contact with body fluids and contaminated items during the dressing change, thereby reducing the risk for infection.
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3. 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.
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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. Completing a further wound assessment and gathering more detailed information about the patient and his or her wound, such as pain level and amount of blood, would be the most appropriate action for the nurse to take.
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4. When changing a patient's surgical dressing 24 hours postoperatively, when would the nurse apply sterile gloves? After performing hand hygiene at the start of the procedure Before removing the inner dressing After removing the original dressing materials and performing hand hygiene a second time Just before cleansing the wound with sterile water
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After performing hand hygiene at the start of the procedure Before removing the inner dressing *After removing the original dressing materials and performing hand hygiene a second time* Just before cleansing the wound with sterile water CORRECT. The nurse would wear clean gloves to remove the contaminated original dressing, and he or she would then perform hand hygiene again. Only then would the nurse apply sterile gloves.
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5. Which action would minimize the risk for cross-contamination while cleansing an infected abdominal surgical wound? Cleansing the wound with sterile water Blotting the incision with dry gauze Wearing sterile gloves to cleanse the wound Using a new gauze pad for each stroke while cleansing the wound
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Cleansing the wound with sterile water Blotting the incision with dry gauze Wearing sterile gloves to cleanse the wound *Using a new gauze pad for each stroke while cleansing the wound* CORRECT. Using a new gauze pad for each stroke minimizes the risk for cross-contamination by preventing contaminated gauze from introducing microorganisms into other areas of the wound.
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1. What is the proper method for cleansing the evacuation port of a wound drainage system? Cleanse it with normal saline. Wash it with soap and warm water. Rinse it with sterile water. Wipe it with an alcohol sponge.
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Cleanse it with normal saline. Wash it with soap and warm water. Rinse it with sterile water. * Wipe it with an alcohol sponge.* CORRECT. Using an alcohol sponge is the correct way to cleanse the port and plug.
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2. What is the nursing action to set up suction for a hemovac drainage system? Set the suction to lowest level possible. Hemovacs are always set to medium suction. Connect to the wall on intermediate suction. Compress the hemovac, creating suction.
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Set the suction to lowest level possible. Hemovacs are always set to medium suction. Connect to the wall on intermediate suction. *Compress the hemovac, creating suction.* CORRECT. For the Hemovac to create suction, the nurse should compress it firmly and replace the plug.
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3. When emptying a Jackson-Pratt drain, which issue should nursing assistive personnel (NAP) report immediately to the nurse as a potential abnormality? The drainage is odorless. The drainage is straw colored. The patient doesn't like looking at the drainage tubing. The amount of drainage was greater today than yesterday.
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The drainage is odorless. The drainage is straw colored. The patient doesn't like looking at the drainage tubing. *The amount of drainage was greater today than yesterday.* CORRECT. An increase in drainage could indicate a complication and must be immediately reported to the nurse.
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4. 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. Tape the tubing to the patient's bed. Attach the tubing to the nearest side rail. Loop the tubing through the bed frame.
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* Attach the tubing to the patient's gown with a safety pin.* Tape the tubing to the patient's bed. Attach the tubing to the nearest side rail. Loop the tubing through the bed frame. CORRECT. The nurse would attach the drainage tubing to the patient's gown with tape and a safety pin to ensure that the suction device stays below the level of the wound and does not pull on the insertion site.
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5. Which action would maximize the suction produced by the Jackson-Pratt drainage system after the system has been emptied? Pinning the tubing to the patient's hospital gown Compressing the bulb while replacing the port cap Emptying the drainage container only when it is 90% full Placing the drainage container below the wound site
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Pinning the tubing to the patient's hospital gown *Compressing the bulb while replacing the port cap* Emptying the drainage container only when it is 90% full Placing the drainage container below the wound site CORRECT. Compressing the bulb while replacing the port cap recharges the drainage system by reestablishing a vacuum.
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Minimize friction and shear by use of lift sheets when repositioning patients; raise the head of the bed no more than _______ (unless medically contraindicated) to prevent sliding and shear injury.
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30 degrees
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Impaired skin at the edge of the ulcer indicates ______ tissue damage. Maceration on the periwound skin indicates the need to select a ____ type of wound dressing.
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progressive new
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1. Which practice protects the nurse from infection when changing the dressing on an infected pressure ulcer? Begin antibiotic therapy before the dressing change. Use appropriate personal protective equipment. Adhere to sterile technique during the intervention. Complete the dressing change in an effective, efficient manner.
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Begin antibiotic therapy before the dressing change. *Use appropriate personal protective equipment.* Adhere to sterile technique during the intervention. Complete the dressing change in an effective, efficient manner. CORRECT. Using personal protective equipment minimizes contact with any contaminants during a dressing change.
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2. The wound bed of a patient's pressure ulcer is red. What does this finding indicate to the nurse? Necrotic tissue Presence of slough Granulation tissue Development of an infection
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Necrotic tissue Presence of slough *Granulation tissue* Development of an infection CORRECT. Granulation tissue is red.
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3. Which measurements would the nurse use to calculate the surface area of a patient's pressure ulcer? Height and weight Length and width Length and depth Width and depth
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Height and weight *Length and width* Length and depth Width and depth CORRECT. Multiplying the wound's length by its width provides the correct surface area.
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4. How would the nurse safely apply an enzyme debridement ointment? Daub ointment on dead tissue at the wound edges. Put ointment on a tongue blade, and gently spread it on the center of the wound. Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin. Apply a gauze dressing to ensure contact with the ointment.
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Daub ointment on dead tissue at the wound edges. Put ointment on a tongue blade, and gently spread it on the center of the wound. * Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin.* Apply a gauze dressing to ensure contact with the ointment. CORRECT. Avoiding contact with surrounding skin prevents tissue damage.
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5. Which action can the nurse delegate to nursing assistive personnel (NAP) to help prevent the development of pressure ulcers in an older adult patient? Reposition the patient at least every 2 hours. Assess the patient's bony prominences every shift. Educate the family about the importance of healthy skin. Assist the patient in the selection of high-protein foods.
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* Reposition the patient at least every 2 hours.* Assess the patient's bony prominences every shift. Educate the family about the importance of healthy skin. Assist the patient in the selection of high-protein foods. CORRECT. Repositioning a patient is within the NAP's scope of practice. The action will help minimize pressure on the skin covering bony prominences.
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On assessing your client's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this client's pressure ulcer? 1 Stage II 2 Stage IV 3 Unstageable 4 Suspected deep tissue damage
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1 Stage II 2 Stage IV *3 Unstageable* 4 Suspected deep tissue damage To determine the stage of a pressure ulcer you examine the depth of the tissue involvement. Since the pressure ulcer assessed was covered with necrotic tissue, the depth could not be determined. Thus this pressure ulcer cannot be staged. Text Reference - p. 1179
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A 36-year-old man is admitted to the hospital following a motor vehicle accident. He has sustained multiple injuries on the forehead, right elbow, and left knee. On his forehead, there is a full thickness loss of skin. The client is given first aid and is treated with antibiotics. Arrange the phases of the healing process in appropriate order. 1. Hemostasis phase 2. Remodeling phase 3. Proliferative phase 4. Inflammatory phase
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1. Hemostasis phase 2. Inflammatory phase 3. Proliferative phase 4. Remodeling phase There are four stages in full-thickness wound repair. These include hemostasis, inflammatory, proliferative, and remodeling. In the first phase, hemostasis, the body tries to control bleeding through clotting. In the inflammatory phase, fluid and inflammatory blood cells are released to contain the infection and help the tissue repair. The proliferative phase involves neovascularization, granulation tissue formation, and the addition of collagen. New epithelium is formed to cover the surface. The final stage, remodeling, gives strength, shape, and color to the scar, but it may take months or years. Text Reference - p. 1182
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Which statement is true about wet-to-dry dressings for mechanical debridement of a wound? 1 It should be removed when partially dry. 2 It causes slight bleeding when removed. 3 It should be only moist, not wet, when applied. 4 It should be left in place for at least 12 hours.
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1 It should be removed when partially dry. 2 It causes slight bleeding when removed. *3 It should be only moist, not wet, when applied.* 4 It should be left in place for at least 12 hours. Wet-to-dry dressings used for mechanical debridement of wounds should be moist, not wet. Application of moist gauze hydrates the wound and helps with quick drying. The gauze should be removed when totally dried, so that it gets stuck to the necrotic tissue. It may not cause bleeding when removed. The dressing is positioned in the wound and held in place by an outer dressing or gauze wrap for four to six hours. This much time would be needed for the gauze to dry and stick to the underlying tissue.
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A nurse inspects the surgical site of a client on the 4th postoperative day and notices ongoing drainage from the site. The wound edges have no epithelialization, and the incision site is red and inflamed. What do these findings suggest about the wound healing? 1 Wound healing by primary intention 2 Wound healing by secondary intention 3 Would healing abnormally by primary intention 4 Wound healing abnormally by secondary intention
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1 Wound healing by primary intention 2 Wound healing by secondary intention *3 Would healing abnormally by primary intention* 4 Wound healing abnormally by secondary intention When surgical incision shows signs of drainage even 3 days after surgery, with inflammation and no epithelialization of the edges, it suggests an abnormal healing of the wound by primary intention. A wound healing by primary intention would have approximated skin edges that are clean and dry, with no risk of infection 4 days after surgery. The surgical wound usually heals by primary intention, and not by secondary intention. Therefore, the wound also cannot be considered as healing abnormally with secondary intention. Text Reference - p. 1190
