Nursing Considerations
What intervention should the nurse implement to promote wound healing?
Skin with nonblanchable erythema, persistent redness, temperature changes, and an abnormal texture is what stage of a wound?
Stage one
What is the most common wound site in paraplegics?
Ischium
How should the process of changing a dressing begin?
Put on gloves and remove previous dressing documenting the drainage amount and type.
Why is packing necessary?
To prevent the wound from closing at the top and not healing underneath, if this occurs fluid can build up in the space and cause an infection which would prolonge healing.
What risk factors put patients at risk for pressure ulcer development?
Impaired sensory perception
Impaired mobility (ex: spinal cord injury)
Trauma, ICU
Alteration in LOC (level of consciousness)
Diabetes
Incontinent
Long term care/nursing homes
Fractures of hip
Shear, friction, moisture
Full-thickness skin loss with extensive destruction. Goes through the fascia and may involve muscles and bone.
Stage 4.
Changing a wound is painful, when should you give pain medication to make this process easier for the patient?
Following the doctor's orders and giving medication as prescribed you will wait 30 minutes to an hour after administration to provide adequate pain relief to the patient.
What should be checked before the dressing change occurs?
Follow orders as prescribed for cleaning the wound and medications that are to be applied. Then put on a new pair of gloves to change the wound.
Used on larger open wounds, this absorbs exudate and as it drys out it will debrief the wound.
What are the types of drainage?
Serous, sanguineous, and Serosanguineous.
Full-thickness skin loss or deep crater. Epidermis and dermis are gone. Does not go through fascia or exposed muscle or bone.
Stage three.
What causes pressure ulcers to occur?
Prolonged pressure on bony prominences causes inadequate blood flow to the area.
True or False, the dressing should be dripping with saline as it is placed into the wound?
False.
"You should pour saline into a clean bowl. Place gauze pads you will use in the bowl. Squeeze the saline from the gauze pads until it is no longer dripping."
The gauze should be damp but not dripping.
What percentage of people get a pressure ulcer in long-term care facilities and ICUs?
Other studies have reported the rate of pressure ulcers as 3% to 22% in hospitalized patients, 2% to more than 20% in nursing homes, and 14 to 44% in ICUs(3)
What is the difference between tunneling and undermining?
Tunneling is a passageway under the surface of the skin that is generally open at the skin level; however, most of the tunneling is not visible. Undermining is a closed passageway under the surface of the skin that is open only at the skin surface. It involves a significant portion of the wound edge.
Abrasion, partial thickness skin loss, involves the epidermis and dermis. Is often described as a shallow crater.
Stage two.
How often should wound care be done?
Typically it is once daily but the orders will specify if more frequent dressing change is needed.
How tightly should a dressing be packed when doing this procedure?
Place the gauze pads in your wound. Carefully fill in the wound and any spaces under the skin using a long cotton-tipped applicator being sure to cover the wound base and edges but not packing so tightly as to impair blood flow and impede healing.
What is dead tissue present in a wound that delays healing, this appears as slough, moist yellow stringy tissue as well as Eschar which is dry black tissue?
Necrosis
The patient is a paraplegic with an additional diagnosis of Alzheimer's, while going over aftercare the nurses notice that the patient is not able to retain this information. Who should the nurse refer this patient to?
Case management and a social worker.
If a wound is covered in slough and eschar what stage would it be?
Unstageable! You can't see the full wound with this.
What foods promote wound healing for a patient?
Carbs, fats, calories, iron, protein, vitamin c, and Zinc
How do you protect the gauze from external factors and keep it in place?
Cover the wet gauze with a large dry dressing pad. Use tape or rolled gauze to hold this dressing in place. Then, sign and date the dressing.
What sources were used?
Nursing fundamentals book.
Med surge book
NCBI
Medline Plus