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How do hypertensive medications affect skin integrity and wound healing
Blood pressure medications decrease the amount of pressure required to occlude blood flow to an area, creating a risk for ischemia.
What is a characteristic of chronic wounds?
Wounds that exceed the anticipated length of recovery are classified as chronic wounds.
A patient has a wound that extends through the epidermis into the dermis. How should the nurse document the depth of this wound?
Partial-thickness wounds extend through the epidermis into the dermis.
A patient is recovering from surgery for an appendectomy. Because the surgeon did not surgically close the wound, what wound healing process will occur?
Secondary intention healing occurs when a wound is left open, and it heals from the inner layer to the surface by filling in with beefy red granulation tissue.
When teaching a patient about the healing process of an open wound after surgery, which point should the nurse make?
Because the wound edges are not approximated, more scar tissue will form.
Wounds healing by secondary intention are more prone to infection therefore, the primary goal is to prevent infection.
While assessing a new wound, the nurse notes red, watery drainage. What type of drainage will the nurse document this as?
Serosanguineous drainage, a combination of bloody and serous drainage, is most commonly seen with new wounds.
What is the difference between dehiscence and evisceration?
With dehiscence there is a separation of one or more layers of wound tissue, and evisceration involves the protrusion of internal viscera (organs) from the incision site.
What causes pressure ulcers?
Pressure ulcers are caused by unrelieved pressure that compromises blood flow to an area, resulting in ischemia (inadequate blood supply) in the underlying tissue.
A patient has an injury on their coccyx that is covered with eschar. What stage is this wound?
eschar is a black, leathery layer made up of necrotic tissue. An ulcer covered in eschar cannot be classified using a staging method because it is impossible to determine the depth.
A patient has a stage 4 pressure ulcer, but now the ulcer is a shallow crater involving only partial skin loss. How should this be staged?
Stage 4 pressure injury, healing
Reverse staging is not done because as the ulcer heals with granulation tissue and becomes shallower, the lost muscle, subcutaneous fat, and dermis are not replaced. Pressure ulcers maintain their original staging classification throughout the healing process but are accompanied by the modifier healing.
A patient that has burns requires monitoring of fluid balance. What method for evaluating wound drainage is most appropriate for assessing fluid loss?
Weigh the dressing
By weighing the dressing before it is applied and after it is removed, the nurse can accurately determine the amount of drainage
What is the treatment for a stage 1 pressure ulcer that is located on the heel of the foot.
Elevation of the foot off the bed.
Pressure ulcers are caused by pressure to an area that restricts blood flow, causing ischemia to underlying tissue. The primary treatment is to relieve the pressure, thus improving blood flow. Elevating the patient’s left heel off the bed would relieve pressure to this area.
what would be an appropriate goal for a patient with a stage 4 pressure ulcer
Would will heal with no evidence of infection
What intervention should the nurse provide for a patient that has a wound with a beefy red wound bed.
Dressing to keep the wound moist and clean
A red wound indicates active healing, and the best treatment is gentle cleansing and a dressing that will ensure a clean, moist wound environment.
A patient has a pressure injury that is covered in dry slough that tightly adheres to the wound. What is the best treatment the nurse could recommend for treating this wound?
A hydrocolloid dressing would conform to this area and form a protective layer against friction and bacterial invasion. It would also promote autolytic débridement of the slough and absorb the exudate from the autolysis.
When would the nurse know care provided to a stage 2 pressure ulcer has been effective?
When the wound bed contains 100% granulated tissue.
** a wound that is healing contains granulated tissue
A patient has a deep wound that also has tunneling. There is a lot of drainage coming from the wound. Which dressing choice would be most appropriate?
Alginate dressing
Alginates are highly absorbent and are appropriate for wounds with moderate to large amounts of drainage. They are ideal for wounds with tunneling, as they will conform to fill the tunnel.
Gauze could adhere to the wound bed and cause trauma when removed.
A hydrogel would increase the drainage, with the potential of macerating surrounding skin.
Hydrocolloids have limited absorptive ability.
A patient has many wounds on his body, how should the nurse perform dressing changes?
Irrigate wounds from least contaminated to most contaminated.
To avoid the possibility of cross-contamination, the wound with the least amount of contamination should be treated first, progressing to the wound with the most contamination.
A patient just had abdominal surgery. What can the nurse give this patient to prevent wound dehiscence?
An abdominal binder. An abdominal binder provides added support to an incision site and decreases the risk of wound dehiscence
What is most important to do for a patient that has a stage 1 pressure ulcer
You want to place the patient on a turn schedule to relieve pressure.
a patient’s wound will be sutured closed after additional healing occurs. Which type of healing is occurring with this wound?
Tertiary
Initially the wound is allowed to heal by secondary intention, and when there is no evidence of edema, infection, or foreign matter, granulating tissue is brought together and the wound edges are sutured closed.
Tertiary intention is a technique used when a wound is clean-contaminated or “dirty” (potentially infected).
DIminished sweat gland activity. Elderly people usually have dry skin