Application to Nursing Care
A wound is showing delayed healing. What should the nurse recommend the patient to add more in their diet?
Vitamin A and C––builds proteins
Vitamin B12––support growth of RBCs; enable cell replication
What are the phases of wound healing?
hemostasis
inflammation
proliferation/granulation
remodeling
Describe all the different stages of pressure injuries
stage 1: non-blanchable erythema of intact skin
stage 2: partial thickness skin loss with exposed dermis
stage 3: full thickness skin loss; visible adipose tissue (fat)
stage 4: full-thickness skin and tissue loss; visible muscle and bone
What would be the nursing diagnosis for a patient that presents with an open tear on the skin, which allows bacteria inside the wound?
impaired skin integrity
Complications of wound healing and please name all 7 of them
keloid
contractures
dehiscence
evisceration
stricture
fistula
adhesions
A nurse is caring for a patient with a pressure ulcer. What type of healing process will occur with this wound?
secondary intention
The nurse is caring for a patient who had knee replacement surgery 5 days ago. The patient's knee appears red and warm to the touch and the patient is requesting increased pain medication. What complication should the nurse be concerned about?
post operative wound infection
This type of wound drainage is clear and watery, often indicating early wound healing.
serous drainage
A patient has a new abdominal wound. The wound has stopped bleeding and clots are beginning to form. What phase of healing is identified?
hemostasis phase
Which one of the orders should a nurse question in the plan of care for an elderly immobile stroke patient with a stage III pressure ulcer?
clean the ulcer every shift with Dakin's solution
What types of solutions can nurses use to irrigate a wound? (3 types)
regular saline, sterile water, and hydrogen peroxide.
A patient has a pressure injury that has skin breakdown with slough and eschar present and no appearance of muscle or bone. What stage is this pressure injury?
Unstageable pressure injury
This classic sign of infection in a wound is characterized by redness spreading from the wound site.
erythema
A patient presents with an increased production of mast cells that have secreted histamine, leading to vasodilation. The extremity that the wound is present in shows edema, warmth, and throbbing. What phase of wound healing is this?
Inflammatory Phase
A patient has a surgical wound on the right lower quadrant of their abdomen. The wound has purulent drainage. The nurse notices the drainage and irrigates the wound. What did the nurse do incorrectly?
The nurse did not collect a sample of the drainage for a wound culture and notify the provider before irrigating the wound.
What are two types of wound dressings a nurse can use?
Hydrocolloid, Hydrogel, Foam dressings, Non-adherent dressings, Alginate dressings, collagen dressings, gauze dressings, Transparent film dressings
A patient has a pressure injury. Upon assessment of the wound, the nurse notes that bone and tendon are visible. What stage pressure injury is this?
Correct Answer: Stage 4
This type of tissue often appears as pale, yellow, and soft in the wound bed, indicating a slower healing process.
slough
A patient is admitted with an open wound on his right upper leg following an MVC accident. What is the priority action that the nurse should take when performing a wound dressing change to prevent the wound from becoming infected?
Hand hygiene prior to performing sterile technique wound care
A nurse goes to change the dressing on a patient’s wound. She applies clean gloves and begins cleaning the wound. She collects a sample to send to the lab for testing, and then irrigates the wound. 2 days later, the wound is infected. What action did the nurse take that caused the infection.
Gloves and procedure need to be STERILE, not just clean
This condition, often caused by prolonged pressure on the skin, leads to tissue damage and open wounds.
What is a pressure ulcer or bed sore?
This term describes the evaluation of a wound's color, temperature, edema, and sensation.
What is wound assessment for skin integrity?
A wound with black or brown tissue indicates the presence of this, signifying necrotic tissue.
eschar
This phase of the nursing process involves analyzing data collected during assessment to identify patient health issues that nurses can address through interventions.
What is the nursing diagnosis phase, where nurses identify patient health problems or potential risks?
This error occurs when a healthcare provider neglects to inquire about patient allergies before applying a dressing, risking allergic reactions.
What is ignoring patient allergies, such as not checking for allergies before applying a dressing, risking potential allergic reactions?