chapter 86 - Kupubook.com
Pressure Ulcers, Wounds, and Wound Management Unit 11 chapter 86 Nursing care of clients with integumentary disorders SectionIntegumentary Disorders Chapter 86 Pressure Ulcers, Wounds, and Wound Management Overview ●● ●● ●● A wound is a result of injury to the skin. Although there are many different types and degrees of injury, the basic phases of healing are essentially the same for most wounds. A pressure ulcer (formerly called a decubitus ulcer) is a specific type of tissue injury caused by unrelieved pressure that results in ischemia and damage to the underlying tissue. Pressure ulcers are classified according to a staging system developed by the National Pressure Ulcer Advisory Panel. The stages are: ◯◯ ◯◯ ◯◯ ◯◯ ◯◯ ◯◯ Suspected deep tissue injury – Discolored but intact skin caused by damage to underlying tissue Stage I – Intact skin with an area of persistent, nonblanchable redness, typically over a bony prominence, which may feel warm or cool to touch. The tissue is swollen and congested, with possible discomfort at the site. With darker skin tones, the ulcer may appear blue or purple. Stage II – Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and may appear as an abrasion, blister, or shallow cavity. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage. Stage III – Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may reach, but not extend thorough the fascia below. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common. Stage IV – Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material). Unstageable – Ulcers whose stages cannot be determined because eschar or slough obscures the wound. View Media Supplement: Rn adult medical surgical nursing Pressure Ulcer Staging (Image) 975 PRESSURE ULCERS, WOUNDS, AND WOUND MANAGEMENT WOUND HEALING AND MANAGEMENT Overview ●● ●● General Principles of Wound Management ◯◯ Wounds impair skin integrity. ◯◯ Inflammation is a localized protective response triggered by injury or destruction of tissue. ◯◯ Wounds heal by various processes and in stages. ◯◯ Wounds may become infected by the invasion of pathogenic microorganisms. ◯◯ Principles of wound care include assessment, cleansing, and protection. ◯◯ Wound care is a nursing responsibility that has a significant impact on wound healing. Stages of Wound Healing ◯◯ ◯◯ ◯◯ ●● The inflammatory stage occurs in the first 3 days after the initial trauma. Attempts are made at the site to: ■■ Control bleeding with clot formation. ■■ Deliver oxygen, WBC, and nutrients to the area via the blood supply. The proliferative stage lasts the next 3 to 24 days. Effects to the wound include: ■■ Replacing lost tissue with connective or granulated tissue. ■■ Contraction of the wound’s edges. ■■ Resurfacing of new epithelial cells. The maturation or remodeling stage involves the strengthening of the collagen scar and the restoration of a more normal appearance. It can take more than 1 year to complete, depending on the extent of the original wound. Healing Process TYPE OF HEALING CHARACTERISTICS WOUND TYPE Primary intention • Little or no tissue loss • Edges are approximated, as with a surgical incision • Heals rapidly • Low risk of infection • Minimal or no scarring Secondary intention • Loss of tissue • Wound edges widely separated, as with pressure ulcers and stab wounds • Increased risk of infection • Scarring Tertiary intention • Widely separated • Deep • Spontaneous opening of a previously closed wound • Risk of infection • Extensive drainage and tissue debris • Closes later • Long healing time 976 RN ADULT MEDICAL SURGICAL NURSING Pressure ulcers, wounds, and wound management Health Promotion and Disease Prevention ●● Maintain clean, dry skin and wrinkle-free linens. ◯◯ ◯◯ Appropriately use pressure-reducing surfaces and pressure-relieving devices. Inspect the skin frequently and document the client’s risk using a tool such as the Braden scale. ◯◯ Clean and dry the skin immediately following urine or stool incontinence. ◯◯ Apply moisture barrier creams to the skin of clients who are incontinent. ◯◯ Use tepid water (not hot), use minimal scrubbing, and pat the skin dry. ◯◯ Encourage clients to consume diets high in protein and vegetables. ◯◯ Encourage clients to take vitamins and supplements. Assessment ●● Risk Factors ◯◯ ◯◯ ◯◯ ◯◯ ◯◯ ◯◯ ◯◯ ◯◯ ◯◯ Increased age delays healing because of: ■■ Loss of skin turgor ■■ Skin fragility ■■ Decreased peripheral circulation and oxygenation ■■ Slower tissue regeneration ■■ Decreased absorption of nutrients ■■ Decreased collagen ■■ Impaired function of the immune system Overall wellness – A compound fracture of the femur in a client who has a head injury will present more healing problems. Immune function is the body’s ability to fight infection by destroying invading pathogens. Medications may interfere with the body’s ability to respond to and/or prevent infection. Nutrition provides energy and elements required for wound healing. Tissue perfusion provides circulation that delivers the required elements for tissue repair and infection control. Obesity – Fatty tissue lacks blood supply. Chronic diseases, such as diabetes mellitus, place additional stress on the body’s healing mechanisms. Chronic stress further impedes healing. Rn adult medical surgical nursing 97 7 Pressure ulcers, wounds, and wound management ◯◯ ◯◯ ●● Smoking impairs oxygenation and clotting. Wound stress, such as from vomiting or coughing, puts pressure on the suture line and disrupts the wound healing process. Subjective and Objective Data ◯◯ Appearance ■■ ■■ ◯◯ Note the color of open wounds. The following colors reflect a wound’s condition: ☐☐ Red – Healthy regeneration of tissue ☐☐ Yellow – Presence of purulent drainage and slough ☐☐ Black – Presence of eschar that hinders healing and must be removed Closed wounds – Skin edges should be well-approximated. Drainage is a normal result of the healing process and occurs during the inflammatory and proliferative phases of healing. ■■ ■■ ■■ Note the amount of drainage from a drain or a dressing. With each cleansing, observe the skin around a drain for irritation and breakdown. The character of drainage is distinguished by consistency, color, and odor. ☐☐ ☐☐ ☐☐ ☐☐ ◯◯ Serous drainage is the portion of the blood (serum) that is watery and clear or slightly yellow in appearance. Sanguineous drainage contains serum and red blood cells. It is thick and appears reddish. Serosanguineous drainage contains both serum and blood. It is watery and appears blood streaked or blood tinged. Purulent drainage is the result of infection. It is thick and contains white blood cells, tissue debris, and bacteria. It may have a foul odor, and its color reflects the type of organism present (green may indicate a pseudomonas infection). Wound closure (staples, sutures, wound closure strips [Steri-strips]) Collaborative Care ●● Nursing Care ◯◯ Provide adequate hydration and meet protein and calorie needs. ■■ ■■ ■■ ■■ 978 Encourage an intake of 2,000 to 3,000 mL of water/day if not contraindicated (due to heart failure or renal failure). Provide education about good sources of protein (meat, fish, poultry, eggs, dairy products, beans, nuts, whole grains). Note if serum albumin levels are low (below 3.5 g/dL), because a lack of protein puts the client at greater risk for delayed wound healing and infection. Provide nutritional support as indicated (vitamin and mineral supplements, nutritional supplements, enteral nutrition, parenteral nutrition). Rn adult medical surgical nursing PRESSURE ULCERS, WOUNDS, AND WOUND MANAGEMENT ◯◯ Perform wound cleansing. ■■ ■■ ■■ ■■ ■■ Cleanse in a direction from the least contaminated toward the most contaminated. Use gentle friction when cleansing or applying solutions to the skin to avoid bleeding or further injury to the wound. While other mild cleansing agents may be prescribed, isotonic solutions remain the preferred cleansing agents. Never use the same gauze to cleanse across an incision or wound more than once. Irrigation with a solution-filled syringe held 2.5 cm (1 in) above the wound may be used. View Media Supplement: ◯◯ Wound Irrigation with Packing and Dry Dressing For wound dressings, use: ■■ Woven gauze (sponges) – Absorb exudate from the wound ■■ Nonadherent material – Does not adhere to the wound bed ■■ ■■ ■■ Self-adhesive, transparent film – A temporary “second skin” ideal for small, superficial wounds Hydrocolloid – An occlusive dressing that swells in the presence of exudate ☐☐ Used to maintain a granulating wound bed ☐☐ May be left in place up to 5 days Hydrogel (Aquasorb) ☐☐ May be used on infected, deep wounds ☐☐ Provides a moist wound bed ◯◯ Use the negative pressure of a wound vacuum-assisted closure if prescribed. ◯◯ Remove sutures/staples as prescribed. ◯◯ Assess onset, quality, duration, and severity of the pain. ◯◯ Administer analgesics as prescribed. ◯◯ Administer antimicrobials (topical and/or systemic) as prescribed. ◯◯ Document the location and type of wound/incision, the status of the wound and the type of drainage, the type of dressing and materials used, the client teaching provided, and how the client tolerated the procedure. RN ADULT MEDICAL SURGICAL NURSING 979 Pressure ulcers, wounds, and wound management ●● Medications ◯◯ Antimicrobial Therapy ■■ ■■ Antimicrobial therapy kills or inhibits the growth of microorganisms such as bacteria, fungi, viruses, and protozoans. Antimicrobial medications either kill pathogens or prevent their growth. Nursing Considerations ☐☐ ☐☐ ☐☐ ◯◯ Monitor for medication effectiveness (reduced fever, increased level of comfort, decreasing white blood cell count). Maintain medication schedule to assure consistent blood levels of antibiotic. Antipyretics (acetaminophen, aspirin) are used for fever and discomfort as prescribed. ■■ ◯◯ Administer antimicrobial therapy as prescribed. Nursing Considerations ☐☐ Monitor fever to determine effectiveness. ☐☐ Graph client’s temperature fluctuations on medical record. Analgesics Therapy ☐☐ ☐☐ Analgesics (hydrocodone [Vicodin] and morphine [Sulfate]) are used for pain in the wound as prescribed. Nursing Considerations XX Administer analgesics therapy as prescribed. XX Monitor effectiveness of medication related to pain. XX ●● Interdisciplinary Care ◯◯ Nutritional services may be consulted for meal choices to promote wound healing. ◯◯ Pain management services may be consulted if pain persists and/or is uncontrolled. ◯◯ ◯◯ ●● Rehabilitation care may be consulted if client has prolonged weakness and needs assistance with increasing level of activity. Wound care consultant may be notified for management of wound care and dressing changes. Care After Discharge ◯◯ ◯◯ ◯◯ 980 Monitor level of consciousness, especially respiratory distress with morphine. Set-up referral services, such as home health, pharmacy services, or wound care consultants, to provide items such as wound dressing materials. Contact community outreach programs, such as Meals on Wheels, or a nutritionist to provide meals high in protein and vegetables to promote wound healing. For a client who has a chronic wound, a long-term care facility may be indicated. Rn adult medical surgical nursing Pressure ulcers, wounds, and wound management ◯◯ Client Education ■■ ■■ ■■ ●● Have the client demonstrate a dressing change before discharge. Encourage the client to eat a diet high in protein and vegetables to promote wound healing. Encourage the client to take vitamins and supplements to promote wound healing. ■■ Remind the client to keep skin clean and dry. ■■ Remind the client to report any signs of infection or further skin breakdown. Client Outcomes ◯◯ The client will have improved skin integrity. ◯◯ The client will be free of infection. ◯◯ The client will be free of pain. Complications ●● Dehiscence is a partial or total rupture (separation) of a sutured wound, usually with separation of underlying skin layers. Evisceration is a dehiscence that involves the protrusion of visceral organs through a wound opening. It is usually caused by the increased flow of serosanguineous fluid about 3 to 11 days postoperatively. ◯◯ ◯◯ ◯◯ Signs/symptoms of dehiscence include: ■■ A significant increase in the flow of serosanguineous fluid on the wound dressings ■■ Immediate history of sudden straining (coughing, sneezing, vomiting) ■■ The client reporting a change or “popping” or “giving way” in the wound area ■■ Visualization of viscera Risk factors include: ■■ Chronic disease ■■ Advanced age ■■ Obesity ■■ Invasive abdominal cancer ■■ Vomiting ■■ Dehydration/malnutrition ■■ Ineffective suturing ■■ Abdominal surgery Evisceration/dehiscence requires emergency treatment. Rn adult medical surgical nursing 98 1 Pressure ulcers, wounds, and wound management ◯◯ Nursing Actions ■■ Call for help. ■■ Stay with the client. ■■ Cover the wound and any protruding organs with sterile towels or dressings that have been soaked in a sterile 0.9% sodium chloride solution. Do not attempt to reinsert the organs. ■■ Position the client supine with the hips and knees bent. ■■ Observe the client for signs of shock. ■■ Maintain a calm environment. View Media Supplement: ●● Infection ◯◯ ◯◯ ◯◯ 982 Dehiscence & Evisceration (Image) Risk factors ■■ Extremes in age (immature immune system, decreased immune function) ■■ Impaired circulation and oxygenation (COPD, peripheral vascular disease) ■■ Wound condition/nature (gunshot wound vs. surgical incision) ■■ Impaired/suppressed immune system ■■ Malnutrition, such as with alcoholism ■■ Chronic disease ■■ Poor wound care, such as breaches in technique Signs and symptoms are usually apparent within 2 to 7 days of injury/surgery. ■■ Purulent drainage ■■ Pain ■■ Redness and edema (in and around the wound) ■■ Fever ■■ Chills ■■ Increased pulse and respiratory rate ■■ Increase in WBC Nursing Actions ■■ Prevent infection by using appropriate asepsis when performing dressing changes. ■■ Provide optimal nutrition to promote the immune response. ■■ Provide for adequate rest to promote healing. ■■ Administer antibiotic therapy as prescribed. Rn adult medical surgical nursing Pressure ulcers, wounds, and wound management Pressure Ulcers Overview ●● ●● ●● ●● ●● Pressure ulcers range from nonblanchable tissue redness to full thickness skin loss with damage to underlying muscle and bone. Excellent nursing care is the primary factor in the prevention of pressure ulcers. The primary focus of prevention and treatment is to relieve the pressure and provide optimal nutrition and hydration. All clients must be assessed regularly for skin-integrity status and evaluated regularly for risk factors that contribute to impaired skin integrity. Pressure ulcers are a significant source of morbidity and mortality among older adults and those who have limited mobility. Assessment ●● Risk Factors ◯◯ Skin changes related to aging ◯◯ Immobility ◯◯ Incontinence or excessive moisture ◯◯ Skin friction and shearing ◯◯ Vascular disorders ◯◯ Obesity ◯◯ Inadequate nutrition and/or hydration ◯◯ Anemia ◯◯ Fever ◯◯ Impaired circulation ◯◯ Edema ◯◯ Sensory deficits ◯◯ Impaired cognitive functioning, neurological disorders ◯◯ ◯◯ Chronic diseases (diabetes mellitus, chronic renal failure, congestive heart disease, chronic lung disease) Sedation that impairs spontaneous repositioning Rn adult medical surgical nursing 98 3 Pressure ulcers, wounds, and wound management Collaborative Care ●● Nursing Care ◯◯ Reposition the client in bed at least every 2 hr and every 1 hr in a chair. Document position changes. ■■ ■■ ■■ ■■ ◯◯ Maintain the head of the bed at or below a 30° angle, unless contraindicated, to relieve pressure on the sacrum, buttocks, and heels. Keep the client from sliding down in bed, as this increases shearing forces that pull tissue layers apart and cause damage. Lift, rather than pull, the client up in bed or in a chair, because pulling creates friction that can damage the outer layer of the skin (epidermis). ■■ Raise the client’s heels off of the bed to prevent pressure on the heels. ■■ Ambulate the client as soon as possible and as often as possible. ■■ Implement active/passive exercises for immobile clients. ■■ Do not massage bony prominences. Provide adequate hydration (2,000 to 3,000 mL/day) (unless contraindicated) and meet protein and calorie needs. ■■ ■■ ◯◯ Place pillows strategically between bony surfaces. Note if serum albumin levels are low (below 3.5 g/dL), because a lack of protein puts the client at greater risk for skin breakdown, slowed healing, and infection. Provide nutritional support, such as vitamin and mineral supplements, nutritional supplements, enteral nutrition, and parenteral nutrition, as indicated. Treatment Stages Interventions Suspected deep tissue injury and Stage I • • • • Stage II • Maintain a moist healing environment (saline or occlusive dressing). • Promote natural healing while preventing the formation of scar tissue. • Provide nutritional supplements as prescribed. • Administer analgesics as prescribed. 984 Relieve pressure. Encourage frequent turning/repositioning. Use pressure-relieving devices (air-fluidized beds). Implement pressure-reduction surfaces (air mattress, foam mattress). • Keep the client dry, clean, well-nourished, and hydrated. Rn adult medical surgical nursing PRESSURE ULCERS, WOUNDS, AND WOUND MANAGEMENT STAGES INTERVENTIONS Stage III • Clean and/or debride: ◯◯ Prescribed dressing ◯◯ Surgical intervention ◯◯ Proteolytic enzymes • Provide nutritional supplements as prescribed. • Administer analgesics as needed. • Administer antimicrobials (topical and/or systemic) as prescribed. Stage IV • Clean and/or debride: ◯◯ Prescribed dressing ◯◯ Surgical intervention ◯◯ Proteolytic enzymes • Perform nonadherent dressing changes every 12 hr. • Treatment may include skin grafts. • Provide nutritional supplements as prescribed. • Administer analgesics as prescribed. • Administer antimicrobials (topical and/or systemic) as prescribed. Unstageable • • • • ●● Eschar should cover wound as protective barrier. Provide nutritional supplements as prescribed. Administer analgesics as prescribed. Administer antimicrobials (topical and/or systemic) as prescribed. ■■ Assess onset, quality, duration, and severity of the pain. ■■ Administer analgesics as prescribed. ■■ Administer antimicrobials (topical and/or systemic) as prescribed. Medications ◯◯ Antimicrobial Therapy ■■ ■■ Antimicrobial therapy kills or inhibits the growth of micro-organisms, such as bacteria, fungi, viruses, and protozoans. Antimicrobial medications either kill pathogens or prevent their growth. Nursing Considerations ☐☐ ☐☐ ☐☐ Administer antimicrobial therapy as prescribed. Monitor for medication effectiveness (reduced fever, increased level of comfort, decreasing WBC count). Maintain medication schedule to assure consistent blood levels of antibiotic. RN ADULT MEDICAL SURGICAL NURSING 985 PRESSURE ULCERS, WOUNDS, AND WOUND MANAGEMENT ◯◯ Antipyretics (acetaminophen, aspirin) are used for fever and discomfort as prescribed. ■■ ◯◯ ■■ Analgesics (hydrocodone [Vicodin] morphine) are used for pain in the wound as prescribed. Nursing Considerations ☐☐ Administer analgesic therapy as prescribed. ☐☐ Monitor effectiveness of medication related to pain. ☐☐ Monitor level of consciousness, especially respiratory distress with morphine. Nutritional services may be consulted for meal choices to promote wound healing. ◯◯ Pain management services may be consulted if pain is persists and/or is uncontrolled. Rehabilitation care may be consulted if the client has prolonged weakness and needs assistance with increasing level of activity. Wound care consultants may be notified for management of wound care and dressing changes. Care After Discharge ◯◯ ◯◯ Set up referral services, such as home health, pharmacy services, or wound care consultants to provide items such as wound dressing materials. Contact community outreach programs, such as Meals on Wheels, or a nutritionist to provide meals high in protein and vegetables to promote wound healing. ◯◯ For a client who has a chronic wound, a long-term care facility may be indicated. ◯◯ Client Education ■■ ■■ 986 Graph client’s temperature fluctuations on medical record. ◯◯ ◯◯ ●● Monitor fever to determine effectiveness. ☐☐ Interdisciplinary Care ◯◯ ●● ☐☐ Analgesics Therapy ■■ ●● Nursing Considerations Have client demonstrate dressing change before discharge. Encourage client to eat a diet high in protein and vegetables to promote wound healing. ■■ Encourage client to take vitamins and supplements to promote wound healing. ■■ Remind client to keep skin clean and dry. ■■ Remind client to report any signs of infection or further skin breakdown. Client Outcomes ◯◯ The client will have improved skin integrity. ◯◯ The client will be free of infection. ◯◯ The client will be free of pain. RN ADULT MEDICAL SURGICAL NURSING Pressure ulcers, wounds, and wound management Complications ●● Deterioration to a Higher Stage Ulceration and/or Infection ◯◯ Nursing Actions ■■ ■■ ●● Assess/monitor the ulcer frequently and report increases in the size or depth of the lesion, changes in granulation tissue (color, texture), and changes in exudate (color, quantity, odor). Follow the facility’s protocol for ulcer treatment. Systemic Infection ◯◯ Nursing Actions ■■ ■■ Assess/monitor the client for signs of sepsis (changes in level of consciousness, persistent recurrent fever, tachycardia, tachypnea, hypotension, oliguria, increased WBC). Prevent infection by using appropriate asepsis when performing ulcer treatment and dressing changes. ■■ Provide optimal nutrition to promote the immune response. ■■ Provide for adequate rest to promote healing. ■■ Administer antibiotic therapy as prescribed. Rn adult medical surgical nursing 98 7 PRESSURE ULCERS, WOUNDS, AND WOUND MANAGEMENT CHAPTER 86: PRESSURE ULCERS, WOUNDS, AND WOUND MANAGEMENT Application Exercises 1. An adolescent client who has diabetes mellitus is recovering from an appendectomy. This is the third postoperative day. The client has been prescribed a regular diet and is tolerating it well. He has ambulated successfully around the unit with the help of his parents and is requesting pain medication every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to 10 after medication is given. His incision is approximated and free of redness with scant serous drainage noted on the dressing. What type of healing process should the nurse expect this wound to be undergoing? Explain. 2. Which of the following diagnostic tests is relevant for assessing the risk of developing a pressure ulcer for an older adult client who has no major health issues? A. Serum albumin B. WBCs C. RBCs D. Serum potassium 3. Which of the following findings may negatively impact wound healing? (Select all that apply.) Family history of pressure ulcers Type 2 diabetes mellitus Strict vegetarian Cigarette smoker Long-term use of glucocorticosteroids 4. Which of the following term describes wound drainage that is thick and yellow? A. Serous B. Sanguineous C. Serosanguineous D. Purulent 988 RN ADULT MEDICAL SURGICAL NURSING PRESSURE ULCERS, WOUNDS, AND WOUND MANAGEMENT Scenario: An older adult woman who has type 2 diabetes mellitus has undergone surgery for a bowel obstruction 6 days ago. Prior to surgery, she experienced nausea and vomiting for 3 days. She has been NPO since the surgery and is receiving IV fluids. During the last 24 hr, she has reported nausea, and she has vomited small amounts of clear liquid three times in the last 8 hr. Her vital signs are stable. The client weighs 81.6 kg (180 lb), is 157.5 cm (5 ft 2 in) tall, and smokes two packs of cigarettes per day. Currently, her incision is well approximated and free of redness, tenderness, or swelling. 5. List the signs and symptoms the nurse should watch for that indicate development of a wound infection. 6. What risk factors for poor healing does this client exhibit? 7. Later that day, the client becomes confused and pulls off her surgical dressing. The nurse enters the room and finds the client with an extensive dehiscence. Which of the following nursing interventions are appropriate? (Select all that apply.) Repack the wound. Call for help. Assist the client to a chair. Cover the wound with a sterile dressing moistened with normal saline. Stay with the client. 8. What placed this client at risk for a wound dehiscence/evisceration? RN ADULT MEDICAL SURGICAL NURSING 989 PRESSURE ULCERS, WOUNDS, AND WOUND MANAGEMENT CHAPTER 86: PRESSURE ULCERS, WOUNDS, AND WOUND MANAGEMENT Application Exercises Answer Key 1. An adolescent client who has diabetes mellitus is recovering from an appendectomy. This is the third postoperative day. The client has been prescribed a regular diet and is tolerating it well. He has ambulated successfully around the unit with the help of his parents and is requesting pain medication every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to 10 after medication is given. His incision is approximated and free of redness with scant serous drainage noted on the dressing. What type of healing process should the nurse expect this wound to be undergoing? Explain. This wound is healing by primary intentions because it is a surgical incision. NCLEX® Connection: Physiological Adaptation: Alterations in Body Systems 2. Which of the following diagnostic tests is relevant for assessing the risk of developing a pressure ulcer for an older adult client who has no major health issues? A. Serum albumin B. WBCs C. RBCs D. Serum potassium Serum albumin would provide information regarding the adequacy of protein intake. Inadequate protein poses a great risk for altered skin integrity and ineffective healing. The other options are not indicative of this finding. NCLEX® Connection: Reduction of Risk Potential: Diagnostic Tests 3. Which of the following findings may negatively impact wound healing? (Select all that apply.) Family history of pressure ulcers X Type 2 diabetes mellitus X Strict vegetarian X Cigarette smoker X Long-term use of glucocorticosteroids Diabetes mellitus negatively impacts the immune response. A strict vegetarian may not have adequate protein intake, which would negatively impact wound healing, as would smoking (because it impairs oxygenation) and the use of glucocorticosteroids (because they depress the immune response). A family history is not indicative of developing pressure ulcers. NCLEX® Connection: Physiological Adaptation: Alterations in Body Systems 990 RN ADULT MEDICAL SURGICAL NURSING PRESSURE ULCERS, WOUNDS, AND WOUND MANAGEMENT 4. Which of the following term describes wound drainage that is thick and yellow? A. Serous B. Sanguineous C. Serosanguineous D. Purulent Wound exudate depends on the presence or absence of infection – Uninfected wounds have serous (clear, thin, maybe slightly yellow) or serosanguineous exudate (thin, blood tinged), and infected wounds have purulent exudate. Purulent drainage is thick and contains white blood cells, tissue debris, and bacteria. The color varies among infective organisms (yellow with Staphylococcus and green with Pseudomonas). NCLEX® Connection: Physiological Adaptation: Alterations in Body Systems Scenario: An older adult woman who has type 2 diabetes mellitus has undergone surgery for a bowel obstruction 6 days ago. Prior to surgery, she experienced nausea and vomiting for 3 days. She has been NPO since the surgery and is receiving IV fluids. During the last 24 hr, she has reported nausea, and she has vomited small amounts of clear liquid three times in the last 8 hr. Her vital signs are stable. The client weighs 81.6 kg (180 lb), is 157.5 cm (5 ft 2 in) tall, and smokes two packs of cigarettes per day. Currently, her incision is well approximated and free of redness, tenderness, or swelling. 5. List the signs and symptoms the nurse should watch for that indicate development of a wound infection. Purulent drainage Pain Redness and edema (in and around the wound) Fever Chills Increased pulse and respiratory rate Increased white blood cell count NCLEX® Connection: Physiological Adaptation: Alterations in Body Systems 6. What risk factors for poor healing does this client exhibit? The client is obese, has diabetes mellitus, smokes, and adequate nutritional intake is impaired. NCLEX® Connection: Physiological Adaptation: Alterations in Body Systems RN ADULT MEDICAL SURGICAL NURSING 991 Pressure ulcers, wounds, and wound management 7. Later that day, the client becomes confused and pulls off her surgical dressing. The nurse enters the room and finds the client with an extensive dehiscence. Which of the following nursing interventions are appropriate? (Select all that apply.) Repack the wound. X Call for help. Assist the client to a chair. X Cover the wound with a sterile dressing moistened with normal sterile saline. X Stay with the client. It is appropriate for the nurse to call for help, stay with the client, and cover the wound with a sterile dressing that is moistened with normal sterile saline. The nurse should not attempt to reinsert the organs and repack the wound. The client should be placed in the supine position with hips and knees bent. NCLEX® Connection: Physiological Adaptation: Alterations in Body Systems 8. What placed this client at risk for a wound dehiscence/evisceration? Age Obesity Abdominal surgery 6 days ago Recent vomiting NCLEX® Connection: Physiological Adaptation: Alterations in Body Systems 992 Rn adult medical surgical nursing
© Copyright 2024