EXAM 2 STUDY GUIDE / NR224 TEST #2
THINK SAFETY FIRST (ALWAYS) AND REMEMBER THE NURSING PROCESS!!
Skin Integrity/Wound Care:
What food provide the most protein for wound healing?
o Meat or dairy products
o Poultry, beef, soy, cheese, whole milk
Which lab indicates affects wound healing?
o Measurement of wound size provides overall changes in dimensions – indicator
for would healing progress (length, width, & depth)
o 3.4 – 5.4 normal serum albumin – indicator of malnutrition
o Best measure of nutritional status is prealbumin – reflects what pt has ingested but
also what body has absorbed, digested, and metabolized
What are the risks for skin breakdown/pressure ulcer?
o Pts experiencing
Decreased mobility
Decreased sensory perception
Fecal or urinary incontinence
Poor nutrition
o Older adults, those who have experienced trauma
o Those with spinal-cord injuries (SCI)
o Sustained a fractured hip
o Those in long-term homes or community care – the acutely ill
o Individuals with diabetes
o Patients in critical care settings
Describe wound drainage
o Amount, color, odor & consistency should be noted
o Amount depends on type of wound
o To quantify wound drainage:
Chart number of dressing used
Frequency of change
o Types
Serous – clear, watery plasma
Purulent – thick, yellow, green, tan or brown
Serosanguineous – pale, pink, watery; mixture of clear and red fluid
Sanguineous – bright red; indicates active bleeding
What is evisceration/dehiscence? Treatment?
o Evisceration - Protrusion of visceral organs through a wound opening
, ‘Emergency that requires surgical repair
Nurse places sterile gauzed soaked in sterile saline over the extruding
tissues to reduce chances of bacterial invasion & drying of the tissues
Immediately place damp sterile gauze over the site contact surgical
team don’t allow pt anything by mouth (NPO) observe for S&S of
shock prepare pt for emergency surgery
Supine/knees bent
o Dehiscence
Partial or total separation of wound layers
Pt at risk for poor wound healing is at risk for dehiscence
Also at risk are those that have constant strain placed on their wounds and
the poor healing qualities of fat tissue
Can happen in abdominal surgical wounds & occurs after a sudden strain
such as coughing, vomiting, or sitting up in bed.
Pts often report feeling as though something has given way
If there is an increase in serosanguineous drainage from wound in the first
few days after surgery be alert for potential for dehiscence.
What dressing would you use for a stage 1?
o No dressing used – resolves slowly without epidermal loss over 7-14 days
o Transparent dressing – protects from shear & friction
o Hydrocolloid – doesn’t always allow visual assessment – pressure redistricution
surface or chair cushion
o Relieve pressure
o Encourage frequent turning and repositioning
o Use pressure-relieving devices, such as air fluidized bed
o Implement pressure-reduction surfaces (air mattress, foamy mattress)
o Keep the client dry, clean, well-nourished and hydrated
o Transparent and hydrocolloid
How do you obtain a wound culture?
o Never collect a wound culture from old drainage
o Clean a wound first w normal saline to remove skin flora – allow to dry
o Needle aspiration
Use a 10ml disposable syringe w 22G needle, pulling 0.5ml of air into
syringe
Insert needle through intact skin next to wound; withdraw plunger and
apply suction to the 10ml mark.
Move needle back and forward at different angles for 2-4 explorations
Remove & safely discard the needle, expel excess air, and cap & prepare
the syringe for the laboratory.
o Quantitative swab procedure
Use sterile swab from culturette tube
Moisten swab w normal saline
THINK SAFETY FIRST (ALWAYS) AND REMEMBER THE NURSING PROCESS!!
Skin Integrity/Wound Care:
What food provide the most protein for wound healing?
o Meat or dairy products
o Poultry, beef, soy, cheese, whole milk
Which lab indicates affects wound healing?
o Measurement of wound size provides overall changes in dimensions – indicator
for would healing progress (length, width, & depth)
o 3.4 – 5.4 normal serum albumin – indicator of malnutrition
o Best measure of nutritional status is prealbumin – reflects what pt has ingested but
also what body has absorbed, digested, and metabolized
What are the risks for skin breakdown/pressure ulcer?
o Pts experiencing
Decreased mobility
Decreased sensory perception
Fecal or urinary incontinence
Poor nutrition
o Older adults, those who have experienced trauma
o Those with spinal-cord injuries (SCI)
o Sustained a fractured hip
o Those in long-term homes or community care – the acutely ill
o Individuals with diabetes
o Patients in critical care settings
Describe wound drainage
o Amount, color, odor & consistency should be noted
o Amount depends on type of wound
o To quantify wound drainage:
Chart number of dressing used
Frequency of change
o Types
Serous – clear, watery plasma
Purulent – thick, yellow, green, tan or brown
Serosanguineous – pale, pink, watery; mixture of clear and red fluid
Sanguineous – bright red; indicates active bleeding
What is evisceration/dehiscence? Treatment?
o Evisceration - Protrusion of visceral organs through a wound opening
, ‘Emergency that requires surgical repair
Nurse places sterile gauzed soaked in sterile saline over the extruding
tissues to reduce chances of bacterial invasion & drying of the tissues
Immediately place damp sterile gauze over the site contact surgical
team don’t allow pt anything by mouth (NPO) observe for S&S of
shock prepare pt for emergency surgery
Supine/knees bent
o Dehiscence
Partial or total separation of wound layers
Pt at risk for poor wound healing is at risk for dehiscence
Also at risk are those that have constant strain placed on their wounds and
the poor healing qualities of fat tissue
Can happen in abdominal surgical wounds & occurs after a sudden strain
such as coughing, vomiting, or sitting up in bed.
Pts often report feeling as though something has given way
If there is an increase in serosanguineous drainage from wound in the first
few days after surgery be alert for potential for dehiscence.
What dressing would you use for a stage 1?
o No dressing used – resolves slowly without epidermal loss over 7-14 days
o Transparent dressing – protects from shear & friction
o Hydrocolloid – doesn’t always allow visual assessment – pressure redistricution
surface or chair cushion
o Relieve pressure
o Encourage frequent turning and repositioning
o Use pressure-relieving devices, such as air fluidized bed
o Implement pressure-reduction surfaces (air mattress, foamy mattress)
o Keep the client dry, clean, well-nourished and hydrated
o Transparent and hydrocolloid
How do you obtain a wound culture?
o Never collect a wound culture from old drainage
o Clean a wound first w normal saline to remove skin flora – allow to dry
o Needle aspiration
Use a 10ml disposable syringe w 22G needle, pulling 0.5ml of air into
syringe
Insert needle through intact skin next to wound; withdraw plunger and
apply suction to the 10ml mark.
Move needle back and forward at different angles for 2-4 explorations
Remove & safely discard the needle, expel excess air, and cap & prepare
the syringe for the laboratory.
o Quantitative swab procedure
Use sterile swab from culturette tube
Moisten swab w normal saline
