Wound care exam 4 foundations

What is a pressure injury?

A pressure injury is damage to the skin and underlying tissue caused by prolonged pressure that decreases blood flow, usually over bony prominences.

What are common locations for pressure injuries?

Common locations include the sacrum, heels, hips, elbows, back of the head, and shoulders.

What does the mnemonic DIDN’T HEAL represent?

DIDN’T HEAL represents factors that impair wound healing: Diabetes, Infection, Drugs, Nutrition problems, Tissue necrosis, Hypoxia, Excessive tension, Another wound, and Low temperature.

What does the TIME mnemonic stand for in wound assessment?

Tissue, Infection or Inflammation, Moisture, and Edge of the wound.

What does a red wound bed indicate?

A red wound bed indicates healthy granulation tissue that should be protected.

What does a yellow wound bed indicate?

A yellow wound bed indicates slough that must be cleaned.

What does a black wound bed indicate?

A black wound bed indicates eschar that usually requires debridement.

When should black eschar NOT be removed?

Black eschar should not be removed if it is stable, dry, intact, and located on the heel with poor circulation.

What is the Braden Scale used for?

The Braden Scale is used to assess a patient’s risk for developing pressure injuries.

What factors are assessed in the Braden Scale?

The Braden Scale assesses sensory perception, moisture, activity, mobility, nutrition, and friction or shear.

What is the scoring range of the Braden Scale?

The Braden Scale ranges from 6 to 23.

What does a low Braden Scale score indicate?

A low score indicates a higher risk for pressure injury.

What score indicates a patient is at risk for pressure injury?

A score of 18 or lower indicates risk, with lower scores indicating greater risk.

Which stage of pressure injury presents with intact skin and nonblanchable redness?

Stage 1.

Which stage of pressure injury presents with a shallow open wound or blister?

stage 2

Which stage of pressure injury presents with visible fat but no exposed bone?

stage 3

Which stage of pressure injury presents with exposed bone, tendon, or muscle?

stage 4

What is an unstageable pressure injury?

A wound covered with slough or eschar that prevents determining the depth.

What is a deep tissue pressure injury (DTI)?

A purple or maroon area of intact skin indicating severe underlying tissue damage.

What is the priority action for any pressure injury?

The priority action is to relieve pressure immediately by repositioning the patient.

What repositioning schedule should be followed for pressure injury prevention?

The patient should be repositioned every 2 hours in bed and every 1 hour in a chair.

What should the nurse NEVER do when caring for pressure injuries?

The nurse should never massage bony prominences, drag the patient across sheets, or use cytotoxic solutions such as hydrogen peroxide, alcohol, or Betadine.

How should heels be protected in patients at risk for pressure injuries?

Heels should be floated off the bed using a pillow under the calves.

How should a nurse pack a wound?

The nurse should pack the wound loosely with moist gauze to fill dead space without applying pressure.

Why should a wound never be packed tightly?

Packing tightly decreases blood flow and can cause further tissue damage.

What safety rule must be followed when packing a wound?

The nurse must document the number of packing materials placed and ensure the same number is removed.

Why must wounds be kept moist?

Wounds must be kept moist because moist environments promote faster healing and tissue regeneration

What solution should be used to cleanse wounds?

Normal saline should be used because it does not damage healthy tissue.

What type of dressing is commonly used for Stage 2 wounds?

Hydrocolloid dressings are commonly used to maintain a moist environment.

What is the purpose of a nonadherent dressing?

A nonadherent dressing prevents trauma to the wound during removal.

When should a wound culture be obtained?

A wound culture should be obtained when signs of infection are present.

What is the correct order regarding wound culture and antibiotics?

The nurse must collect the wound culture before administering antibiotics.

How is a wound culture collected?

The wound is cleaned with normal saline first, and then a sterile swab is rotated in the wound bed.

What is wound hemorrhage?

Wound hemorrhage is excessive bleeding from a wound.

What is the priority nursing action for wound hemorrhage?

The nurse should apply direct pressure immediately.

What should the nurse do if bleeding continues after applying pressure?

The nurse should reinforce the dressing and notify the provider.

What is wound dehiscence?

Wound dehiscence is partial or complete separation of a surgical incision.

What is a common sign of wound dehiscence?

A popping sensation and increased drainage.

What is the first nursing action for dehiscence?

The nurse should assess the wound.

What is evisceration?

Evisceration is the protrusion of organs through a wound.

What is the priority action for evisceration?

The nurse should cover the organs with a sterile saline-moistened dressing immediately.

What should NEVER be done in evisceration?

The nurse should never push organs back into the wound.

What are signs of a wound infection?

Signs include purulent drainage, redness, warmth, swelling, pain, and fever.

What does green drainage from a wound indicate?

Green drainage indicates a Pseudomonas infection.

What must be done before administering antibiotics for a wound infection?

A wound culture must be obtained first.

What serious complication can result from untreated wound infection?

Sepsis.

How should sutures and staples be cared for?

The nurse should keep the area clean, monitor for signs of infection, and follow provider orders.

How are sutures or staples removed safely?

Every other suture or staple is removed first to prevent wound separation.

What is done after sutures or staples are removed?

Steri-strips are applied to support the wound.

What type of drain is a Penrose drain?

A Penrose drain is an open drain.

What type of drain is a Jackson-Pratt (JP) drain?

A Jackson-Pratt drain is a closed suction drain.

How does a Penrose drain work?

It allows fluid to drain passively onto a dressing.

How does a JP drain work?

It uses suction from a compressed bulb to remove fluid.

Which drain has a higher risk of infection?

The Penrose drain has a higher risk of infection.

How does the nurse ensure a JP drain is functioning properly?

The nurse ensures the bulb is compressed to maintain suction.

What must be done before closing a JP drain bulb?

The bulb must be compressed.

What should the nurse monitor in all drains?

The amount, color, and consistency of drainage.

What drainage is expected after surgery?

Serosanguineous drainage.

Which ulcer is very painful?

Arterial ulcer.

Which ulcer has mild to moderate pain or may be painless?

Venous ulcer.

What type of pain occurs with arterial ulcers?

Sharp, stabbing, or burning pain, especially with elevation or at night.

What type of pain occurs with venous ulcers?

Dull, aching pain that improves with elevation.

What relieves arterial ulcer pain?

Dangling the leg.

What relieves venous ulcer pain?

Elevating the leg.

Where are arterial ulcers located?

Toes, feet, lateral malleolus, and pressure points.

Where are venous ulcers located?

Medial lower leg, ankle, or gaiter area.

What does an arterial ulcer look like?

Punched out, pale, dry, with minimal drainage.

What does a venous ulcer look like?

Irregular, moist, with drainage, edema, and warmth.