Wound care pt 2

Patient Profile: 58-year-old female, 5 days post-op complete hysterectomy (ovarian cancer)
Home Health Visit: Nurse finds the patient disoriented in a chair.
Incision Assessment: Abdominal incision open with intestines protruding, indicating evisceration.
Actions to Take:
  - Indicated Actions:
    - Call Emergency Services: Necessary due to the severity of evisceration.
    - Cover wound with sterile, saline-soaked gauze: Protects abdominal contents and reduces risk of infection.
  - Contraindicated Actions:
    - Place abdominal binder on patient: Risk of trapping abdominal contents, worsening the situation.
    - Assist the patient to ambulate to the car: Movement could lead to further complications.
    - Push abdominal contents back into the abdomen: This is dangerous and could cause damage.
    - Rouse the patient and provide wound care education: Priority is on immediate care, not education.

Patient Assignments: RN to perform dressing change on a sacral pressure injury.
Priority Nursing Interventions: Select all that apply.
  - Priority Actions:
    - Cleanse wound with normal saline: Maintains a clean environment for healing.
    - Apply moist hydrocolloid dressing per wound care order: Supports a moist healing environment.
    - Reposition patient to left lateral position: Reduces pressure on wound.
    - Document tolerance of dressing change: Critical for care continuity and assessment.
  - Non-Priority Actions:
    - Apply lotion to wound after cleaning: Can irritate the wound.
    - Provide education on offloading pressure: Important but can follow immediate interventions.
    - Notify Wound Care RN of findings after dressing change: Important for ongoing care but not a priority during the change.
    - Leave the wound open to air: Not indicated; wounds heal better in a moist environment.

Assessment Findings to Document:
  - Pain Scale: Mild discomfort at a level of 3/10 during dressing change.
  - Wound Characteristics:
    - Breakdown in sacral area with dimensions of 4 cm (length) x 3 cm (width) x 1.5 cm (depth).
    - Granulation tissue plus moderate yellow slough and moderate serous drainage, no foul odor.
    - Surrounding skin shows slight erythema, but no warmth or induration.
    - Undermining and tunneling noted, indicates further assessment for stage classification.

Stage Classification: Based on wound assessment, documented as a Stage 3 pressure injury.
Wound Characteristics for Stage 3 Pressure Injury:
- Full-thickness loss of skin, with visible fat, but no exposure of bone or muscle.
- Granulation tissue is present; slough may or may not be visible.
Contraindications in Management: Ignoring signs of infection is critical; monitor for increased drainage or foul odor.

Correct Wound Care Techniques:
- Clean with Normal Saline: Recommended for routine wound management.
- Moisture-Retentive Dressings: Promote optimal wound healing conditions.
Incorrect Wound Care Techniques:
  - Hydrogen Peroxide Application: Damages healthy tissue, delays healing; not to be used routinely.
  - Dry Air Exposure: Leaves wounds prone to scab formation and hinders healing.
  - Ignoring Redness or Warmth: Signs of potential infection; all changes should be reported.
  - Dry Cotton Gauze for Packing: Can stick and damage tissue; recommends using moist dressings instead.

Findings in Stage 4 Pressure Injury:
  - Full-thickness tissue loss with exposed bone, muscle, or tendon.
  - Expected Signs:
    - Undermining: Presence of hollowed areas beneath the wound.
    - Slough: Dead tissue present.
    - Tunneling: Deep tunnels within the wound.
    - Foul drainage or odor: Indicates possible infection.
    - Notable Exclusions:
      - No sutures present; they are indicative of surgical wounds.
      - Pain is not typically reported at this stage due to depth.