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Pressure ulcers and wound careMedical-Surgical Nursing-7th edition

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Question Answer
What are the signs and symptoms of an infected wound?
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Fever, tenderness, pain, increased WBC, and/or inflamed wound edges.
Infection can appear as early as _______ days. Surgical infections usually appear _______ days postoperatively.
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2-3 days; 4-5 days
Dehiscence most commonly occurs _______ days after injury.
Show Answer
11-Mar
Who is at high risk for dehiscence?
Show Answer
Obese, poor nutrition, and/or present infection.
What is a strategy for preventing dehiscence?
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Place a folded thin blanket or pillow over the abdominal wound when client is coughing.
What should you do if evisceration occurs?
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Place sterile towels soaked in sterile saline over the extruding tissues to decrease bacterial invasion and drying of tissue; NPO; Watch for shock; and Prepare for surgery.
What conditions can cause fistula formation?
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Trauma, infection, radiation, cancer, and Chron's.
_______ increases the risk of infection and fluid/electrolyte imbalance.
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Fistula
What scales are used to assess risk of pressure ulcers?
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Norton and Braden.
How is the Norton scale of pressure ulcer risk different from the Braden scale?
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Norton: Five factors: physical, mental, activity, mobility and incontinence. 5 - 20. Braden: Six factors: sensory, moisture activity, mobility, nutrition, friction and shear. 6 - 23. 18 is cutoff, most commonly used.
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What factors impact pressure ulcer formation and healing?
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Nutrition: proteins, A, C, zinc and copper; Tissue Perfusion; Infection; Age; and Psychosocial.
What are the major components of a skin assessment?
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Sensation, mobility, continence, and presence of wound.
What should you do if you suspect abnormal reactive hyperemia?
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Outline the area with a marker to make reassessment easier.
When you note hyperemia you should note the location, size and color and reassess in _______.
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one hour
What are signs of a potential nutritional problem?
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Decrease of 50% of body weight, Lose 10 pounds in a brief amount of time, and/or wt under 90% of body weight.
A client at risk for pressure ulcers had been admitted to acute care. What is the minimum that they should be assessed for ulcer development?
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Once a day.
An injury is the result of a rusty barbed wire. What should you ask the client?
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Date of last tetanus (every 5 years).
Prior to removing a dressing, you should _______ 30 minutes before exposing the wound.
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give analgesics
1 gram of drainage = _______mL
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1 mL
How do you get an accurate measure of drainage within a dressing?
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Weigh it and compare with same dressing that is clean and dry OR chart #/frequency of changes.
You notice a sudden decrease in drainage through the tubing may indicate...
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a blocked drain (*Call HCP)
  
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