NURS 221 - Final Exam
What is wound dehiscence?
A partial or total rupture (separation) of a sutured wound, usually with separation of underlying skin layers
What is a partial or total rupture (separation) of a sutured wound, usually with separation of underlying skin layers called?
Dehisce...
NURS 221 - Final Exam
What is wound dehiscence?
A partial or total rupture (separation) of a sutured wound, usually with separation of underlying skin
layers
What is a partial or total rupture (separation) of a sutured wound, usually with separation of
underlying skin layers called?
Dehiscence
What is wound evisceration?
A dehiscence that involves the protrusion of visceral organs through a wound opening
What is a dehiscence that involves the protrusion of visceral organs through a wound opening called?
Evisceration
What are manifestations of wound dehiscence?
Significant increase in the flow of serosanguineous fluid on the wound dressings, immediate history of
sudden straining, client reporting a "popping" sensation or "giving way" in the area, visualization of
viscera
How can dehiscence/evisceration be prevented?
Thin, folded blanket or small pillow over surgical wounds when client coughs in order to support the
wound
What are immediate nursing interventions for wound dehiscence?
Call for help, cover wound with sterile towels or dressings soaked with sterile normal saline, position
client supine with hips and knees bent, observe for indications of shock, keep the client NPO
How soon after surgery does infection most commonly occur?
3-11 days
What are manifestations of surgical infection?
Purulent drainage, pain, redness, edema, fever, chills, odor, increase in HR and RR, increase in WBC
count
What are the causes of pressure ulcers?
Inhibited blood flow r/t immobility, incontinence, friction/shearing, inadequate nutrition/hydration,
vascular problems
Describe a stage 1 pressure ulcer
Non-blanchable erythema
Describe a stage 2 pressure ulcer
Partial thickness, involves epidermis and dermis; can appear as an abrasion, blister, or shallow crater;
may be scant drainage
, Which pressure ulcer stage involves partial thickness loss?
2
Which pressure ulcer stage can appear as an abrasion, blister, or shallow crater?
2
Describe a stage 3 pressure ulcer
Full-thickness skin loss, appears as a deep crater without showing muscle or bone; drainage and
infection are common
Describe a stage 4 pressure ulcer
Full-thickness tissue loss, damage to muscle, bone, or supporting structures; can be sinus tracts, deep
pockets of infection, tunneling, undermining, eschar, slough
Which scale measures the risk for pressure ulcers?
Braden scale
How can a nurse help to prevent pressure ulcers?
Keep skin dry and clean, wrinkle-free sheet, reposition every 2 hours in bed and every one hour in
chair, head at most 30 degrees, raise heels, ambulate as much as possible, shift weight every 15
minutes if mobile, minimize friction, use barriers and pressure-reducing devices, do not massage bony
prominences, ensure serum albumin is 3.5 or higher; provide vitamin A, C, copper, and zinc
How often should a patient be re-positioned?
Every 2 hours in bed, 1 hour in chair
What angle should the HOB be for a patient at risk for a pressure ulcer?
At most 30 degrees unless contraindicated
What should serum albumin level be?
At least 3.5
Which vitamins and minerals are important for a patient at risk for pressure ulcers?
Vitamin A, C, zinc, copper
Position for administering oral meds
90 degrees to promote swallowing
Position for administering eye meds
Upright or supine, tilt head slightly, look up at the ceiling
Position for administering ear meds
Upright or on side, remain in position 2-3 minutes
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