Editing Nursing Skills and Procedures – LPN Flashcards (section)

== Wound Care ==

;In what direction is a wound cleansed, and how many gauze pads are used?
:From least contaminated to most contaminated, meaning from the incision outward, using a new gauze for every stroke. A used gauze never returns to the wound.

;What should be done if a dressing adheres to the wound bed?
:Moisten it with sterile normal saline and remove it gently. Pulling a stuck dressing off tears away new granulation tissue, causes pain, and can cause bleeding.

;Why is wound packing placed loosely?
:Tight packing raises pressure in the wound bed, impairs perfusion, and delays healing. Packing material is counted in, counted out, and documented.

;Describe serous, sanguineous, serosanguineous, and purulent drainage.
:Serous is clear and watery and expected. Sanguineous is bright red fresh bleeding. Serosanguineous is pink and watery and common in the first 48 hours. Purulent is thick, opaque, yellow, green, tan, or brown and suggests infection.

;Which wound findings should be reported to the registered nurse?
:Purulent or malodorous drainage, spreading redness, increasing pain especially after the third postoperative day, fever, wound edges separating, and any bleeding that saturates the dressing.

;What are the first nursing actions if the wound edges separate and tissue protrudes?
:Stay with the client, position low Fowler with knees flexed, cover with sterile gauze moistened with sterile normal saline, never push anything back in, keep the client NPO, and notify the registered nurse and provider immediately.