Editing Nursing Skills and Procedures – RN Flashcards (section)

== Wound Management ==

;Differentiate a stage 3 pressure injury from a stage 4.
:Stage 3 is full thickness with visible adipose tissue, possible undermining and tunneling, and no exposed fascia, muscle, tendon, ligament, cartilage, or bone. Stage 4 exposes or allows direct palpation of those deeper structures.

;When is a pressure injury documented as unstageable, and what does deep tissue pressure injury look like?
:Unstageable when slough or eschar obscures the base so depth cannot be determined. Deep tissue pressure injury is persistent nonblanchable deep red, maroon, or purple discoloration, or a blood-filled blister, over intact or nonintact skin.

;Why is stable dry eschar on an ischemic heel left intact?
:It functions as the body's biological cover over poorly perfused tissue. Keep it dry, offload the heel, and report any new erythema, fluctuance, drainage, odor, or softening, which signal infection and change the plan.

;Match the dressing to the wound: heavy exudate, dry wound bed, clean shallow stage 2.
:Heavy exudate calls for alginate or foam. A dry wound bed calls for hydrogel to donate moisture. A clean shallow stage 2 wound suits a hydrocolloid, which maintains moisture and promotes autolytic debridement.

;Why is wet-to-dry gauze no longer recommended as routine wound care?
:It performs nonselective mechanical debridement that removes healthy granulation tissue along with necrotic tissue, is painful, and disrupts moisture balance. It should be questioned when ordered for a clean granulating wound.

;List the contraindications to negative pressure wound therapy.
:Untreated osteomyelitis, malignancy within the wound, exposed vessels, organs, or anastomoses, and necrotic tissue with eschar. Frank blood in the canister is an emergency.

;How is a wound culture correctly obtained?
:Cleanse the wound with normal saline first, then swab viable tissue in the wound bed with a rotating motion. Do not culture pus, slough, or eschar, and obtain the specimen before antibiotics when possible.

;State the full nursing response to wound evisceration.
:Stay with the client, position low Fowler with knees flexed, cover the viscera with sterile gauze moistened with sterile normal saline, never attempt reinsertion, keep the client NPO, monitor for hypovolemic shock, and notify the surgeon immediately.