Wound questions?

UM Review RN, ASN, RN · Mar 18, 2008

We'd love to help, but we need to know how much you've come up with on your own.

Remember, textbooks are not the only way to answer a question. Google is your friend. Try "wound assessment" as the keywords.

jmgrn65, RN · Mar 18, 2008

fellow nsg students i'm having difficulties with the following questions and would appreciate some help. thanks :)
your clt. mrs smith has a post laparotomy incision that did not heal well and now requires a ns wet dry dressing change tid. upon questioning your overall comfort level with the dressing change, she states, "it really hurts once they get into it."
1.describe your next set of interventions?
i'm not sure what i would do with my clt. do i stop? give her meds? wait ?you have to do the drsg, so pain meds would be what you will need to do. wounds will hurt.
2. how do you know when granulatation is occuring? is it when the epithelium tissue starts to fill
yes you are on the right track.
3. what is normal inflammatory response w/ wounds? this is when all the wbc, macrophage are drawn to the injure area , increase blood flow
and last i had no idea
you may see some slight redness around the wound. i think you should look this question up. you will definetly need to know this and you are on the right track.
4. how would you culture a wound if ordered by a doc?
you need a special cotton swab like (for lack of better word) and you would stick in the middle of the wound without touching any part of skin. once your in the middle of wound swab it usually in a circular or twirling movement, bring it straigt out with out touching anything and place back in container.
three hrs after you did the current dressing (the one you are doing now) you take mrs smith vs & note the dressing has saturated through the current one with sanguineous drainage.
5. what nsg interventions would you do and why? change the dressing? doc the color, amt?
you have answered your own question
6. what would you do if you found that the wound had a dehiscence? contact the doctor?
do you really have to ask this one?
7. explain the 3 type of wound healing? i just wanted to make sure this had to do with the primary, secondary, tertiary right

ok angie was right we don't answer homework questions. i helped answer some because it had looked like you put some thought it in them.

i think that you need to look up some answer in your book, because us telling you will not help, and it may not be what your book says then you won't get the right answers for test. looking up answer is a good way of learning. good luck

Daytonite, BSN, RN · Mar 18, 2008

mrs. smith states, "it really hurts once they get into it (wound change)".

give pain medication 15 to 30 minutes prior to doing a wound change for the patient's comfort.

how do you know when granulation is occurring?

you can see it. granulation tissue comes from connective tissue and appears red and granular in appearance. it is abundant in new capillaries (which is why it appears red).

what is normal inflammatory response with wounds?

see the explanation of the pathophysiology of inflammation on this thread:

https://allnurses.com/forums/f50/histamine-effect-244836.html

. this process never changes. the exudate that forms as a result of inflammation (1) dilutes toxins produced by any bacteria in the wound and toxic products released by dying cells, (2) carries plasma proteins, antibodies, leukocytes, phagocytes and lymphocytes to the site of the wound, and (3) carries away bacterial toxins, dead cells, debris and other products of inflammation via lymphatic vessels.

inflammation can only occur in vascularized tissues and the most severe damage can occur in inflammation at the borders on a wound where there is vascularization and perfusion

.

important point:

inflammation must occur because without it, healing could not occur. acute inflammation is so closely tied to healing that it is sometimes called the

defense phase of healing

. [page 228,

pathophysiology: the biologic basis for disease in adults and children

, third edition, by kathryn l. mccance and sue e. heuther]

how would you culture a wound if ordered by a doctor?

here are two websites from hospital procedure manuals on how to collect a wound specimen:

three hours after you did the current dressing (the one you are doing now) you take mrs. smith's vs & note the dressing has saturated through the current one with sanguineous drainage. what nursing interventions would you do and why?

document time, amount, any odor and color of drainage. either reinforce current dressing, or completely change the dressing. check for evidence of dehiscence, evisceration or inflammation. make sure the outer skin of the wound remains dry and protected from drainage. clean outward; clean from the inside of the wound to the outside area.

what would you do if you found that the wound had a dehiscence?

dehiscence is when sutures do not hold and a surgical wound opens up. check to see if any visceral organs are visible and/or protruding (evisceration) which requires immediate notification of the surgeon. in either case, make sure the wound is covered with a sterile dressing and notify the physician.

explain the 3 types of wound healing?

first intension

- the edges of the wound close. the wound is not serious enough for the inflammatory response to be evoked or the formation of new capillaries is necessary. new cells replace the dead ones and the ends of damaged capillaries stretch across to rejoin each other. there may or may not be scar formation; any scar formation may only be temporary.

second intention

- healing by granulation. healing proceeds much slower than by first intention. granulations form at the top of the wound first leaving the bottom of the wound unhealed and often unseen to the naked eye, so the wound may need to be deliberately kept open in order for the bottom area healing to occur.

third intention

- healing by granulation of an ulcer or cavity with complications such as formation of a thick scar or keloid, sinus track or fistula that interfere with the functioning of that part of the body or cause a deformity.

please, please, please. . .learn the pathophysiology of the inflammation response because it is going to come up time and time again when you are doing care plans for patients who have infections of any kind. you need to have a good grasp of what is going on and what conditions underlie the cardinal signs of inflammation: redness, heat, swelling, and pain (they occur in that order) because you are going to see them just about every day of your working nurse life until the day you retire from nursing. you will see it with iv sites, sore throats due to the presence of an n/g or et tube, wounds, pneumonia and any kind of illness where the body is fighting off an infection or dealing with immunity. mark my words. . .learn it now or be ignorant of what is going on and unable to intelligently explain to patients what is happening to them.

araujojr · Mar 20, 2008

THANKS :) that clears up a lot. it's hard to learn all this w.o seeing it visually

Daytonite, BSN, RN · Mar 20, 2008

THANKS :) that clears up a lot. it's hard to learn all this w.o seeing it visually

You have my total agreement on that. After you've seen a variety of these it will start to make more sense.

I've had two surgical wounds that dehisced and healed by second intention, both abdominal. Dehiscence, by the way, is due to physician error in suturing technique, but don't go around saying that unless you're looking to make enemies of the docs and hospital administration. This last one took about 4 months to heal. Toward the end, the surface skin opening wanted to close fast and the surgeon kept telling me to deliberately keep larger pieces of gauze in the opening to hold it open so the lower part of the wound, which was almost 4 inches deep, had time to catch up in healing. Contrary to your first question--I had no pain. However, because it involved the colon I did get a septic infection. The infection was in my blood stream before I even had any symptoms of a problem.