Flashcards in Wound Care Deck (89)
The nurse is caring for a patient with an ostomy. The nurse notes that the ostomy is putting out watery effluent. The nurse recognizes that this is indicative of which location?
a. Descending colon
b. Sigmoid colon
c. Ileal portion of the small intestine
d. transverse colon
An opening in the ileal portion of the small intestine is an ileostomy, and the fecal effluent will be watery to thick liquid that will contain some digestive enzymes. A colostomy in the descending or sigmoid colon generally results in a stool similar to that normally passed through the rectum. If the opening is in the transverse or ascending colon, the effluent will vary from thick liquid to semi-formed stool.
The nurse is caring for a patient who has an ostomy. The nurse notices that the effluent ranges from a thick liquid to a semi-formed stool. The nurse recognizes that this is indicative of which location?
a. Descending colon
b. Ileal portion of the small intestine
c. Sigmoid colon
d. Transverse or ascending colon
If the opening is in the transverse or ascending colon, the effluent will vary from thick liquid to semi-formed stool. A colostomy in the descending or sigmoid colon generally results in a stool similar to that normally passed through the rectum. An opening in the ileal portion of the small intestine is an ileostomy, and the fecal effluent will be watery to thick liquid that will contain some digestive enzymes.
The nurse is caring for a patient who had a colostomy placed 5 days earlier. The nurse notes that the stoma is red and moist. Which action should the nurse take?
a. Notify the physician immediately.
b. Apply pressure.
c. Note the condition of the stoma in her notes.
d. Change the appliance pouch.
The stoma should be red or pink and moist. After assessment the nurse will note the appearance of the stoma in the patient HER. If it is gray, purple, or black, report this to the charge nurse or physician immediately. Pressure is applied to control active bleeding. The information given in the question does not indicate that there is a need to change the appliance at this time.
In caring for a patient who had a fecal surgical diversion, which nursing intervention is essential?
a. Place a pouch over the newly created stoma.
b. Place a dressing over the stoma.
c. Wait several days before placing a pouch.
d. Prepare several pouches in advance.
Immediately after a fecal surgical diversion, it is necessary to place a pouch over the newly created stoma to contain effluent when the stoma begins to function. The pouch will keep the patient clean and dry, will protect the skin from drainage, and will provide a barrier against odor. Dressings would obstruct the opening and would become saturated with fecal material. Preparing multiple pouches in advance would be counterproductive; in the immediate postoperative period, the stoma may be edematous and the abdomen distended. These symptoms eventually resolve, but during this time, it will be necessary to revise the pouching system to meet the changing size of the stoma and the changes in body contours.
When planning care for a patient who has a colostomy, which intervention is important for the nurse to perform when pouching the colostomy ?
a. Leave an intact skin barrier in place for 3 to 7 days.
b. Use soap and water to cleanse the peristomal skin.
c. Empty the pouch when it is two-thirds full.
d. Use tape to secure pouches that have minor leaks.
Observe the existing skin barrier and pouch for leakage and length of time in place. The pouch should be changed every 3 to 7 days, not daily. To minimize skin irritation, avoid unnecessary changing of the entire pouching system, but if the effluent is leaking under the wafer, change it, because skin damage from the effluent will cause more skin trauma than will be caused by early removal of the wafer. Cleanse the peristomal skin gently with warm tap water using a washcloth; do not scrub the skin. Pat the skin dry. Avoid soap; it leaves residue on the skin, which interferes with pouch adhesion. Pouches must be emptied when they are one-third to one-half full, because the weight of the pouch may disrupt the seal of the adhesive on the skin. If the ostomy pouch is leaking, change it. Taping or patching it to contain effluent leaves the skin exposed to chemical or enzymatic irritation.
When providing care for a patient with a colostomy or an ileostomy, the nurse recognizes that which is an expected assessment finding?
a. A moist, reddish-pink stoma
b. A dry, purplish stoma
c. Erythema on the skin around the stoma
d. No drainage noted from the stoma when washed
Normal findings in a patient with a postoperative ostomy that is healing include a stoma that is moist and reddish-pink, skin that is intact and free of irritation, and sutures that are intact. The stoma is edematous initially and shrinks over the next 4 to 6 weeks. A necrotic stoma is manifested by a purple or black color and a dry instead of moist texture. The stoma is functioning normally when the stoma drains a moderate amount of liquid or soft stool and flatus in the pouch. Flatus indicates the return of peristalsis after surgery. Flatus is noted by bulging of the pouch. (Flatus may not be observable if the pouch has a gas filter.)
The nurse is caring for a preterm infant in the neonatal intensive care unit who has multiple stomas. Given the uniqueness of infants, which action is essential for the nurse to take?
a. Apply an ostomy pouch using standard sealants.
b. Use a pouch that can accommodate increased amounts of flatus.
c. Use multiple pouches (one for each stoma).
d. Be aware that the stoma size will remain the same as the baby grows.
Because babies swallow large amounts of air while sucking, it is normal to expect flatus. Make sure that the pouch can accommodate increased amounts of flatus after feeding, or be prepared to release flatus frequently. The skin of a preterm infant is not fully developed and is more absorbent than the skin of a full-term infant. Do not use skin sealants and adhesive removers unless they are approved for preterm infant use. Neonates may have multiple stomas on their tiny abdomens that are the result of corrective bowel surgeries. Select a cut-to-fit pouch that allows multiple stoma openings in the skin barrier yet still fits on the neonate’s abdomen. Usually, a baby triples its birth weight in the first year. As a baby grows in size, so does the stoma.
In caring for a patient who has a pouching for a noncontinent urinary diversion, which nursing intervention is essential?
a. Empty the pouch when it is one-third to one-half full.
b. Remove the ureteral stents after 2 days.
c. Pouch the stoma with the patient sitting up.
d. Dispose of used pouches in the toilet.
Empty pouches when they are one-third to one-half full so that the weight of the pouch does not disrupt the seal. A surgeon places the stents; these will be removed during the hospital stay or at the first postoperative visit with the surgeon. Place the patient in a semi-reclining position. If possible, provide the patient a mirror for observation. Properly dispose of used pouches and soiled equipment according to facility policy.
When assessing the patient with a noncontinent urinary diversion, the nurse finds that the urine has mucous shreds. Which action should the nurse take?
a. Culture any drainage.
b. Instruct the patient to consume less water.
c. Note the characteristics of the urine in her notes.
d. Cleanse the stoma with soap and water.
Mucous shreds are normal when urine flows through an intestinal segment. Obtain a urine specimen for culture and sensitivity to test for possible infection when ordered by the physician if urine output is less than 30 mL/hr, or if the urine has a foul odor. Teach patients the significance and importance of drinking 1.5 to 2 quarts of fluid daily to prevent urinary tract infection. Avoid soap; it leaves residue on the skin, which interferes with pouch adhesion.
The nurse has removed the patient’s old urostomy pouch and is attempting to measure the stoma opening for placement of a new pouch. Which action should the nurse take next?
a. Place the patient in a prone position.
b. Cleanse the peristomal skin with warm soap and water.
c. Remove any stents that are in place.
d. Place rolled gauze at the stoma opening.
Wick the stoma continuously during pouch measurement and change. Place a rolled gauze wick at the stomal opening. Using a wick at the stoma opening prevents the peristomal skin from becoming wet with urine during a pouching-change procedure. Position the patient in a semi-reclining position. Avoid soap when cleansing the area. In the immediate postoperative period, urinary stents extend out from the stoma. A surgeon places the stents to prevent stenosis of the ureters at the site where the ureters are attached to the conduit. The stents will be removed during the hospital stay or at the first postoperative visit with the surgeon.
A patient who has a urostomy is being discharged to home. Which instruction will the nurse to provide to the patient?
a. Restrict fluid intake to reduce urine output.
b. Report any mucus in his urine.
c. Keep unused pouches in the refrigerator.
d. Shower without covering the pouch.
The patient may shower without covering the pouch. Teach patients the significance and importance of drinking 1.5 to 2 quarts of fluid daily to prevent urinary tract infection. Patients should avoid storing pouches in extremely hot or cold locations like the refrigerator. Teach patients that some mucus in the urine is expected, but that they should report to their physician any blood in the urine, excessively cloudy urine, chills, fever (101° F or higher), or back (flank) pain.
The nurse is caring for a patient who has a urinary diversion. She notices that the patient has a temperature of 102° F and foul-smelling urine. What action should the nurse take?
a. Obtain a urine culture from the patient’s pouch.
b. Catheterize the patient to obtain a sterile urine specimen.
c. Notify the physician.
d. Realize that these are normal findings.
Common symptoms of a UTI include fever and foul-smelling odor. The Nurse will need to contact the physician immediately. The physician will order a catheterization so that a urine sample may be obtained. Although the nurse realizes the need for catheterization, it is an invasive procedure, and an invasive procedure requires a physician’s order. Obtaining a specimen of urine in a pouch does not result in an accurate finding because of the likely risk of contamination by microorganisms. Some mucus in the urine is expected.
The nurse is preparing to catheterize a patient who has a urostomy and uses a two-piece pouch system. The nurse should take which action?
a. Place the patient in a semi-recumbent position.
b. Remove both pieces of the pouch system.
c. Remove the pouch and leave the barrier attached.
d. Use sterile gloves to remove the system.
Remove the pouch. If the patient uses a two-piece system, remove the pouch but leave the barrier attached to the skin. Position the patient sitting, if possible; gravity facilitates the flow of urine. Sterile gloves are used for the actual catheterization. Clean gloves are all that are necessary for removing the pouch.
The nurse is caring for a patient who will have surgery in the morning to have a colostomy placed. The nurse is aware of the physical and emotional stresses that the patient will experience. These include which of the following? (Select all that apply.)
a. Body image changes
b. Fear of social rejection
c. Sexual function and intimacy issues
d. Loss of independence
e. Heightened immunity
ANS: A, B, C, D
In addition to the stresses of illness and surgical recovery, patients with ostomies face body image changes, fear of social rejection, concern about sexual function and intimacy, and the need for help with personal care. It is very important to provide an effective pouching system to facilitate the emotional adjustment to the ostomy. A supportive nurse makes the initial period of adjustment easier.
The opening created into the abdominal wall for fecal or urinary elimination is known as a _______________.
Certain diseases or conditions require surgical intervention to create an opening into the abdominal wall for fecal or urinary elimination. This opening is called a stoma and is constructed from a section of colon or small intestine.
The output from a urinary or fecal stoma is called the _______________.
The output from the stoma is called the effluent.
A ______________ is an opening in the large intestine or colon for elimination of fecal material.
An opening in the large intestine or colon is a colostomy, and the fecal effluent will vary in consistency depending on where the opening in the colon is surgically created.
An opening that is in the ileal portion of the small intestine is an ____________.
An opening in the ileal portion of the small intestine is an ileostomy, and the fecal effluent will be watery to thick liquid that will contain some digestive enzymes.
An ostomy that is created from a portion of the ileum to form a stoma through which urine can exit the body is called a(n) _____________.
urostomy or ileal conduit
A urostomy or ileal conduit is created from a 6- to 8-inch portion of the intestine that is resected from the ileum. One end of the conduit is sutured closed, and the ureters are implanted through the mucosa. The other end is brought out of the abdominal wall, and a stoma is formed through which urine can exit the body.
When is healing by primary intention expected?
a. When the wound is left open and is allowed to heal
b. When a surgical wound is left open for 3 to 5 days
c. When connective tissue development is evident
d. When the edges of a clean incision remain close together
Healing by primary intention occurs when the edges of a clean surgical incision remain close together. The wound heals quickly, and tissue loss is minimal or absent. The skin cells quickly regenerate, and the capillary walls stretch across under the suture line to form a smooth surface as they join. Wounds that are left open and are allowed to heal by scar formation are classified as healing by secondary intention. Connective tissue development is evident during healing by secondary intention. Healing by tertiary intention occurs when surgical wounds are not closed immediately but are left open for 3 to 5 days to allow edema or infection to diminish.
The nurse is caring for a patient who has a dressing over a surgical wound created the night before. The dressing has never been changed. How should the nurse proceed?
a. Change the dressing so she can assess the wound.
b. Administer an analgesic 30 to 45 minutes before a dressing change.
c. Culture the wound if wound exudate is present.
d. Administer an analgesic 30 minutes after a dressing change.
To promote patient comfort, administer an analgesic as ordered, usually 30 to 45 minutes before changing the dressing. However, you will need to assess to determine the best time for analgesic administration before providing wound care. Do not remove an initial surgical dressing for direct wound inspection until a physician writes a medical order for removal. The presence of wound exudate is an expected stage of epithelial cell growth.
The nurse is caring for a patient with a large stasis ulcer. She has just changed the wound dressing and is using a negative-pressure wound system. What can the nurse tell the patient about the functioning of this system?
a. Decreases the amount of angiogenesis
b. Reduces mechanical stretch of tissue
c. Dressing should not need to be changed for 48 hours
d. Helps create a dry environment
The dressing is changed on a scheduled basis, usually no earlier than 48 hours. Researchers believe that blood flow increases because of the removal of wound fluid and angiogenesis (development of new blood vessels), and that this stimulates the production of new blood vessels via mechanical stretch of the tissue. The dressing placed into the wound maintains a moist environment to facilitate healing. A suction device is placed over the dressing, and the dressing, suction, and wound area are covered with a transparent dressing, which provides the air-tight seal necessary for negative-pressure wound therapy (NPWT).
The nurse is in the process of irrigating the wound for a patient who has a large pressure ulcer on his buttock. How should the nurse proceed?
a. Use irrigation pressures of less than 4 psi.
b. Cleanse in a direction from most contaminated to least contaminated.
c. Irrigate so that the solution flows from least contaminated to most contaminated.
d. Irrigate with clean irrigation solution only.
When one is irrigating, all the solution flows from the least contaminated to the most contaminated area. The pressure needed to irrigate wounds is between 4 and 15 psi. Irrigating solutions are sterile.
The nurse is changing a surgical dressing and is cleansing the wound. She knows that:
a. the incision line should be cleansed last.
b. she should start at one end of the incision line and swab the entire length.
c. she should start at the center of the incision line and swab toward one end.
d. she should work in a circular motion around the incision line.
The center is the most important part of the suture line; therefore, using a sterile swab or gauze, clean the suture line by starting at the center of the suture line and working toward one end. With another sterile swab or gauze, start at the center of the incision and work toward the other end. All other cleansing involves moving from one end to the other on each side of the incision. Work in straight lines, moving away from the suture line with each successive stroke.
The nurse answers the patient’s call light to find the patient agitated and stating that she “felt something pop.” The nurse finds that the patient’s abdominal surgical wound has eviscerated. What should the nurse do?
a. Try to reinsert the abdominal contents.
b. Cover the wound with a dry sterile dressing.
c. Notify the surgeon when he makes rounds.
d. Cover the wound with a moist saline dressing.
This is a surgical emergency, and the nurse needs to cover the wound with a moist saline dressing, immediately notify the surgeon, and prepare the patient for emergency surgery.
The nurse prepares to irrigate the patient’s wound. What is the primary reason for this procedure?
a. Decrease scar formation.
b. Remove debris from the wound.
c. Improve circulation from the wound.
d. Decrease irritation from wound drainage.
Wound irrigations promote wound healing by removing debris from a wound surface, decreasing bacterial counts, and loosening and removing eschar. The primary purposes of wound irrigation do not include decreasing scar formation, improving circulation, or decreasing irritation.
Which of the following approaches is correct technique when wound irrigation is performed?
a. Placing the patient in supine position
b. Placing the syringe directly into the wound
c. Using sterile technique for a chronic wound
d. Selecting a soft catheter for deep wounds with small openings
If the patient has a deep wound with a narrow opening, attach a soft catheter to the syringe to permit the fluid to enter the wound. Position the patient comfortably to permit gravitational flow of irrigating solution through the wound and into the collection receptacle. Hold the syringe tip 2.5 cm (1 inch) above the upper end of the wound and over the area being cleansed; this prevents syringe contamination. Wound cleansing and irrigation are accomplished using sterile technique (surgical wounds) or clean technique (some chronic wounds).
On which types of wounds may the nurse use a pulsatile high-pressure lavage for irrigation?
a. Graft sites
b. Wounds with exposed blood vessels
c. Necrotic tissue
d. Wounds with exposed muscle or tendons
Pulsatile high-pressure lavage is often the irrigation of choice for necrotic wounds. The amount of irrigant is wound size dependent. Pressure settings on the device need to remain between 4 and 15 psi. Do not use this type of irrigation with graft sites or exposed blood vessels, muscle, tendon, or bone.
When should a nurse consider culturing a wound?
a. When the tissue is clean and dry
b. When exudate is not present
c. When the patient is afebrile
d. When the surrounding area shows inflammation
Consider culturing a wound if it has a foul, purulent odor; inflammation surrounds the wound; a nondraining wound begins to drain; or the patient is febrile.