Chapter 4: Wound Care
Critical Thinking Exercises: Questions, Answers, and Sources / References
Critical thinking questions are in bold type, and the answers are italicized. Additional resources or references are provided below.
- Your patient has a post operative hip incision. You notice that the wound is slightly inflamed and not approximated, with some yellowish exudate present. What should be your next steps?
- Apply Steri-Strips with small openings between to allow drainage. Notify prescriber. Anticipate wound culture and antibiotics. Assess for other factors that increase the patient’s risk of delayed healing and risk of infection, and implement strategies within the nurse’s scope to mitigate those factors. E.g., if nutrition is poor, consult dietary.
- If anemic, hyperglycemic consult prescriber.
- As you select your supplies, you notice that the sterile saline container was opened exactly 24 hours ago. What would be your next steps?
- Technically, opened solutions are stable and usable for 24 hours. If in doubt, throw it out.
- Your patient is 3 days post op open sigmoid resection. When getting out of bed they cough and feel a pull in their abdominal incision. They call you for help. You examine the wound and notice the wound edges have separated, and abdominal contents are beginning to protrude. What should you do?
- Assist patient to bed if they aren’t in bed.
- Summon help.
- Assess vital signs.
- Apply sterile saline compresses over dehisced organs.
- Notify prescriber.
- Anticipate emergency surgery.
- Offer analgesic if necessary and reassurance to patient.
- Keep the patient NPO.
- Why do pressure ulcers require a clean technique for cleansing, rather than aseptic technique?
Pressure ulcers are contaminated wounds. While they require clean technique, they do not require sterile technique.
- What patient teaching should you include for post op patients going home with surgical wounds?
- Smoking cessation strategies if person is willing.
- Promote adequate nutrition with a well-balanced diet that includes protein, carbohydrates, fats, and at least 1.5–2 liters/day fluids.
- Showers are OK. Baths aren’t. Soaking in water might encourage bacterial growth and result in wound infection.
- Protect the wound from friction or shear.
- Wounds can be exposed for 48 hours post op if dry and approximated.
- Keep leaking wounds clean (shower) and dry (dressing).
- Report concerns of increased redness, swelling, or unusual drainage.
Healthwise Staff. (2017). Incision care after surgery. HealthLinkBC. https://www.healthlinkbc.ca/health-topics/tc4128spec