a surgical incision with sutured approximated edges
Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention. Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention. If a wound that is healing by primary intention becomes infected, it will heal by secondary intention. Wounds that heal by secondary intention take longer to heal and form more scar tissue. Connective tissue healing and repair follow the same phases in healing. However, differences occur in the length of time required for each phase and in the extent of new tissue formed. Wounds healed by tertiary intention, or delayed primary closure, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed.
Stage II
A stage II pressure ulcer involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II could present as a blister, abrasion, or shallow crater. A stage I pressure ulcer is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III ulcer presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Ulcers at this stage may include undermining and tunneling. Stage IV ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling.
Apply elastic stockings.
-This client is exhibiting signs and symptoms of venous insufficiency. Venous insufficiency occurs as a result of prolonged venous hypertension, which stretches the veins and damages the valves. Signs and symptoms of venous insufficiency include itching and tingling, dull aching sensations, cramping and heaviness in legs, thickened skin, hyperpigmentation, discomfort when standing, painless ulcerations, and leg
edema. Treatment for venous insufficiency focuses on preventing stasis, decreasing edema, and promoting venous return. Elastic stockings should be worn during the day and evening, and applied before getting out of bed. Elastic or compression stockings reduce venous stasis and assist in venous return of blood to the heart.
Keep bed linens smooth
-One simple way to promote comfort is by removing or preventing painful stimuli. This is especially important for
clients who are immobilized postoperatively. The nurse should monitor the client more frequently and change linens as needed if the client is diaphoretic, has draining wounds, or is incontinent. The linens should remain clean, dry, and free of wrinkles.
Monitor transcutaneous electrical nerve stimulation (TENS) therapy
-This is effective for controlling postsurgical and procedural pain. This therapy requires a prescription from the provider. The TENS unit consists of a battery-powered
transmitter, lead wires, and electrodes. A mild electrical current is passed through the electrodes and stimulates the skin. The client controls the device. The client should feel a buzzing or tingling sensation. The client will adjust the intensity and quality of skin stimulation until pain relief occurs.
Give a back massage.
-Massage is effective for producing physical and mental relaxation, reducing pain, and enhancing the effectiveness of pain medication. This will promote sleep
and comfort.
Teach relaxation techniques, such as guided imagery
-Relaxation techniques, such as meditation, yoga, guided imagery, and deep breathing, alter cognitive pain perception. Relaxation techniques promote a sense of well-being and diminish stress. This in turn can help the client develop confidence to manage the challenges of pain.
Immobilize ankle for 4 to 6 weeks is incorrect.
-The client should rest the ankle, but immobilization
is not necessary for a first-degree sprain. Initially, the client may need to avoid weight bearing. Immobilization is indicated for 4 to 6 weeks in third-degree sprains, or when severe ligament damage occurs. As a result of a third-degree sprain, arthroscopic surgery may be necessary. Because this client experienced a first-degree sprain, prolonged immobilization is not necessary.
Elevate ankle above the level of the heart is correct.
-In order to reduce inflammation as a result of the
sprain, the client should elevate the ankle above the level of the heart to promote venous return and decrease edema. For example, the nurse should position the client on the bed with the client's foot propped up on one or two pillows to elevate the ankle above the heart.
Apply heating pad to the ankle several times daily is incorrect.
-A first-degree sprain requires rest, ice, compression, and elevation (RICE). Immediately after the injury, the nurse should reinforce to the client to
rest, ice, compress, and elevate the ankle. Heat may be applied after 48 hr, but the client should not apply heat during the initial 48 hr of injury.
Wrap ankle with an elasticized compression bandage is correct.
-Application of an elasticized compression bandage for a few days following the injury is necessary to reduce swelling and provide joint support. Compression also can help with pain relief and is facilitated by wrapping an elasticized compression bandage around the injured
extremity. If the client reports throbbing, discomfort, or the wrap is too tight, the nurse should remove and rewrap the bandage with less stretch. The nurse should begin from the distal point of the extremity (toes) and move toward the proximal point (up the leg) in order to promote venous return.
Apply intermittent cold compress to the ankle for the first 24-48 hr is correct.
-Cold is used for the first 24-48 hr. For a client who has a muscle sprain, an ice bag is an ideal
nonpharmacological intervention to prevent edema formation as well as to anesthetize the body part. Cold provides short-term pain relief and also limits swelling by reducing blood flow to the injured area through vasoconstriction. The nurse should reinforce to the client not to apply ice directly to the skin or leave ice on the ankle for more than 20 min at a time. Longer exposure can damage the skin and even potentially result in frostbite.
Place client
in supine position is incorrect.
-The nurse should provide dignified and sensitive care to the client and the family. The nurse should elevate the head of the bed as soon as possible after death to prevent discoloration of the face.
Determine whether an autopsy has been ordered is correct.
-It is important to determine whether an autopsy has been ordered because an autopsy or organ donation has specific requirements at the time of death. If an autopsy is ordered, tubes, equipment, and
indwelling lines must remain in place until the coroner deems otherwise.
Cover body with a sheet and place head on pillow is correct.
-The nurse should cover the body with a clean sheet, place head on a pillow, and leave arms outside covers if possible. The nurse should close eyes by gently holding them shut, leave dentures in mouth to maintain facial shape, and cover any signs of body trauma. The client should be presentable for viewing by family and friends.
Maintain cultural
and religious rituals regarding death is correct.
-There are cultural and religious rituals and mourning-specific practices that loved ones use to achieve inner peace and expression of grief. One's culture greatly influences what behaviors and rituals are expected at the time of death. Institutional guidelines and end-of-life care procedures for clients from all cultures provide standards based on compassion, maintaining privacy and dignity, and respect for clients' and family members'
cultural beliefs and practices.
Cleanse body, maintaining standards regarding body fluids is correct.
-Cleanse body thoroughly while maintaining safety standards for body fluids and contamination. Maintain precautions implemented during the life of the client. For instance, if the client was on contact precautions, contact precautions should be maintained during postmortem care. Micro-organisms can be transmitted after the death of the client.
Add
the amount of bladder irrigation to the total output is incorrect.
-The irrigation solution that should be used is sterile normal saline, unless otherwise directed by the surgeon. The amount of bladder irrigation solution should be subtracted from the total urine output amount. For example, if the total urine output is 2,500 mL and the amount of irrigation is 1,000 mL, subtract 1,000 from 2,500 and record 1,500 mL as the total urine output.
Use sterile technique when preparing the
irrigation solution is correct.
-Using sterile technique decreases the risk of contamination with micro-organisms and reduces the possibility of infection. Many clients who undergo a TURP are older adults who may have other chronic diseases that increase their susceptibility to infection. These clients should also be observed closely for manifestations of infection, such as fever and elevated WBC.
Ensure the drainage tubing is patent and without obstruction is correct.
-For
continuous drainage, the nurse should be sure that the clamp on the drainage tubing is open and check the volume of fluid in the drainage bag. The nurse should make sure the drainage tubing is patent and without obstruction or kinks. This ensures a continuous, even irrigation of the catheter system. It prevents accumulation of solution in the bladder, which can cause bladder distention and possible injury.
Contact the surgeon if the client reports a continual need to void is incorrect.
-The catheter used following a TURP is large and is pulled taut and secured to the client's leg. This provides traction that holds the catheter balloon against the internal sphincter of the bladder. As a result, the client probably will experience a continual need to void. The nurse should inform the client that the urge to void is expected. However, the client should not attempt to void around the catheter because this can cause bladder spasms, which can be painful and initiate bleeding.
Notify the surgeon if the urine is bright red in appearance or has large clots is correct.
-It is important to record the type and amount of irrigation solution used and the character of the drainage. It is normal to see a few small blood clots, but urine that is bright red, ketchup-like, or has large clots is an indication of bleeding and should be reported to the surgeon. The client's Hgb and Hct should be monitored as well to help determine the degree of blood loss.