The nurse also should consider tendon or ligament injuries, the presence of a foreign body, and peripheral nerve damage. The emergency nurse should assess the patient for associated injuries, such as fractures, dislocations, or neurovascular compromise associated with the wound. Identify care measures taken by the patient before arrival. Evaluate the patient's tetanus immunization status.ĭ. Determine the time elapsed since the injury occurred.Ĭ. When evaluating a patient who presents with a laceration, which assessment is the priority?Ī. Lacerations are open wounds that result from shearing force through the skin layers. A contusion results from blunt trauma that causes blood accumulation under the skin, but no break in the skin. Abrasions occur when friction removes the epidermal layer of the skin and can also remove part of the dermis, exposing deeper skin layers. This injury most commonly occurs in the fingertips or tip of the nose. Avulsion Avulsions are characterized by full-thickness tissue loss that prevents wound edge approximation. Which injury is characterized by full-thickness tissue loss and commonly affects the fingertips or tip of the nose?ĭ. Shaving the hair around a laceration is not recommended because it destroys the hair follicles and increases the risk of infection. It provides no protection against anaerobes. Cleansing with hydrogen peroxide solution causes oxygen absorption in the wound and cell destruction. Even with a soft brush (direct contact), it can destroy tissue. Scrubbing the wound vigorously destroys surrounding tissue and increases the risk of infection. The preferred method of wound cleansing is high-pressure irrigation because it is excellent at removing debris and decreasing the risk of infection. Cleansing the wound with hydrogen peroxide solution.ĭ. Scrubbing the wound vigorously for 10 minutes.Ĭ. Shaving the hair follicles around the wound.ī. When caring for a wound, which intervention is associated with the lowest infection rate?Ī. Staples should not be used in areas of the scalp with permanent hair loss because of poor aesthetic results. No liquid or ointment should be applied to a wound closed with surgical glue-not staples. The use of sutures-not staples-minimizes scar formation. Scarring is more pronounced, so expect to use staples in areas where a scar is not bothersome. They are a fast, economical method to close a wound, but do not provide the same quality of closure as sutures. Staples are typically used if linear lacerations require closure on the scalp, trunk, or extremities. Staples do not provide the same quality of closure as sutures. Staples can be used in areas of the scalp with permanent hair loss. No liquid or ointment should be applied to a wound closed with staples.ĭ. Wound closure with staples minimizes scar formation.Ĭ. Staples do not provide the same quality of closure as sutures.**ī. Which statement accurately characterizes the use of staples for wound closure?Ī. The remodeling (maturation) phase is the final phase of wound healing, which usually begins about 2 to 3 weeks after the injury and may last up to 2 years. This phase occurs 12 to 72 hours after injury and ends about 3 weeks after injury. In the proliferative phase, inflammatory processes make the wound more painful and edematous. In the inflammatory phase, macrophages move to the site and phagocytize bacteria and debris. Maturation phase Wound healing occurs in overlapping phases. Macrophages first move to the injury site during which phase of wound healing?ĭ. Examining for a foreign body and obtaining a detailed health history are not part of a thorough neurovascular examination, but can provide information that helps determine the plan of care. Determining the severity of the pain is not part of a neurovascular examination, but wound assessment is most effective after adequate pain control is achieved. A thorough neurovascular examination includes testing sensation, strength, and flexor and extensor tendon function. Evaluating flexor and extensor tendon function. Which assessment should the nurse include in a thorough neurovascular examination of a hand injury?ĭ.
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