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What are the key steps in preparing for a wound inspection?
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Position the patient to expose only the wound area, prepare a biohazard bag, apply clean gloves, and remove the soiled dressing.
What are the initial steps to take before performing a wound assessment?
Review patient's last wound assessment, ask the patient to rate pain on a scale of 0 to 10, and observe patient anxiety during procedure explanation.
What final steps should be taken post-wound assessment to ensure patient safety and hygiene?
Apply dressing as prescribed, reassess pain, clean work area, perform hand hygiene, and record findings.
What should be included in the documentation after completing a wound assessment?
Document wound measurements, tissue characteristics, signs of infection, exudate details, and patient pain level, comparing with prior assessments.
How should a nurse introduce themselves to verify patient identity during a wound assessment?
The nurse should introduce themselves and ask the patient for their name and birthday to verify identity, using two identifiers.
What signs should be documented to indicate infection in a wound?
Signs of infection include erythema, increased drainage or odor, and potential changes in wound margins.
What might rounded wound edges suggest about the healing process?
Rounded wound edges may indicate delayed healing.
Explain the process to assess wounds healing by secondary intention.
Measure wound length, width, and depth, identify tissue type and percentage intact, examine for granulation, slough, or necrotic tissue, and document exudate characteristics.
Describe the characteristics of wound healing by primary intention.
Edges are approximated (sutured, stapled, or taped), and there is potential evidence of infection such as erythema, odor, or drainage.
What does the presence of a healing ridge beneath the skin indicate?
A healing ridge indicates firm tissue development, which is a positive sign of healing.
How do lifestyle factors such as smoking affect wound healing?
Lifestyle factors like smoking can impede wound healing by reducing blood flow and oxygenation to tissues.
What factors should be evaluated during dressing examination?
Examine the color, consistency, and odor of drainage, and determine if the dressing is saturated, slightly moist, or dry.
What observations of adjacent skin should be noted during wound assessment?
Inspect the color, texture, temperature, and integrity of skin surrounding the wound for additional clues about healing.
How should undermining or tunneling be documented during wound measurement?
Use a clock face notation to document the location and extent of undermining or tunneling.
How does epithelialization at the wound edges relate to healing?
Epithelialization at wound edges indicates progress in the healing process.
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