Wound Care Unexpected Outcomes

Front 1

What should you do if the drainage system is empty although the wound is draining?

Back 1

1. Position the tubing to enhance gravity flow and eliminate kinks or pressure on the tubing.
2. Gently "milk" the tubing to release any clots that may block the tubing.

Front 2

What should you do if the drainage containers expand rapidly?

Back 2

1. Check all connections for leakage.
2. Tape or otherwise eliminate leaks in the system.

Front 3

What should you do if an excessive amount of bright, bloody drainage accumulates over a short time (Ex: 4 hours)? Drainage that is bright red in large amounts may indicate hemorrhage.

Back 3

1. Report excessive bright red drainage to the surgeon.
2. Keep client on NPO status because it may be necessary to return to surgery for suturing of a bleeding vessel.

Front 4

What should you do if a wound infection develops as evidenced by unexpected purulence or foul odor?

Back 4

1. Request physician order to collect diagnostic specimen for culture and sensitivity.
2. Assess for additional indications of infection:
Fever
Elevated white blood cell count
Redness
Swelling
Increasing pain
3. Report findings to the physician.

Front 5

What should you do if pain results from manipulation of the drainage device or accumulation of drainage within the wound?

Back 5

Secure tubing to minimize irritation from moving or pulling at the insertion site.

Front 6

What should you do if infection accompanied by inflammation and edema increase patient's pain?

Back 6

Report unrelieved increasing pain to the physician.

Front 7

What should you do if the wound appears inflamed and client reports increased tenderness at wound site?
Purulent drainage is evident and/or an odor is present.

Back 7

1. Monitor client for signs of infection—for example, fever and/or increased white blood cell (WBC) count.
2. Assess drainage for appearance and odor. Note approximate amount of drainage by documenting number of dressing changes required or weighing dressing (1 gm = 1 mL of drainage).
3. Notify physician.
4. Obtain wound cultures as ordered.

Front 8

What should you do if wound drainage increases?

Back 8

1. Increase frequency of dressing changes.
2. Notify physician, who may consider drain placement or alternate dressing method.

Front 9

What should you do if the wound bleeds during dressing change?

Back 9

1. Observe color and amount of drainage. If excessive, you may need to apply direct pressure.
2. Inspect area along dressing and directly underneath client to determine the amount of bleeding.
3. Obtain vital signs as needed.
4. Notify physician of findings.

Front 10

What should you do if the client reports a sensation that "something has given way under the dressing."?

Back 10

1. Observe wound for increased drainage or dehiscence (partial or total separation of wound layers) or evisceration (total separation of wound layers and protrusion of viscera through the wound opening).
2. Protect wound.
3. Cover wound with sterile moist dressing.
4. Instruct client to lie still.
5. Notify physician.

Front 11

What should yo do if the client or caregiver is unable to perform dressing change?

Back 11

1. Provide additional teaching and support.
2. Obtain services of home care agency as needed.

Front 12

What should you do if the skin does not blanch when firmly pressed and/or skin has a purple discoloration or has significant color changes?

Back 12

1. These are early signs of pressure-related injury.
2. Reassess frequency of turning schedule.
3. Per agency's protocol, obtain order for a pressure reduction support surface.

Front 13

What should you do if the skin surrounding the ulcer becomes macerated?

Back 13

1. Reduce exposure of surrounding skin to topical agents and moisture.
2. Consider the use of a liquid skin barrier on periwound skin.

Front 14

What should you do if the ulcer becomes deeper with increased drainage and/or development of necrotic tissue?

Back 14

1. Notify physician for possible change in pressure ulcer status.
2. Additional consults—for example, a wound care nurse specialist—may be indicated.
3. Obtain necessary wound cultures.

Front 15

What can hemorrhage occurring after hemostasis indicates?

Back 15

1. A slipped surgical suture
2. A dislodged clot, infection
3. Erosion of a blood vessel by a foreign object (e.g., a drain)

Front 16

How can the nurse can detect internal bleeding?

Back 16

1. Looking for distention or swelling of the affected body part
2. A change in the type and amount of drainage from a surgical drain
3. Signs of hypovolemic shock (e.g., increased pulse, decreased blood pressure, cool, clammy skin)

Front 17

What should you do if the dressing does not stay in place?

Back 17

1. Evaluate size of dressing used for adequate (1 to 1.5 inches) margin.
2. Dry skin thoroughly before reapplication.

Front 18

What should you do if the outer layer of client's skin tears on removal of dressing?

Back 18

Adhesive backing may be too strong for fragile skin. Use non-adhesive-backed transparent dressing.