A nurse assessing a pressure ulcer - remarkable, ratherClassification[ edit ] According to level of contamination, a wound can be classified as: Clean wound — made under sterile conditions where there are no organisms present, and the skin is likely to heal without complications. Contaminated wound — usually resulting from accidental injury; there are pathogenic organisms and foreign bodies in the wound. Infected wound — the wound has pathogenic organisms present and multiplying, exhibiting clinical signs of infection yellow appearance, soreness, redness, oozing pus. Colonized wound — a chronic situation, containing pathogenic organisms, difficult to heal e. Open[ edit ] Open wounds can be classified according to the object that caused the wound: Incisions or incised wounds — caused by a clean, sharp-edged object such as a knife , razor , or glass splinter. Lacerations — irregular tear-like wounds caused by some blunt trauma. a nurse assessing a pressure ulcer
A nurse assessing a pressure ulcer VideoUnderstanding Pressure Injury Staging
Dyspnea, especially on exhalation Paradoxical chest movement Rationale: Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement.
This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands.
Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest. What would the nurse anticipate to be prescribed for the client?
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Out-of-bed activities Immobilization of the affected leg Placing the affected leg in a dependent position Immobilization of the w leg Rationale: Autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3 to 7 days. This period of immobilization allows the autograft time to adhere to the wound bed. Getting out of bed, going to the bathroom, and placing the grafted leg dependent would put stress on the grafted wound. The nurse should include which intervention as a priority in the plan of link for the client?
Initiate an intravenous IV line for the administration of fluids. Consult with the psychiatric department regarding genetic counseling. Call the blood bank and request preparation of a unit of packed red blood cells.
Call the respiratory department to prepare for intubation and mechanical ventilation. Rationale: The priorities in management of sickle cell crisis are hydration therapy and pain relief. To achieve this, the client is given IV fluids to promote hydration and reverse the agglutination of sickled cells in small blood vessels. Opioid analgesics may be given to relieve the pain that accompanies the crisis. Genetic counseling is recommended but not during the acute phase of illness. Red blood cell transfusion may be done in selected circumstances such as aplastic crisis or when the episode is refractive ulcr other therapy.
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Oxygen would be administered according to individual need, but the client would not require intubation and mechanical ventilation. In the acute phase, http://rectoria.unal.edu.co/uploads/tx_felogin/puritan-writers-the-wonders-of-the-invisible/why-are-most-jehovah-witnesses-black.php nurse plans for which priority intervention? Correct the acidosis. Apply a monitor for an electrocardiogram. Administer short-duration insulin intravenously. Rationale: Lack of insulin absolute or relative is the primary cause of DKA. Cardiac monitoring is important due to alterations in potassium levels associated with DKA and its treatment, but applying an electrocardiogram monitor is not the priority action.
Ambulate following a meal.]