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    Sas 4 Cabahug, Victoria Mae I

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    bekbekk cabahug
    The document discusses wound healing and provides details on the three phases: 1) first-intention healing which results in minimal scarring, 2) second-intention healing or granulation which occurs in infected wounds or those not closed, and 3) third-intention healing which occurs after deep wounds are re-sutured later. It then provides a case study on a patient who sustained injuries including facial fractures in a car crash. It asks discussion questions about the patient's condition and care including airway maintenance, postoperative assessments, discharge teaching, and priority nursing diagnoses. Finally it provides multiple choice questions related to wound healing, respiratory conditions, and laryngeal assessments that must be answered within 60 minutes.

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    Sas 4 Cabahug, Victoria Mae I

    Uploaded by

    bekbekk cabahug
    139 views4 pages
    The document discusses wound healing and provides details on the three phases: 1) first-intention healing which results in minimal scarring, 2) second-intention healing or granulation which occurs in infected wounds or those not closed, and 3) third-intention healing which occurs after deep wounds are re-sutured later. It then provides a case study on a patient who sustained injuries including facial fractures in a car crash. It asks discussion questions about the patient's condition and care including airway maintenance, postoperative assessments, discharge teaching, and priority nursing diagnoses. Finally it provides multiple choice questions related to wound healing, respiratory conditions, and laryngeal assessments that must be answered within 60 minutes.

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    Sas 4 Cabahug, Victoria Mae i

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    The document discusses wound healing and provides details on the three phases: 1) first-intention healing which results in minimal scarring, 2) second-intention healing or granulation which occurs in infected wounds or those not closed, and 3) third-intention healing which occurs after deep wounds are re-sutured later. It then provides a case study on a patient who sustained injuries including facial fractures in a car crash. It asks discussion questions about the patient's condition and care including airway maintenance, postoperative assessments, discharge teaching, and priority nursing diagnoses. Finally it provides multiple choice questions related to wound healing, respiratory conditions, and laryngeal assessments that must be answered within 60 minutes.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    139 views4 pages

    Sas 4 Cabahug, Victoria Mae I

    Uploaded by

    bekbekk cabahug
    The document discusses wound healing and provides details on the three phases: 1) first-intention healing which results in minimal scarring, 2) second-intention healing or granulation which occurs in infected wounds or those not closed, and 3) third-intention healing which occurs after deep wounds are re-sutured later. It then provides a case study on a patient who sustained injuries including facial fractures in a car crash. It asks discussion questions about the patient's condition and care including airway maintenance, postoperative assessments, discharge teaching, and priority nursing diagnoses. Finally it provides multiple choice questions related to wound healing, respiratory conditions, and laryngeal assessments that must be answered within 60 minutes.

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    of 4

    CABAHUG, VICTORIA MAE I

    SESSION 4

    LESSON PREVIEW

    Enumerate the 3 phases of wound healing.

    1. First-Intention Healing
    - Wounds made aseptically with a minimum of tissue destruction that are properly closed heal
    with little tissue reaction by first intention (primary union). When wounds heal by first-intention
    healing, granulation tissue is not visible and scar formation is minimal.

    2. Second-Intention Healing
    - Second-intention healing (granulation) occurs in infected wounds (abscess) or in wounds in
    which the edges have not been approximated. When an abscess is incised, it collapses partly, but
    the dead and dying cells forming its walls are still being released into the cavity. For this reason,
    a drainage tube or gauze packing is inserted into the abscess pocket to allow drainage to escape
    easily.

    3. Third-Intention Healing
    - Third-intention healing (secondary suture) is used for deep wounds that either have not been
    sutured early or break down and are re-sutured later, thus bringing together two opposing
    granulation surfaces. This results in a deeper and wider scar. These wounds are also packed
    postoperatively with moist gauze and covered with a dry sterile dressing.

    CHECK FOR UNDERSTANDING (60 minutes)

    You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point
    will be given to correct answer and another one (1) point for the correct ratio. Superimpositions or
    erasures in you answer/ratio is not allowed. You are given 60 minutes for this activity:

    Case Study: Read and examine the case thoroughly.


    Patient Profile: F.N. is a 28-year-old male patient who sustained bilateral fractures of the nose,
    three rib fractures, and a comminute fracture of the tibia in an automobile crash 5 days ago. An
    open reduction and internal fixation of the tibia were performed the day of the trauma. F.N. is now
    scheduled for a rhinoplasty to reestablish an adequate airway and improve cosmetic appearance.

    Subjective Data
    Reports facial pain at a level of 6 on a 10-point scale
    Expresses concern about his facial appearance
    Complains of dry mouth

    Objective Data
    RR 24
    HR 68 bpm
    Bilateral ecchymosis of eyes (raccoon eyes)
    Periorbital edema and edema of face reduced by about half since second hospital day
    Has been NPO since midnight in preparation for surgery

    Discussion Questions
    1. When F.N. was admitted, examination of his nose revealed clear drainage. What is the
    significance of the drainage? What testing is indicated?

    Clear drainage in the nose after facial trauma may be cerebrospinal fluid (CSF) that
    is leaking from the central nervous system following fractures of the face. Testing at the
    bedside or in the laboratory with strips that indicate glucose can differentiate CSF from
    mucus

    2. What is the reason for delaying repair of F.N.’s nose for several days after the trauma?

    The vascularity of the face may cause excessive edema following facial trauma and surgery
    to repair fractures may need to be delayed until the edema subsides

    3. What measures should be taken to maintain F.N.’s airway before and after surgery?

    Airway can be maintained best by keeping F.N. in an upright position and controlling
    edema of the upper airway. After surgery, cold compresses and head elevation may help to
    decrease edema, reduce dyspnea, and minimize discomfort. F.N. may have PO fluids when awake
    and cold fluids will help to decrease the swelling. Activity restriction to prevent bleeding and
    injury include no nose blowing, swimming, heavy lifting, strenuous exercise, or large facial
    movements

    4. Priority Decision: When F.N. arrives in the post anesthesia care unit (PACU) following surgery,
    what priority assessments should the nurse make in the immediate postoperative period?

    Respiratory status—rate, depth, and rhythm—should be assessed frequently to note


    respiratory distress. Vital signs should be taken and observation of the surgical site for hemorrhage
    and edema should also be done often.

    5. Priority Decision: F.N.’s nasal packing is removed in 24 hours and he is to be discharged. What
    priority predischarge teaching should the nurse provide?

    F.N. needs to be taught how to clean the nose and nares with cotton swabs and water or
    hydrogen peroxide and to apply water-soluble jelly to the nares; to continue using the external
    plastic splint as ordered; to report any continued drainage of serosanguineous fluid from the nose
    after 24 hours or any fresh bleeding; and to not use aspirin or aspirin-containing products for pain
    relief. F.N. should also be educated about symptoms of postoperative infection. Activity restriction
    to prevent bleeding and injury will be decreased as the rhinoplasty heals.
    6. Priority Decision: Based on the assessment data presented, what are the priority nursing
    diagnoses? Are there any collaborative problems?

    Nursing diagnoses:
    • Disturbed body image related to postoperative edema and changed facial
    appearance
    • Acute pain related to incisional edema
    • Risk for ineffective breathing pattern related to presence of packing and nasal
    edema
    Collaborative problems:
    Potential complications: nasal hemorrhage, nasal hematoma, infection

    Multiple Choice

    1. D
    RATIO: Handwashing remains the most effective preventive measure to reduce the transmission
    of organisms. Taking prescribed antibiotics, using warm salt-water gargles, and dressing warmly
    do not suppress transmission. Antibiotics are not prescribed for a cold.
    2. D
    RATIO: The use of topical decongestants is controversial because of the potential for a rebound
    effect. The patient should hold his or her head back for maximal distribution of the spray. Only
    the patient should use the bottle.
    3. D
    RATIO: For a patient diagnosed with acute sinusitis, the nurse should instruct the patient that hot
    packs, increasing fluid intake, and elevating the head of the bed can promote drainage. Applying
    a mustard poultice will not promote sinus drainage. Postural drainage is used to remove
    bronchial secretions.
    4. C
    RATIO: Management of acute laryngitis includes resting the voice, avoiding irritants (including
    smoking), resting, and inhaling cool steam or an aerosol. Fluid intake should be increased. Warm
    clothes on the throat will not help relieve the symptoms of acute laryngitis.
    5. D
    RATIO: If pressure to the midline septum does not stop the bleeding for epistaxis, additional
    treatment of silver nitrate application, Gelfoam, electrocautery, or vasoconstrictors may be used.
    Suction may be used to visualize the nasal septum, but it does not alleviate the bleeding. Irrigation
    with a hypertonic solution is not used to treat epistaxis.
    6. C
    RATIO: Each of the listed diagnoses is valid, but ineffective airway clearance is the priority
    nursing diagnosis for all conditions.
    7. A
    RATIO: The nurse stresses the importance of humidification at home and instructs the family to
    obtain and set up a humidification system before the patient returns home. Air-conditioning may
    be too cool and too drying for the patient. A water purification system or a radiant heating system
    is not necessary.
    8. A
    RATIO: Hoarseness is an early symptom of laryngeal cancer. Dyspnea, dysphagia, and lumps are
    later signs of laryngeal cancer. Alopecia is not associated with a diagnosis of laryngeal cancer.
    9. D
    RATIO: A cotton tampon may be used to try to stop the bleeding. The use of ice on the bridge of
    the nose has no scientific rationale for care. Laying the client down on the cot could block the
    client's airway. Hospital admission is necessary only if the bleeding becomes serious.
    10. B
    RATIO: Considering the known risk factors for cancer of the larynx, it is essential to assess the
    patient's history of alcohol intake. Infection is a risk in the postoperative period, but not an
    appropriate answer based on the patient's history. Depression and nonadherence are risks in the
    postoperative phase, but would not be critical short-term assessments.

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