NCLEX-PN

drainage may be serous, sanguineous, serosanguinous, or purulent . Surrounding areas are also diligently inspected. Furthermore, the section covers the three types of wound healing ; primary intention healing, secondary intention healing, and tertiary intention healing. The treatment of pressure ulcers and other similar wounds is based on the RYB Color Code of Wounds , which categorizes wounds into red, yellow, and black, with treatments ranging from surgical and mechanical debridement to enzymatic and autolytic methods. Less commonly employed wound care and cleansing methods are described below: Hydrotherapy Hydrotherapy may be recommended for clients with severe wounds, such as severe burns or wounds with untreatable necrosis, especially when the wound is large. Hydrotherapy involves the use of a therapeutic whirlpool at approximately 37 degrees Celsius, and occasionally, an antiseptic solution may be added to the water. However, it should be noted that hydrotherapy is not suitable for clients with arterial insufficiency or venous ulcer wounds . Potential complications include the risk of cross-contamination among clients who use the same whirlpool. This can be mitigated through meticulous disinfection of the whirlpool after each use, as well as rinsing the client's wound area after exposure to the therapeutic whirlpool water. Pulsed Lavage Pulsed lavage employs saline and a pulsatile high-pressure lavage device to irrigate wounds and remove exudate. Complications associated with pulsed lavage include wound disruption when the pressure is excessive and occupational-related infections when appropriate personal protective equipment, such as goggles, face masks, gowns, and gloves, is not utilized to shield staff from sprays and splashes. Selection of sterile wound dressings depends on various factors, including the stage of healing and specific wound characteristics. Options include traditional gauze dressings, interactive and transparent dressings with polymeric components, and bioactive dressings containing alginate, collagen, and hydrocolloids. Procedure for Suture and Staple Removal The process for removing surgical sutures and staples, following the validation of the removal order and proper client identification using two unique identifiers, is as follows: 1.​ Preparation: Ensure a clean and sterile environment for the procedure. 2.​ Cleansing: Cleanse and disinfect the surgical wound with a topical antiseptic to minimize the risk of infection. 3.​ Suture Removal: If removing sutures, proceed as follows: a.​ Knot Lifting: Using sterile forceps, carefully lift each suture knot from the wound.

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