NLE Fundamentals of Nursing & the Nursing Process — Basic Oxygenation, Elimination & NutritionRevision Notes

Formulas

Exam Tips

• ALWAYS: restlessness = earliest sign of hypoxia. This is the most commonly tested concept in oxygenation.
• Venturi mask = COPD and controlled FiO₂. If the stem says 'COPD' and asks for oxygen delivery method, the answer is almost always Venturi mask.
• Memorize the flow rate-FiO₂ pairs: NC 1–6 L/min (24–44%), simple mask 5–10 L (40–60%), NRB 10–15 L (up to 95%), Venturi = precise.
• Suction sequence: Hyperoxygenate → Insert without suction → Apply suction only on WITHDRAWAL → Limit to 10–15 seconds → Hyperoxygenate again.
• Positioning: high-Fowler's or orthopneic for ALL dyspnea/respiratory distress questions unless stated otherwise.

Key Points

• Normal SpO₂ is 95–100%; SpO₂ below 90% indicates hypoxemia and requires immediate action.
• Hypoxia has early signs (restlessness, anxiety, tachypnea, tachycardia, accessory muscle use) and late signs (cyanosis, bradycardia, confusion, decreased LOC). Restlessness is ALWAYS the earliest sign.
• Cyanosis is a LATE sign — never wait for cyanosis to act. Intervene at the first sign of restlessness or tachypnea.
• Position a dyspneic patient in HIGH-FOWLER'S (90°) or orthopneic position (sitting, leaning forward on an overbed table) to maximize diaphragmatic excursion and lung expansion.
• Nasal cannula: 1–6 L/min, delivers approximately 24–44% FiO₂. Comfortable; allows talking and eating. Above 6 L/min, humidification is essential; higher flows dry mucosa without significantly increasing FiO₂.
• Simple face mask: 5–10 L/min, delivers approximately 40–60% FiO₂. Minimum 5 L/min to flush exhaled CO₂ from the mask.
• Partial rebreather mask: 10–12 L/min, approximately 60–75% FiO₂. The reservoir bag must remain inflated during both inspiration and expiration.
• Non-rebreather mask: 10–15 L/min, up to 80–95% (near 100%) FiO₂. Used in emergencies. One-way valves prevent rebreathing exhaled gas. Keep reservoir bag inflated.
• Venturi mask: delivers a PRECISE, FIXED FiO₂ (24%, 28%, 31%, 35%, 40%, 60%). Preferred for COPD patients requiring controlled oxygen therapy.
• COPD patients with CO₂ retention: target SpO₂ of 88–92%. Use Venturi mask at prescribed flow. Excessive oxygen blunts the hypoxic respiratory drive.
• Oxygen supports combustion: no smoking, no open flames, no petroleum-based products near oxygen equipment. Post 'Oxygen in Use' signs per hospital policy.
• Suctioning: hyperoxygenate BEFORE and AFTER each pass; apply suction ONLY on withdrawal; limit each pass to 10–15 seconds; use sterile technique.
• Airway clearance strategies: deep breathing and coughing exercises, incentive spirometry, adequate hydration, positioning (semi-Fowler's to Fowler's), chest physiotherapy.

Definitions

Section Title

Oxygenation: Concepts, Assessment, and Nursing Interventions

Common Mistakes

• Giving a nasal cannula at >6 L/min — this does NOT significantly increase FiO₂ but DOES cause nasal mucosal drying and discomfort.
• Running a simple face mask below 5 L/min — this allows CO₂ rebreathing and can cause hypercapnia.
• Waiting for cyanosis to call the physician — cyanosis is LATE. Intervene at restlessness.
• Applying suction during tube insertion (on the way IN) instead of on withdrawal — causes mucosal trauma and hypoxia.
• Giving high-flow oxygen to a COPD patient without SpO₂ monitoring — may suppress their only remaining respiratory drive.
• Forgetting to hyperoxygenate before and after suctioning — increases risk of procedurally induced hypoxia.

Exam Tips

• Sims' position = enemas. This is a classic NLE question. The left lateral position is the ONLY acceptable position for enema administration.
• Dusky/dark stoma = REPORT IMMEDIATELY. No nursing interventions can fix vascular compromise — it needs surgical evaluation.
• ORS + zinc = Philippine DOH standard for pediatric diarrhea. Expect this in community health questions.
• Fecal impaction paradox: liquid stool leaking around impaction looks like diarrhea — assess rectally before treating for diarrhea.
• Enema solution height: 30–45 cm. Lower if cramping occurs. This is frequently tested as a dosage/calculation-type question in clinical scenarios.

Key Points

• Normal bowel patterns vary widely — from 3 times a day to 3 times a week. Always compare to the PATIENT'S baseline.
• Constipation management: increase dietary fiber, increase fluid intake (minimum 2–3 L/day if not contraindicated), promote ambulation, establish a regular toileting time (usually 20–30 minutes after a meal to use the gastrocolic reflex).
• Pharmacological management of constipation: stool softeners (docusate sodium/Colace), bulk-forming laxatives (psyllium/Metamucil), osmotic agents (lactulose), stimulant laxatives (bisacodyl).
• Fecal impaction: a hard, immovable mass of stool in the rectum. Paradoxically, liquid stool may leak AROUND the impaction — this is not true diarrhea. Requires digital removal with a physician's order.
• Diarrhea: frequent, loose, watery stools. Priority concern: DEHYDRATION and ELECTROLYTE IMBALANCE (especially hypokalemia). Priority intervention: fluid and electrolyte replacement.
• Philippine DOH protocol for acute diarrhea in children: Oral Rehydration Solution (ORS) + zinc supplementation for 10–14 days. This is the standard at rural health units and community health centers.
• Enema administration: LEFT LATERAL (SIMS') POSITION to follow the natural sigmoid curve. Insert rectal tube 7–10 cm in adults. Raise solution container 30–45 cm (12–18 inches) above the anus. Instill slowly; stop and lower the container if cramping occurs.
• Types of enemas: cleansing enema (tap water, normal saline, soapsuds — stimulates evacuation); retention enema (oil-based — softens stool, held 30+ minutes); return-flow/Harris flush (for gas relief).
• Ostomy assessment: healthy stoma is PINK to RED and MOIST. A DUSKY, DARK, or PALE stoma indicates impaired circulation — report IMMEDIATELY. This is the most critical stoma assessment finding.
• Ostomy pouch: empty when 1/3 to 1/2 full. Protect peristomal skin with skin barrier. Provide psychosocial support and thorough discharge teaching.
• Colostomy vs. ileostomy: colostomy output is more formed (closer to the rectum = more formed); ileostomy output is liquid (small intestine).

Definitions

Section Title

Bowel Elimination: Assessment, Constipation, Diarrhea, Enemas, and Ostomy

Common Mistakes

• Positioning the patient in the RIGHT lateral position for an enema — ALWAYS use LEFT lateral (Sims') to follow the sigmoid colon curve.
• Raising the enema solution container too high (>45 cm) — causes rapid infusion, cramping, and poor retention.
• Ignoring liquid stool leaking around a fecal impaction and treating it as true diarrhea.
• Failing to report a dusky or dark stoma immediately — this is a vascular emergency.
• Emptying the ostomy pouch when completely full instead of 1/3 to 1/2 full — full pouch increases leakage risk.
• Giving tap water enemas repeatedly — can cause fluid and electrolyte imbalance (water intoxication). Use with caution in elderly and pediatric patients.

Formulas

Exam Tips

• 30 mL/hour = minimum acceptable urine output. ANY output below this requires IMMEDIATE physician notification. Memorize this number.
• Balloon inflation sequence: INSERT → WAIT FOR URINE FLOW → INFLATE. Never reverse this order.
• Drainage bag ALWAYS below bladder — even during transfers and ambulation. Clamp the tubing or use a leg bag during movement.
• Duration = #1 CAUTI risk factor. The NLE may ask about prevention — the answer is always early removal.
• Female vs. male insertion depth: 5–7.5 cm (female) vs. 17–20 cm (male). Know the difference.

Key Points

• Normal adult urine output: approximately 1,500 mL/day (about 30–50 mL/hour).
• Minimum acceptable urine output: 30 mL/hour. Output below this MUST be reported to the physician — it indicates possible renal hypoperfusion.
• Key urinary elimination terms: oliguria (<400 mL/day), anuria (<50 mL/day or no output), polyuria (>2,500 mL/day), dysuria (painful urination), nocturia (waking to urinate), urinary frequency, urgency, retention, incontinence.
• Urinary catheterization: STERILE TECHNIQUE (surgical asepsis) is mandatory. Use the smallest appropriate catheter size.
• Inflate the Foley balloon ONLY AFTER urine flows freely into the drainage tube — this confirms the catheter is in the bladder, not the urethra.
• Catheter care: keep the drainage bag BELOW the level of the bladder AT ALL TIMES to prevent backflow (retrograde contamination). Maintain a closed drainage system.
• CAUTI prevention: the single greatest risk factor is DURATION of catheterization. Remove the catheter as early as clinically possible.
• Female catheter insertion depth: 5–7.5 cm (approximately 2–3 inches). Male insertion depth: 17–20 cm (approximately 6–8 inches), advance slightly further when resistance is met at the sphincter.
• Promoting natural voiding: provide PRIVACY, appropriate positioning (women sit, men stand if able), run water within hearing, pour warm water over the perineum, respond promptly to urge, ensure adequate fluid intake.
• Bladder training: scheduled voiding with gradually increasing intervals for urge incontinence.
• Kegel (pelvic floor) exercises: for stress urinary incontinence; involves contracting and relaxing pelvic floor muscles.

Definitions

Section Title

Urinary Elimination: Normal Parameters, Catheterization, and Promoting Voiding

Common Mistakes

• Inflating the catheter balloon BEFORE urine flows — risks urethral trauma or balloon inflation in the urethra, causing pain and injury.
• Placing the drainage bag ON the bed or at the same level as the bladder — allows backflow and increases CAUTI risk.
• Using the wrong catheter insertion depth — inserting too shallowly in males before reaching the bladder is a common error.
• Leaving a catheter in longer than necessary 'just to monitor output' — prolongs CAUTI risk unnecessarily.
• Disconnecting the drainage system to obtain a urine sample instead of using the sampling port — breaks the closed system and introduces contamination.

Exam Tips

• Placement verification sequence: ASPIRATE → CHECK pH (≤5 = gastric) → CONFIRM EXTERNAL LENGTH → X-RAY (for initial insertion, gold standard).
• HOB 30–45° DURING and 30–60 min AFTER feeding. This is the most important nursing intervention to prevent aspiration in tube feeding.
• If a scenario describes a patient becoming coughing or cyanotic during NGT insertion → WITHDRAW IMMEDIATELY (tube may be in the airway).
• Do NOT crush EC or SR/XL tablets. This is a medication safety principle tested across multiple NLE subject areas.
• Room temperature formula = comfort and safety. Cold formula = diarrhea and cramping.

Key Points

• Enteral nutrition is used when a patient cannot eat orally but has a FUNCTIONING gastrointestinal tract.
• Routes: nasogastric tube (NGT), orogastric tube, gastrostomy/PEG tube, jejunostomy tube.
• VERIFY tube placement BEFORE EVERY feeding and medication administration — this is the most important safety step.
• Most reliable BEDSIDE method: check gastric aspirate pH (pH ≤5 confirms gastric placement). Also verify external tube length against the marked insertion point.
• GOLD STANDARD for initial tube placement confirmation: CHEST/ABDOMINAL X-RAY. An X-ray must be done after initial NGT insertion before first use.
• The old 'whoosh test' (air auscultation) is UNRELIABLE and is NO LONGER RECOMMENDED as the sole method of verifying placement.
• Elevate the HEAD OF BED (HOB) at 30–45° DURING feeding AND for 30–60 minutes AFTER feeding to prevent aspiration — the most serious complication of enteral feeding.
• Check gastric residual volume per facility policy. If residual is high per protocol, hold the feeding and reassess.
• Feed at ROOM TEMPERATURE — cold formula can cause cramping, diarrhea, and patient discomfort.
• Flush the tube with 30–60 mL of water BEFORE and AFTER each feeding and before and after each medication to maintain tube patency.
• Give medications separately; use liquid formulations when available. Do NOT crush enteric-coated (EC) or sustained-release (SR/XL) tablets.
• Flush between each medication when giving multiple drugs via tube.
• Monitor for complications: aspiration, diarrhea (most common complication), dehydration, hyperglycemia, and refeeding syndrome in malnourished patients.
• Refeeding syndrome: dangerous electrolyte shifts (especially hypophosphatemia) when nutrition is reintroduced too rapidly to malnourished patients.

Definitions

Section Title

Enteral (Tube) Feeding: Safety, Technique, and Monitoring

Common Mistakes

• Using only the 'whoosh test' (air auscultation) to verify tube placement — this is UNRELIABLE; gastric pH and X-ray are required.
• Starting a feeding without elevating the HOB — the most preventable cause of aspiration pneumonia in tube-fed patients.
• Crushing enteric-coated or sustained-release medications for tube administration — destroys the drug coating and alters pharmacokinetics dangerously.
• Giving formula cold from the refrigerator — causes cramping, diarrhea, and vasoconstriction of the gastric mucosa.
• Forgetting to flush before and after medications — leads to tube clogging and drug interactions.
• Mixing all medications together before administration — drugs may interact; always administer separately with individual flushes.

Formulas

Exam Tips

• NEX = Nose, Ear, Xiphoid. This measurement question appears frequently. Know what each letter stands for.
• Head FLEXED FORWARD (chin to chest) during NGT insertion. NOT extended. NOT neutral. FLEXED.
• Cough + cyanosis during insertion = WITHDRAW TUBE IMMEDIATELY. This is a safety emergency.
• High-Fowler's for insertion AND feedings. Consistency in positioning is the key message.
• X-ray is gold standard ONLY for INITIAL insertion. After that, bedside pH + external length check suffices per current evidence-based practice.

Key Points

• Measure tube length using the NEX method: Nose tip (N) → Earlobe (E) → Xiphoid process (X). Mark this point on the tube with tape.
• Position: HIGH-FOWLER'S (60–90°) for NGT insertion to facilitate safe passage into the esophagus.
• Head position: chin to chest (head FLEXED FORWARD) when the tube reaches the nasopharynx — this closes the trachea and opens the esophageal route.
• Instruct the patient to SWALLOW or SIP WATER as the tube is advanced to promote esophageal entry and ease passage.
• STOP AND WITHDRAW IMMEDIATELY if the patient coughs, chokes, gags excessively, or becomes CYANOTIC — tube may be in the airway.
• Confirm placement with pH of aspirate, external tube measurement, and X-ray (gold standard for initial insertion).
• Secure the tube to the nose with tape; avoid pressure on the naris to prevent nasal pressure ulcers.
• Mark the tube at the nostril with a permanent marker or tape — use this as the reference for daily measurement to detect migration.
• Contraindications to nasogastric tube: facial fractures, basilar skull fractures, recent nasal surgery, esophageal varices, esophageal stricture (use orogastric route or surgical access).

Definitions

Section Title

Nasogastric Tube Insertion Technique

Common Mistakes

• Extending the head BACKWARD during NGT insertion — this opens the trachea and increases airway insertion risk. Always FLEX forward.
• Not stopping when the patient coughs or becomes cyanotic — continuing risks fatal respiratory complications.
• Failing to lubricate the tube adequately — increases mucosal trauma and patient discomfort.
• Not measuring tube length beforehand — increases risk of improper placement depth.
• Using only one verification method (e.g., only pH) without confirming tube length — always use at least two bedside methods plus X-ray at initial insertion.

Formulas

Exam Tips

• Daily weight = MOST ACCURATE fluid status indicator. More accurate than I&O alone. If the question asks about the best method to monitor fluid balance, answer is DAILY WEIGHT.
• 1 kg = 1 liter. Simple but critical. If a patient gains 3 kg overnight, that is approximately 3 liters of excess fluid.
• FVD signs: dry mouth, poor skin turgor, tachycardia, hypotension, dark urine, weight LOSS.
• FVE signs: edema, crackles, JVD, hypertension, dyspnea, weight GAIN.
• Fever increases fluid loss: account for insensible loss increase when calculating replacement needs in febrile patients.

Key Points

• Accurate I&O monitoring detects fluid imbalance early and guides clinical decision-making.
• Intake includes: ALL oral fluids, IV fluids, blood/blood products, tube feeding (formula + flushes), and irrigants not withdrawn.
• Output includes: urine, emesis/vomitus, diarrhea, drainage from wounds/tubes (NG suction, chest tube, JP drain, Penrose drain), blood loss, and insensible losses (estimated).
• Normal adult fluid balance: approximately 2,000–2,500 mL intake and 2,000–2,500 mL output per day.
• DAILY WEIGHT is the MOST ACCURATE indicator of fluid status. Weigh the patient at the same time each day, on the same scale, wearing similar clothing, after voiding.
• 1 kg change in body weight ≈ 1 liter of fluid gained or lost.
• Fluid Volume Deficit (FVD / Dehydration): thirst, dry mucous membranes, decreased skin turgor (tenting), concentrated urine (dark, amber), decreased urine output, weight loss, tachycardia, hypotension, elevated hematocrit.
• Fluid Volume Excess (FVE / Overhydration): edema (especially dependent edema), weight gain, crackles (rales) on lung auscultation, distended neck veins (JVD), hypertension, bounding pulse, dyspnea.
• Management of FVD: increase oral/IV fluid intake, monitor I&O and daily weight, identify and treat underlying cause.
• Management of FVE: fluid and sodium restriction, diuretics (as ordered), monitor daily weight, I&O, respiratory status.
• Insensible fluid loss: estimated at approximately 500–1,000 mL/day through skin (perspiration) and respiration; increases with fever (approximately 100–150 mL extra per degree Celsius above normal).

Definitions

Section Title

Fluid Intake and Output (I&O) Monitoring and Fluid Balance

Common Mistakes

• Using daily weight only once a week — fluid status can change dramatically in 24–48 hours; daily weights are the standard.
• Weighing the patient at inconsistent times, on different scales, or with different clothing — invalidates comparison.
• Forgetting to include tube feeding flushes in intake calculation — can lead to significant under-recording of intake.
• Not documenting drainage output from wound drains and NGT suction — leads to inaccurate fluid balance assessment.
• Relying on thirst alone to assess hydration in elderly patients — the thirst mechanism is diminished in older adults, making objective assessment more critical.

Formulas

Exam Tips

• Wound healing nutrients = Protein + Vitamin C + Zinc. Memorize all three together as a set.
• Albumin = 3 weeks. Prealbumin = 2–3 days. If the NLE asks which lab best reflects CURRENT/ACUTE nutritional status → PREALBUMIN.
• Pinggang Pinoy: Go (rice/carbs) = energy; Grow (fish/meat) = protein; Glow (vegetables/fruits) = vitamins and minerals. Use this framework in community health diet teaching scenarios.
• For post-op diet progression questions: CLEAR LIQUID first, then full liquid, soft, regular. Never skip steps.
• BMI formula: weight (kg) ÷ height² (m). Know how to calculate and classify results.

Key Points

• Macronutrients: Carbohydrates (4 kcal/g) — primary energy source; Proteins (4 kcal/g) — tissue building and repair; Fats (9 kcal/g) — concentrated energy, fat-soluble vitamins, cell membrane integrity.
• Micronutrients: Vitamins (A, B-complex, C, D, E, K) and Minerals (calcium, iron, zinc, potassium, sodium, phosphorus).
• Nutritional assessment: anthropometric data (height, weight, BMI, mid-upper arm circumference), dietary history, laboratory values (serum albumin, prealbumin, total protein, hemoglobin), clinical signs.
• Albumin: reflects nutritional status over the PAST 3 WEEKS (longer half-life ~20 days). Prealbumin: reflects nutritional status over the PAST 48–72 HOURS (shorter half-life ~2 days) — more sensitive to acute changes.
• Nutrients essential for WOUND HEALING: PROTEIN (tissue synthesis and repair), VITAMIN C (collagen synthesis), ZINC (enzyme function and cell proliferation). These three are the top NLE answers for wound healing nutrition.
• Vitamin C deficiency: Scurvy — poor wound healing, bleeding gums, perifollicular hemorrhages.
• Therapeutic diets in Philippine clinical practice: Low-sodium (hypertension, heart failure, renal disease), diabetic/carbohydrate-controlled (DM), low-fat/low-cholesterol (cardiovascular), renal diet (restrict protein, potassium, phosphorus), high-fiber (constipation, diverticulosis), clear liquid → full liquid → soft → regular (diet progression post-operatively).
• Philippine nutrition education context: DOH/FNRI Pinggang Pinoy is the Filipino food plate model (akin to MyPlate), using a bilao to show proportions of Go (energy foods), Grow (body-building foods), and Glow (regulatory foods).
• BMI classification (WHO/Philippine context): Underweight <18.5, Normal 18.5–24.9, Overweight 25–29.9, Obese ≥30.

Definitions

Section Title

Nutrition Basics and Therapeutic Diets

Common Mistakes

• Confusing albumin and prealbumin timelines — albumin reflects 3 weeks; prealbumin reflects 48–72 hours. Wrong answers here are a common NLE pitfall.
• Forgetting zinc and vitamin C in wound healing — protein alone is NOT sufficient. All three (protein, vitamin C, zinc) are essential.
• Teaching a diabetic patient to avoid ALL carbohydrates instead of controlling the type and amount — this is dietary mismanagement.
• Not considering the patient's cultural food preferences in teaching — in the Philippines, rice is a staple and must be addressed practically in diabetic diet counseling.
• Advancing diet too quickly post-operatively — follow the prescribed progression: clear liquid → full liquid → soft → regular.

Exam Tips

• EVISCERATION = EMERGENCY. Sterile saline-moistened dressing + low-Fowler's + knees flexed + NPO + call surgeon. Memorize this response completely.
• Wound color: RED = protect; YELLOW = debride (slough); BLACK = debride (necrosis). This is a color-coded framework for wound management.
• Phases of healing in ORDER: Hemostasis → Inflammatory → Proliferative → Maturation. Know all four and what happens in each.
• Never use H₂O₂ or full-strength Betadine on granulation tissue — this is a safety principle tested in both fundamentals and medical-surgical NLE questions.
• Wound healing nutrition triad: Protein + Vitamin C + Zinc. Also note that controlled blood glucose is critical for diabetic patients with wounds.

Key Points

• Wound healing types: PRIMARY INTENTION (clean edges approximated — e.g., surgical incision closed with sutures); SECONDARY INTENTION (wound left open, heals from the base up by granulation — e.g., pressure ulcers, large lacerations); TERTIARY INTENTION (delayed primary closure — wound left open initially, then sutured later after edema or infection resolves).
• Phases of wound healing: (1) HEMOSTASIS (immediate — vasoconstriction, platelet aggregation, clot formation); (2) INFLAMMATORY phase (days 1–4 — redness, warmth, swelling, pain, exudate — NORMAL and necessary); (3) PROLIFERATIVE phase (days 4–21 — granulation tissue formation, angiogenesis, wound contraction, re-epithelialization); (4) MATURATION/REMODELING phase (up to 2 years — collagen remodeling, scar formation, tensile strength increases).
• Wound bed color assessment: RED = healthy granulation tissue (protect, keep moist); YELLOW = slough (fibrinous debris — requires debridement); BLACK = necrotic eschar (requires debridement — impairs healing).
• Wound cleaning direction: from LEAST contaminated to MOST CONTAMINATED — clean to dirty — or from the incision OUTWARD. Never swab back toward the wound.
• Use sterile technique for open and surgical wounds. Use normal saline for wound cleansing (isotonic, non-cytotoxic). AVOID full-strength Betadine/povidone-iodine or hydrogen peroxide on granulation tissue — cytotoxic and impairs healing.
• Wound complications: INFECTION (increasing redness, warmth, edema, purulent drainage, fever, wound odor); DEHISCENCE (wound edges separate — apply sterile dressing, notify physician); EVISCERATION (organs protrude through wound — surgical EMERGENCY).
• EVISCERATION management: Cover organs with STERILE SALINE-MOISTENED dressing. Do NOT attempt to push organs back. Keep patient in LOW-FOWLER'S with KNEES FLEXED to reduce abdominal tension. Keep NPO. Notify surgeon IMMEDIATELY. Monitor for shock.
• Drains: Penrose drain (open drain, passive drainage); Jackson-Pratt/JP drain (closed, bulb suction — compress bulb after emptying to maintain suction); Hemovac drain (closed, disc-shaped reservoir — compress after emptying). Measure and record all drainage output as part of I&O.
• Nutrition for wound healing: Protein (tissue synthesis), Vitamin C (collagen synthesis), Zinc (wound healing enzymes), adequate hydration, controlled blood sugar (hyperglycemia impairs healing).
• Risk factors impairing wound healing: malnutrition, diabetes mellitus, obesity, steroid use, advanced age, poor circulation/perfusion, infection, smoking.

Definitions

Section Title

Basic Wound Care: Assessment, Healing, and Nursing Management

Common Mistakes

• Using hydrogen peroxide or full-strength povidone-iodine on granulation tissue — these are cytotoxic and DAMAGE healthy healing tissue.
• Cleaning the wound from outside/dirty area TOWARD the incision — always clean FROM clean TO dirty, outward from the wound center.
• Trying to push eviscerated organs back into the abdomen — NEVER do this. Cover and get surgical help immediately.
• Not recognizing early wound infection signs — waiting until fever is present; earlier signs are increasing local redness, warmth, and wound odor.
• Using a dry dressing on a granulating wound — promotes desiccation and impairs epithelialization; moist wound healing is evidence-based practice.
• Forgetting to empty JP drain before measuring output — if the bulb is not re-compressed, suction is lost and accurate measurement is impossible.