During a walk, an older man suffers a laceration from a broken tree branch. Rank the nurse's interventions in order, beginning with the most important intervention
a. Flush and cleanse the wound well.
b. Investigate a possible safety hazard.
c. Instruct him to keep the wound covered.
d. Verify a current tetanus immunization.
A, B, C, D
Flushing and cleansing the wound helps prevent the invasion of potential pathogens from the tree into the man's system. This most basic nursing intervention is the nurse's first priority because it helps maintain physiological functioning. Without the wound being clean, the remaining nursing interventions cannot be effective. The second most important task for the nurse is to instruct the patient to keep the wound covered; the inflammatory response can take 48 to 72 hours to begin in an older adult. Covering the wound will help keep the wound clean and prevent contamination. Without the action of the body's defense mechanisms at the wound in an older adult, inflamma-tory mediators remain inactive, allowing potential pathogens to remain unchecked, increasing the risk for infection. The third most important task is for the nurse to ensure that the older adult has a current tetanus immunization; tetanus is associated with breaks in the skin. The lowest-priority task for the nurse is to ensure the broken tree branch does not present a safety hazard; therefore the nurse questions the older adult for additional information and takes any necessary action to prevent another accident.
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