Chap. 32: skin integrity
penetrating versus puncture would
penetrating would involves debris left in the wound while puncture does not
heating pad range
105-109
temperature of sitz bath?
105-109F
How often are tegaderms changed?
3-5 days
How long should cold therapy in an ice bag be applied?
30 min.
The nurse recognizes that which client is at greatest risk for the development of skin cancer?
55 year old from california for 20 years. male, higher age, and freckles predispose to skin cancer
Which vitamins are involved with collagen synthesis?
Vit C
The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?
a surgical incision with sutured approximated edges=aligned edges.
How long should heat generally be applied?
about 20 min.
A client's risk for the development of a pressure injury is most likely due to which lab result?
albumin
Early warning sign of pressure injury
blanching than nonblanching (stage 1)
While assessing an adult client's feet for fungal disease using a Wood light, the nurse documents the presence of a fungus when the fluorescence is
blue
An abrasion wound involves..
chafing
What type of drainage would be used with pluerisy?
chest tube
What type of gloves are required for chronic wounds such as pressure ulcers?
clean gloves, not sterile gloves.
a contusion is considered what type of wound?
closed wound
What is the dermis primarily composed of?
collagen
What should be done if black tissue is found in a trochanter pressure ulcer the nurse is assigned to dress?
cover with sterile gauze and contact provider; eschar on heel (calcenous eschar) is okay.
How often are bandages replaced for wounds?
varies by drainage but usually 24 hours.
What kind of hair is this?
vellus; pilus erector
T or F. Sterile gloves should be worn to change a pressure ulcer dressing?
False; regular gloves needed.
A penrose drain would be used when?
For edematous wounds.
What type of suction device would be used after a masectomy?
Jackson Pratt bulb suction
What is the blue light used to look for fungal infections.
Wood's light
What does a penrose drain look like?
a flap of plastic sticking outside a wound with safety pin over gauze bandage.
the epidermis is composed of which type of cells, which lack what?
epithelial cells (stratified); blood supply
What type of tissue is the border of wound considered and of what is it composed?
granuloma composed of macrophages.
What function does Vit. B serve in skin integrity
helps wound healing
How does high BP effect wound healing?
high BP=less tissue perfusion=delayed wound healing
Why must hematomas be drained?
increased pressure can block perfusion resulting in ischemia
SDTI suspected deep tissue injury results from which type of action
shear/sliding such as sliding a patient across a sheet
How often should bed ridden patient be rotated to prevent pressure ulcers? How long should a wheel chair patient be rotated?
2 hours; 4 hours
How often are the dressings on negative pressure wound therapy changed
2 to 3 days
How long should a cold compress be changed?
20 min. alternating over 2-3 hours with heat
The nurse is caring for a client who has reported to the emergency department with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely:
2nd degree
An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site?
A transparent film
A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?
Clean the wound from the top to the bottom and from the center to outside.
Which action should the nurse perform when applying negative pressure wound therapy?
Cut foam to the shape of the wound and place it in the wound.
The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time?
Discontinue the therapy and assess the client.
A nurse must make an unoccupied bed. Which nursing action is most important 1. Position the call bell in reach 2. Place a pull sheet on top of the draw sheet 3. Ensure that the bottom sheet is free of wrinkles. 4. Complete one side of the bed before completing the other side.
Ensure that the bottom sheet is free of wrinkles
The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture?
Keep the swab and the inside of the culture tube sterile.
What position would someone with an abdominal evisceration be placed in?
LOW Fowlers position and would covered with NaCl dressing
Are CNA allowed to change dressings or irrigate wounds?
NO
What type of drain is used to drain bile after having the gallbladder removed?
T-tube
A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.
True; exits into granade.
A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn?
Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown
The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate?
Your wound will heal slowly as granulation tissue forms and fills the wound.
What type of would would a severed finger be classified as?
avulsion
What are the notches in nails called and what do they indicate?
beau's lines; trauma, nutritional defeciency or psoriasis
A nurse is caring for a client on a medical-surgical unit who has had an evisceration of an abdominal wound after a coughing episode. Which action by the nurse is appropriate in this situation? Select all that apply.
covering the wound with a gauze moistened with normal saline placing the client in the low Fowler position using sterile technique
What wound complication would this bottle be applied to a sterile towel and the health care provider contacted?
dehiscense
what term does the picture on the left and right represent?
dehiscense and evisceration
How often should a bed bound patient and a chair bound patient be repositioned to prevent ulcers?
every 2 hours; every one hour for chair bound.
The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing?
fish b/c it contains protein. also would want vitamin A & C
How does an unstagable pressure ulcer differ from a full thickness stage IV pressure ulcer?
involvement of eschar or slough (usu. yellowish)
How does skin integrity change with age?
less excretions from sebaceous glands causes drier skin and less collagen results in wrinkly skin
what is this called and what causes it?
linea nigra occurs due to hormonal changes during pregnancy.
What term is used for wrinkled toes?
maceration
How does incontinence increase risk for pressure ulcers?
moisture (urea and feces) provides nutrients and a breeding ground for bacteria; feces makes the perineal area more alkaline, encouraging bacterial growth.
The nurse observes the client for signs of stage I pressure injury development, which most likely will include which finding?
nonblanchable redness
The nurse is caring for a bedridden client who is at risk for the development of pressure injuries. In which position can the nurse place the client to relieve pressure on the trochanter area?
oblique position
Which phase of healing involves granulation tissue?
proliferative phase.
How to remove dressing?
pull on dressing while pushing opposing skin. pull in direction of hair.
The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room?
transparent
A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?
transparent dressing; tegaderm
The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surigical wound during a dressing change. What instructions should the RN provide the LPN regarding this action?
use cotton tip applicator instead of finger on open wounds; sterile technique versus clean.
Where are spiral turns of bandage used and where are figure 8 turns of band used?
wrist, fingers, trunk; around joints
Top 4 areas of pressure injuries?
Coccyx, sacrum, trocanter, and calcaneous (heel)
To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question?
Do you experience incontinence.
What wound complication is an abdominal surgery patient at risk for if they cough excessively?
evisceration
What color are SDTI?
purple or maroon
A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red, raised rash under the client's breasts. This manifestation is most consistent with:
rash from yeast infection
A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action?
remove by wetting with saline; crusting is normal, infection is not.
The nurse is using the Braden Scale to determine a client's risk for pressure injuries. What criteria will the nurse assess? Select all that apply.
sensory perception nutrition ability friction
What is the most common cause of shear pressure ulcers?
sliding down the bed
A 23-year-old woman has presented to the clinician to follow up her recent diagnosis of psoriasis. Which of the following assessments of the client's nails would be consistent with the client's diagnosis?
small pits on nails. Psoriasis=Pits
the nurse is instructing a group of high school students about risk factors associated with various skin cancers. The nurse should instruct the group that
squamous cell cancer occurs with sun exposure.
What stage of pressure ulcer is a partial and full thickness wound?
stage II and stage III
direction of bandage application on amputated foot.
start at wound and work upward.
surgical wounds:____ techniqe::pressure ulcers:____ technique
sterile technique; clean technique
