Chapter 31: Skin Integrity and Wound Care

The health care provider prescribes negative-pressure wound therapy for a client with a pressure injury. Before initiating the treatment, it is important for the nurse to implement which nursing assessment? Assess the client's mental status. Assess the wound for active bleeding. Assess for the use of antihypertensives. Assess the client for claustrophobia.

Assess the wound for active bleeding. Explanation: Negative-pressure wound therapy (NPWT) promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed. NPWT is not considered for the use in the presence of active bleeding. The nurse needs to assess for the use of anticoagulants, not antihypertensives, because these can cause bleeding. Mental status and the presence of claustrophobia are not significant when initiating negative-pressure wound therapy.

A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion? Puncture of the skin Tearing of the skin and tissue with some type of instrument; tissue not aligned Tearing of a structure from its normal position Cutting with a sharp instrument with wound edges in close approximation with correct alignment

Tearing of a structure from its normal position Explanation: An avulsion involves tearing of a structure from its normal position on the body. Tearing of the skin and tissue with some type of instrument with the tissue not aligned is a laceration. Cutting with a sharp instrument with wound edges in close approximation and correct alignment is an incision. A puncture of the skin is simply a puncture.

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? Pasta salad Banana Green beans Fish

Fish Explanation: To promote wound healing, the nurse should ensure that the client's diet is high in protein, vitamin A, and vitamin C. The fish is high in protein and is therefore the most appropriate choice to promote wound healing. Pasta salad has a high carbohydrate amount with no protein. Banana has a high amount of vitamin C but no protein. Green beans have some protein but not as much as fish.

The nurse is caring for a client in the emergency department with a cut receivied 15 minutes ago while preparing dinner at home. The nurse understands the client's wound is in which phase of wound healing? Hemostasis phase Inflammatory phase Maturation phase Proliferation phase

Hemostasis phase Explanation: Hemostasis is the initial phase after an injury. Hemostasis stimulates other cells to come to the wound to begin with other phases of wound healing. The inflammatory phase follows hemostasis; white blood cells move into the wound to remove debris and to release growth factors. The proliferation phase is the regenerative phase in which granulation tissue is formed. The maturation phase involves collagen remodeling.

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage types should the nurse document? Serous Purulent Sanguineous Serosanguineous

Serosanguineous Explanation: Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink in color. Serous drainage is a clear drainage consisting of the serous portion of the blood. Sanguineous drainage consists of red blood cells and looks like blood. Purulent drainage has various colors such as green or yellow; this drainage indicates infection.

A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage? Supports the area around the wound Reduces swelling and inflammation Keeps the wound clean Maintains a moist environment

Supports the area around the wound Explanation: Bandages and binders are used to secure dressings, apply pressure, and support the wound. A roller bandage is a continuous strip of material wrapped on itself to form a cylinder or roll and is applied using a circular turn, spiral turn, or figure-of-eight turn. It is effective for use around joints, such as the knee, elbow, ankle, and wrist.

A full-thickness or third-degree burn develops a leathery covering called a(an): eschar. static. abrasion. erythema.

eschar. Explanation: The full-thickness or third-degree burn appears dry and leathery. The term for this presentation is called eschar. Eschar is a thick, leathery scab or dry crust that is necrotic.

A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing? contusion puncture incision avulsion

contusion Explanation: A contusion is an injury to soft tissue, so this is what the nurse expects to see based on the incident. A puncture involves an opening of skin caused by a narrow, sharp, pointed object such as a nail. An incision involves a clean separation of skin and tissue with smooth, even edges. An abrasion involves stripped surface layers of skin. An avulsion has stripped away of large areas of skin and underlying tissues.

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use? circular turn spica turn figure-of-eight turn spiral-reverse turn

figure-of-eight turn Explanation: A figure-of-eight turn is used for joints like elbows and knees. Other answers are incorrect.

The nurse is caring for a woman with a labile carbuncle. Which intervention will most likely be included in the plan of care? Apply an ice pack to relieve pain. Cleanse labia with scented soap. Soak in a warm bath for drainage. Expose the area to a heat lamp.

Soak in a warm bath for drainage. Explanation: Heat promotes vasodilation, allowing for the consolidation of pus in infected areas. Scented products may contain chemicals that promote irritation to the infected area and have no curative benefits to this particular client. Cold application will result in vasoconstriction and will not promote healing.

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. False True

True Explanation: A Penrose drain is an open drainage system that exits the skin through a stab wound. The purpose a Penrose drain is to provide a sinus tract for drainage.

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question? "Have you had any recent illnesses?" "Do you use any lotions on your skin?" "Do you experience incontinence?" "How many meals a day do you eat?"

"Do you experience incontinence?" Explanation: The client's health history is an essential component for assessing the client's integumentary status and identification of risk factors for problems with the skin. The priority question addresses a source of moisture on the skin. Moisture makes the skin more susceptible to injury because it can create an environment in which microorganisms can multiply and the skin is more likely to blister, suffer abrasions, and become macerated (softening or disintegration of the skin in response to moisture). Sound nutrition is important in the prevention and treatment of pressure injuries. The number of meals eaten per day does not give a clear assessment of nutritional status. The nurse should question the client about skin care regimens, such as the use of lotions, but this would not be the priority in determining the risk for pressure injury development. Asking the client about any recent illnesses is not a priority in determining the risk for pressure injury development.

The nurse is teaching a client about healing of a minor surgical wound by first-intention. What teaching will the nurse include? "The margins of your wound are not in direct contact." "This is a complex reparative process." "The surgeon will leave your wound intentionally open for a period of time." "Very little scar tissue will form."

"Very little scar tissue will form." Explanation: Very little scar tissue is expected to form in a minor surgical wound. Second-intention healing involves a complex reparative process where margins of the wound are not in direct contact. Third-intention healing takes place when wound edges are intentionally left widely separated and are later brought together for closure.

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? "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." "Your wound will heal slowly as granulation tissue forms and fills the wound." "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." "As soon as the infection clears, your surgeon will staple the wound closed."

"Your wound will heal slowly as granulation tissue forms and fills the wound." Explanation: This statement is correct as it provides education to the client "Your wound will heal slowly as granulation tissue forms and fills the wound". Large wounds with extensive tissue loss may not be able to be closed by primary intention, which is surgical intervention. Secondary intention, in which the wound is left open and closes naturally and this is not done if less scar is neccesary. Third intention is when a wound is left open for a few days and then if there is no indication of infection, the surgeon closes the wound.

A client recovering from abdominal surgery sneezes, and then screams, "My insides are hanging out!" What is the initial nursing intervention? Contact the surgeon. Assess for impaired blood flow to the area of evisceration. Monitor for pallor and mottle appearance of the wound. Apply sterile dressings with normal saline over the protruding organs and tissue.

Apply sterile dressings with normal saline over the protruding organs and tissue. Explanation: The nurse will immediately apply sterile dressing moistened with normal saline over the protruding organs and tissue, and call out for someone to contact the surgeon. While waiting for the surgeon, the nurse will continue to assess the area of evisceration and monitor the client's status.

A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has ordered fly larvae to debride the wound. Which of the following types of debridement does the nurse understand has been ordered? Mechanical debridement Enzymatic debridement Autolytic debridement Biosurgical debridement

Biosurgical debridement Explanation: Biosurgical debridement uses fly larvae to clear the wound of necrotic tissue. This is accomplished through an enzyme the larvae releases. Autolytic debridement involves using the client's own body to break down the necrotic tissue. Enzymatic debridement involves the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed. Mechanical debridement involves physically removing the necrotic tissue, such as surgical debridement.

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? Maceration Necrosis Evisceration Desiccation

Desiccation Explanation: Desiccation is localized wound dehydration. Maceration is localized wound overhydration or excessive moisture. Necrosis is death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area. Reference:

The nurse is caring for a client who needs blood drawn for analysis. When gathering supplies, which dressing will the nurse select to cover the site where the needle was inserted to gather blood? Tegasorb Duoderm OpSite Gauze

Gauze Explanation: Gauze dressings absorb blood or drainage. Transparent dressings like OpSite are used to protect intravenous insertion sites. Hydrocolloid dressings like Duoderm and Tegasorb are used to used keep a wound moist.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough, a bad odor, and extends into the muscle. How will the nurse categorize this pressure injury? Stage I Stage III Stage II Stage IV

Stage IV Explanation: Stage IV pressure injuries are characterized as exposing muscle and bone, and may have slough and a foul odor. Stage I pressure injuries are characterized by intact, but reddened, skin that is unblanchable. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage.

A nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client?

Subcutaneous tissue Explanation: The subcutaneous tissue is the skin layer that is responsible for storing fat for energy. The epidermis is the outer layer that protects the body with a waterproof layer of cells. The dermis contains the nerves, hair follicles, blood vessels, and glands. The muscle layer moves the skeleton. Reference:

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown. The nurse packs the wound cavity tightly with dressing material. The nurse uses wet-to-dry dressings continuously.

The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. Explanation: A wound with heavy exudate will need a more absorptive dressing and a dry wound will require rehydration with a dressing that keeps the wound moist. The nurse would not keep the surrounding tissue moist. The nurse would not pack the wound cavity tightly, rather loosely. The nurse would not use wet-to-dry dressings continuously.

A client with anorexia nervosa has developed a pressure injury on the sacrum. Which laboratory result would indicate the client is at nutritional risk? Albumin level of 3.5 mg/dL (35 g/L) Total lymphocyte count of 1,500/mm3 (1.50 x 109/L) Arm muscle circumference 90% of standard Body weight decrease of 3%

Total lymphocyte count of 1,500/mm3 (1.50 x 109/L) Explanation: The following laboratory criteria indicate that a client is nutritionally at risk for development of a pressure injury: albumin level <3.2 mg/dL (normal, 3.5-5 mg/dL), prealbumin <19 mg/dL (normal 16-40 mg/dL), body weight decrease of 5% to 10%. Additional laboratory tests to consider in clients at risk for or presenting with pressure injuries include: total lymphocyte count <1,800/mm3 (normal, 1,000- 4,000/mm3), hemoglobin A1C >8% (normal <6%), glucose >120 mg/dL (normal 70-120 mg/dL). Although one of the options is body weight decrease of 5%, it is not the best answer. The best answer is total lymphocyte count of 1,500/mm3.

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury? Use pillows to maintain a side-lying position as needed. Elevate the head of the bed 90 degrees. Provide incontinent care every 4 hours as needed. Place a foot board on the bed.

Use pillows to maintain a side-lying position as needed. Explanation: Using pillows to maintain a side-lying position allows the nursing staff to change position to alleviate and alternate pressure on client's bony prominences. The client's position should be changed a minimum of every 2 hours. In addition, incontinent care should be performed a minimum of every 2 hours and as needed to decrease moisture and irritation to the skin. A foot board prevents footdrop in clients but does not decrease the risk for pressure injury. Reference:

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces? a client sitting in a chair who slides down a client who must remain on his back for long periods of time a client who lifts himself up on his elbows a client who lies on wrinkled sheets

a client sitting in a chair who slides down Explanation: Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Clients who are pulled, rather than lifted, when being moved up in bed (or from bed to chair or stretcher) are at risk for injury from shearing forces. A client who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a client who sits in a chair but slides down. The client that is most likely to develop a pressure ulcer from shearing forces would be a client sitting in a chair who slides down.

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? a wound healing naturally that becomes infected. a wound left open for several days to allow edema to subside a surgical incision with sutured approximated edges a large wound with considerable tissue loss allowed to heal naturally

a surgical incision with sutured approximated edges Explanation: Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention. Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention. If a wound that is healing by primary intention becomes infected, it will heal by secondary intention. Wounds that heal by secondary intention take longer to heal and form more scar tissue. Connective tissue healing and repair follow the same phases in healing. However, differences occur in the length of time required for each phase and in the extent of new tissue formed. Wounds healed by tertiary intention, or delayed primary closure, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed.

What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing? transparent films alginates hydrocolloid dressings hydrogels

hydrocolloid dressings Explanation: Hydrocolloids are occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment; provide minimal to moderate absorption of drainage; maintain a moist wound environment; and may be left in place for three to seven days, thus resulting in less interference with healing. Hydrogels maintain a moist wound environment and are best for partial or full-thickness wounds. Alginates absorb exudate and maintain a moist wound environment. They are best for wounds with heavy exudate. Transparent films allow exchange of oxygen between wound and environment. They are best for small, partial-thickness wounds with minimal drainage.

When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding? avulsion abrasion incision laceration

incision Explanation: An incision involves a clean separation of skin and tissue with smooth, even edges. Therefore, the nurse documents the finding as an incision. An avulsion has stripped away of large areas of skin and underlying tissues. An abrasion involves stripped surface layers of skin. A laceration involves separation of skin and tissue with torn, irregular edges. Therefore, the nurse does not document the finding as an avulsion, abrasion, or laceration.

A nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by: primary intention. secondary intention. tertiary intention. dehiscence.

primary intention. Explanation: Wounds healing by primary intention form a clean, straight line with little loss of tissue. Wounds healing by secondary intention are large wounds with considerable tissue loss. The edges are not approximated. Healing occurs by formation of granulation tissue. Wounds healing by delayed primary intention or tertiary intention are left open for several days to allow edema or infection to resolve or exudates to drain. They are then closed. Dehiscence is wound separation, not wound healing.

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action? removing dead or infected tissue to promote wound healing removing excess drainage and wet tissue to prevent maceration of surrounding skin removing purulent drainage from the wound bed in order to accurately assess it stimulating the wound bed to promote the growth of granulation tissue

removing dead or infected tissue to promote wound healing Explanation: Debridement is the act of removing debris and devitalized tissue in order to promote healing and reduce the risk of infection. Debridement does not directly stimulate the wound bed, and the goal is neither assessment nor the prevention of maceration.

The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include? "You will receive medication through this device." "It provides a way to remove drainage and blood from the surgical wound." "This drain minimizes the chance for bacteria to enter the surgical site." "The bulb-like system will stay in place permanently after your mastectomy."

"It provides a way to remove drainage and blood from the surgical wound." Explanation: The bulb-like drain allows for removal of blood and drainage from the surgical site. It does not provide a route for medication administration, decrease the chance for infection, nor does it stay attached permanently.

The nurse is teaching a client about wound care at home following a Cesarean section to deliver her baby. Which client statement requires further nursing teaching? "I will not remove the staples myself." "Steri-Strips will hold my wound together until it heals." "I may have staples in place for a number of days." "After delivery, I will have sutures in place."

"Steri-Strips will hold my wound together until it heals." Explanation: After a Cesarean section, a client will be sutured and have staples put in place for a number of days. The healthcare provider or nurse will remove staples. Steri-Strips are not strong enough to hold this type of wound together.

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes a Penrose drain intact. Which statement is true about Penrose drains? A Penrose drain has a round collection chamber with a spring that is kept under negative pressure. A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. A Penrose drain is a closed drainage system that is connected to an electronic suction device. A Penrose drain promotes drainage passively into a dressing.

A Penrose drain promotes drainage passively into a dressing. Explanation: A Penrose drain is an open drainage system that promotes drainage of fluid passively into a dressing. Additional drains include the Jackson-Pratt drain that has a small bulblike collection chamber that is kept under negative pressure. A Hemovac is a round collection chamber with a spring inside that also must be kept under negative pressure.

A nurse is cleaning the wound of a gunshot victim. Which is a recommended guideline for this procedure? Clean the wound from the top to the bottom, and center to outside. Once the wound is cleaned, dry the area with an absorbent cloth. Clean the wound from the bottom to the top, and outside to center. Use clean technique to clean the wound.

Clean the wound from the top to the bottom, and center to outside. Explanation: Using sterile technique, clean the wound from the top to the bottom, and from the center to the outside, from the area with the least contamination to the most. Dry the area with a gauze sponge and not a n absorbent cloth in the same manner and apply ointment and dressing. "Use clean technique to clean the wound" is not descriptive enough of how to clean the wound.

A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline, then inserting it gently into the wound at a 90-degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method? Size Depth Direction Tunneling

Depth Explanation: When measuring the depth of a wound, the nurse moistens a sterile, flexible applicator with saline and inserts it gently into the wound at a 90-degree angle, with the tip down. The nurse then marks the point on the swab that is even with the surrounding skin surface, or grasps the applicator with the thumb and forefinger at the point corresponding to the wound's margin. Finally, the nurse removes the swab and measures the depth with a ruler. Size is measured with a ruler on the outside of the wound. Tunneling is measured by a finger probe or sterile probe instrument. Direction is a visual inspection.

A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation? Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. Pick the crusts off the sutures with the forceps before removing them. Do not attempt to remove the sutures because they need more time to heal. Moisten sterile gauze with sterile saline to loosen crusts before removing sutures.

Moisten sterile gauze with sterile saline to loosen crusts before removing sutures. Explanation: If sutures are crusted with dried blood or secretions, making them difficult to remove, the nurse should moisten sterile gauze with sterile saline and gently loosen crusts before removing sutures. Washing the sutures with antimicrobial soap is not necessary and may decrease the clots and crusts that have formed since surgery. Picking the crusts off with sutures can be painful for the client and destroy the clot/crust formation. The sutures need to be removed and waiting is not appropriate.

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly? The nurse uses a safety pin to attach the pad to the bedding. The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly. The nurse covers the heating pad with a heavy blanket. The nurse places the heating pad under the client's neck.

The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly. Explanation: The nurse would keep the heating pad in place for 20 to 30 minutes, assessing it regularly. The nurse would not use a safety pin to attach the pad to the bedding. The pin could create problems with this electric device. The nurse would not place the heating pad directly under the client's neck. The nurse would not cover the heating pad with a heavy blanket.

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 dressing with a nonadherent coating a gauze dressing precut halfway to fit around the IV line a gauze dressing premedicated with antibiotics

a transparent film Explanation: Transparent film dressings are semipermeable, waterproof, and adhesive, allowing for visualization of the access site to aid assessment, as well as protecting the site from microorganisms. Gauze dressings, as suggested in the other three options, do not allow the nurse to visualize the site without partially or completely removing the dressing.

A client's risk for the development of a pressure injury is most likely due to which lab result? glucose 110 mg/dL sodium 135 mEq/L albumin 2.5 mg/dL hemoglobin A1C 7%

albumin 2.5 mg/dL Explanation: An albumin level of less than 3.2 mg/dL indicates the client is nutritionally at risk for the development of a pressure injury. Hemoglobin A1C levels greater than 8% place the client at risk for the development of pressure injuries due to prolonged high glucose levels. Glucose levels greater than 120 mg/dL are a risk factor for the development of pressure injuries. Sodium of 135 mEq/L is normal and would not place the client at risk for the development of a pressure injuries.

The nurse would recognize which client as being particularly susceptible to impaired wound healing? an obese woman with a history of type 1 diabetes A client who is n.p.o. (nothing by mouth) following bowel surgery a man with a sedentary lifestyle and a long history of cigarette smoking a client whose breast reconstruction surgery required numerous incisions

an obese woman with a history of type 1 diabetes Explanation: Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process. This is a greater risk factor for impaired healing than is smoking and sedentary lifestyle. Large incisions in and of themselves do not necessarily complicate the healing process. Short-term lack of food intake is not as significant as longer-term lack of nutrition.

A postoperative client describes the following during a transfer, "I feel like something just popped." The nurse immediately assesses for: evisceration. herniation. infection. dehiscence.

dehiscence. Explanation: Dehiscence is a total or partial disruption in wound edges. Clients often report feeling the incision has given way. Manifestations of infection include redness, warmth, swelling, and heat. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents.