Chapter 32: Skin integrity and wound care

The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity? "Be sure to take at least two showers daily to remove all microorganisms from the skin." "Do not apply skin moisturizers after bathing, as this creates a reservoir for skin infection." "Drink 8 ounces of water three times daily and once at bedtime to remain hydrated." "Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer."

"Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer.

pressure injury

(1) localized damage to the skin and underlying tissue that usually occurs over a bony prominence or is related to the use of a (medical or other) device; (2) any lesion caused by unrelieved pressure that results in damage to underlying tissue; formerly known as pressure ulcer

What are the three different types of tape?

-adhesive: used for support, strength, securement, provide pressure, immobilization, approximate wound edges -paper/plastic:increased comfort, secure dressing -microfoam: compression

list and describe the systemic factors that affect wound healing

-age -circulation and oxygenation -nutritional status wound etiology -medication and health status

What are some causes/factors of pressure injury development?

-external pressure -friction and shear -immobility -poor skin hygiene -diabetes -fractures -poor nutrition -moisture -age -mental status

list and describe wound complications

-infection -hemorrhage -dehiscence and eviseration -fistula formation

describe the phases of wound healing

-inflammatory phase: white blood cells and macrophages move to wound -proliferation phase: new tissue id built -maturation phase:collagen is remodeled making wound stronger

list the type of wounds

-intentional -unintentional -contusion -abrasion -puncture -avulsion -chemical -thermal -penetrating -laceration

Describe how to cleanse a woundd that is not approximated

-moisten a sterile gauze -use a new gauze for each circle -clean wound in circle or half circles -clean to at least 1 in beyond the end of the new dressing

How do negative pressure wound therapies work?

-noninvasive device that applies pressure to wound bed though a unit attached to a dressing/sponge -highly absorbent -decreases bacterial colonization -stimulate increased blood supply and granulation

When assessing a patient for being at high risk for pressure injury what are you looking at?

-poor skin hygiene -immunosuppression -previous pressure injury -obesity -diabetes -diminished sensory perception

list and describe the local factors that affect wound healing

-pressure -desiccation -maceration -trauma -edema -infection -excessive bleeding -necrosis -biofilm

What are some interventions that could help prevent a pressure injury from forming?

-preventing infections -promoting wound healing -prevent further injury -emotional comfort -facilitate coping

List the 3 main types of dressings

-transparent: allow exchange of oxygen, can see through dressing -hydrocolloid: limit oxygen exchange, inner layer is self adherent, outer layer seals and protects wound -hydrogels: maintain a moist wound environment

Describe how to cleanse a wound that is approximated

-use normal saline -sterile equipment is used -use a new swab or gauze for each downward stroke -wipe from clean area to less clean area

How do pressure injuries affect body image?

-when skin and tissues are traumatized, their image changes -wounds visible to others can result in feelings of conspicuousness, ugliness, and diminished self worth

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? Tearing of the skin and tissue with some type of instrument; tissue not aligned Cutting with a sharp instrument with wound edges in close approximation with correct alignment Tearing of a structure from its normal position Puncture of the skin

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.

A nurse is providing wound care to a pressure injury that formed on the heel of a bedridden client several months ago. Which guideline should inform the nurse's practice? It is appropriate to use clean technique during this procedure. The nurse must diligently apply the principles of asepsis. Sterility must be maintained throughout the procedure. The nurse should apply chlorhexidine or an alternative disinfectant to the wound bed.

Chronic wounds and pressure injuries may be treated using clean technique; aseptic technique is not always necessary. Disinfectants are not normally applied to wound beds except in exceptional circumstances.

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? Desiccation Maceration Necrosis Evisceration

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.

A nurse caring for a client who has a surgical wound after a caesarean birth notes dehiscence of the wound, what is the main priority of nursing care? Notify the surgeon STAT Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement Approximate the wound edges and use wound closure tapes to hold it together and contact the surgeon Irrigate the open wound areas with sterile normal saline, apply a sterile dressing, and contact the surgeon

Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement, With dehiscence, there is an unintentional separation of wound edges, especially in a surgical wound. Dehiscence is not a medical emergency. However, the nurse will notify the surgeon and protect the open wound areas with a sterile saline-moistened dressing. Also, the nurse will implement preventative measures such as splinting the wound with a pillow during movement to prevent further dehiscence or evisceration. Approximating the wound edges and applying wound closure tapes may cause the client undue pain and trap bacteria in the wound. Irrigating the open wound may cause unwanted bacteria from the surrounding area to wash into the wound.

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

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.

An older adult client who is scheduled for surgery asks about self-care at home after the surgery is complete. What education will the nurse provide? Select all that apply. "It may take you longer to heal than someone younger." "Eat nourishing foods after surgery to promote healing." "Try to do everything by yourself at home to build your strength back." "Wound healing can take longer if you have been exposed often to the sun." "Monitor your moods after surgery. Depression after surgery is not normal."

Wound healing can be delayed in older adult clients, especially those with long-term sun exposure. Eating healthy foods can speed healing. A home health aide can assist with caregiving to reduce stress. Depression, which is abnormal after surgery, can affect wound healing. It is not advisable to encourage the client to do everything alone at home to build strength, as this could be dangerous if the client is not physically capable.

The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response? "This is normal tissue." "That is old clotted blood underneath the wound" "That is called undermining, a type of tissue erosion." "That is necrotic tissue, which must be removed to promote healing."

Wounds that are brown or black are necrotic and not considered normal. Slough is dead moist, stringy dead tissue on the wound surface that is yellow, tan, gray, or green. Undermining is tissue erosion from underneath intact skin at the wound edge.

2. A nurse caring for patients in the PACU teaches a novice nurse how to assess and document wound drainage. Which statements accurately describe a characteristic of wound drainage? Select all that apply. a.Serous drainage is composed of the clear portion of the blood and serous membranes. b. Sanguineous drainage is composed of a large number of red blood cells and looks like blood. c. Bright-red sanguineous drainage indicates fresh bleeding and darker drainage indicates older bleeding. d. Purulent drainage is composed of white blood cells, dead tissue, and bacteria. e. Purulent drainage is thin, cloudy, and watery and may have a musty or foul odor. f. Serosanguineous drainage can be dark yellow or green depending on the causative organism.

a, b, c, d. Serous drainage is composed primarily of the clear, serous portion of the blood and serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged.

8. The nurse is cleaning an open abdominal wound that has unapproximated edges. What are accurate steps in this procedure? Select all that apply. a. Use standard precautions or transmission-based precautions when indicated. b. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. c. Clean the wound in full or half circles beginning on the outside and working toward the center. d. Work outward from the incision in lines that are parallel to it from the dirty area to the clean area. e. Clean to at least 1 in beyond the end of the new dressing if one is being applied. f. Clean to at least 3 in beyond the wound if a new dressing is not being applied.

a, b, e. The correct procedure for cleaning a wound with unapproximated edges is: (1) use standard precautions and appropriate transmission-based precautions when indicated, (2) moisten sterile gauze pad or swab with prescribed cleansing agent and squeeze out excess solution, (3) use a new swab or gauze for each circle, (4) clean the wound in full or half circles beginning in the center and working toward the outside, (5) clean to at least 1 in beyond the end of the new dressing, and (6) clean to at least 2 in beyond the wound margins if a dressing is not being applied.

6.A nurse who is changing dressings of postoperative patients in the hospital documents various phases of wound healing on the patient charts. Which statements accurately describe these stages? Select all that apply. a.Hemostasis occurs immediately after the initial injury. b. A liquid called exudate is formed during the proliferation phase. c. White blood cells move to the wound in the inflammatory phase. d. Granulation tissue forms in the inflammatory phase. e. During the inflammatory phase, the patient has generalized body response. f. A scar forms during the proliferation phase.

a, c, e. Hemostasis occurs immediately after the initial injury and exudate occurs in this phase due to the leaking of plasma and blood components out into the injured area. White blood cells, predominantly leukocytes and macrophages, move to the wound in the inflammatory phase to ingest bacteria and cellular debris. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. New tissue, called granulation tissue, forms the foundation for scar tissue development in the proliferation phase. New collagen continues to be deposited in the maturation phase, which forms a scar.

1.Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise, as well as pain and redness at the surgical site. Which intervention is most important to include in this patient's nursing care plan? a.Document the findings and continue to monitor the patient. b. Administer antipyretics, as prescribed. c. Increase the frequency of assessment to every hour and notify the patient's primary care provider. d. Increase the frequency of wound care and contact the primary care provider for an antibiotic prescription.

a. The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.

15. A nurse is measuring the depth of a patient's puncture wound. Which technique is recommended? a.Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down. b.. Draw the shape of the wound and describe how deep it appears in centimeters. c. Gently insert a sterile applicator into the wound and move it in a clockwise direction. d.. Insert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface with a marker.

a. To measure the depth of a wound, the nurse should perform hand hygiene and put on gloves; moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down; mark the point on the swab that is even with the surrounding skin surface, or grasp the applicator with the thumb and forefinger at the point corresponding to the wound's margin; and remove the swab and measure the depth with a ruler.

What does applying heat to a wound do?

accelerates the inflammatory response to promote healing

Negative pressure wound therapy

activity that promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid

What is the difference between acute and chronic wounds

acute: heals within days to weeks chronic:do not progress through normal sequence of repair, remains in inflammatory phase

How often should a skin assessment take place in the different health care settings? Acute long-term home health

acute: on admission, reassess every shift long-term:on admission, reassess weekly for four weeks, home health care:on admission, reassess at every visit

Fistula

an abnormal passage from an internal organ to the skin or from one internal organ to another

When preparing to change the dressing for a patient when should you administer pain medication if needed?

an hour before

Explain the braden scale

assesses mental status, continence, mobility, activity, nutrition to look at risk for pressure injuries

9.A nurse is developing a care plan for an 86-year-old patient who has been admitted for right hip arthroplasty (hip replacement). Which assessment finding(s) indicate a high risk for pressure injury development for this patient? Select all that apply. a.The patient takes time to think about responses to questions. b. The patient is 86 years old. c. The patient reports inability to control urine. d. The patient is scheduled for a hip arthroplasty. e. Lab findings include BUN 12 (older adult normal 8 to 23 mg/dL) and creatinine 0.9 (adult female normal 0.61 to 1 mg/dL). f. The patient reports increased pain in right hip when repositioning in bed or chair.

b, c, d, f. Pressure, friction, and shear, as well as other factors, usually combine to contribute to pressure injury development. The skin of older adults is more susceptible to injury; incontinence contributes to prolonged moisture on the skin, as well as negative effects related to urine in contact with skin; hip surgery involves decreased mobility during the postoperative period, as well as pain with movement, contributing to immobility; and increased pain in the hip may contribute to increased immobility. All these factors are related to an increased risk for pressure injury development. Apathy, confusion, and/or altered mental status are risk factors for pressure injury development. Dehydration (indicated by an elevated BUN and creatinine) is a risk for pressure injury development.

12. After an initial skin assessment, the nurse documents the presence of a reddened area that has blistered. According to recognized staging systems, this pressure injury would be classified as: a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

b. A stage 2 pressure injury involves partial-thickness loss of dermis and presents as a shallow open ulcer with a red pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister.

13. The nurse uses the RYB wound classification system to assess the wound of a patient whose arm was cut on a factory machine. The nurse documents the wound as "red." What would be the priority nursing intervention for this type of wound? a. Irrigate the wound. b. Provide gentle cleansing of the wound. c. Debride the wound. d. Change the dressing frequently.

b. Red wounds are in the proliferative stage of healing and reflect the color of normal granulation tissue. Wounds in this stage need protection with nursing interventions that include gentle cleansing, use of moist dressings, and changing of the dressing only when necessary, and/or based on product manufacturer's recommendations. To cleanse yellow wounds, nursing interventions include the use of wound cleansers and irrigating the wound. The eschar found in black wounds requires debridement (removal) before the wound can heal.

3. A patient who has a large abdominal wound suddenly calls out for help because the patient feels as though something is falling out of her incision. Inspection reveals a gaping open wound with tissue bulging outward. In which order should the nurse perform the following interventions? Arrange from first to last a. .Notify the health care provider of the situation. b. Cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution. c.Place the patient in the low Fowler's position.

c, b, a. Dehiscence and evisceration is a postoperative emergency that requires prompt surgical repair. The correct order of implementation by the nurse is to place the patient in the low Fowler's position (to prevent further physical damage), cover the exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution (to protect the viscera), and notify the health care provider of the situation (to address the issue, likely with surgery). Note that the interprofessional team may be completing the activities simultaneously in the clinical setting, but the priority identified above is important to understand.

7.The nurse assesses the wound of a patient who was cut on the upper thigh with a chain saw. The nurse documents the presence of biofilms in the wound. What is the effect of this condition on the wound? Select all that apply. a. Enhanced healing due to the presence of sugars and proteins b. Delayed healing due to dead tissue present in the wound c. Decreased effectiveness of antibiotics against the bacteria d. Impaired skin integrity due to overhydration of the cells of the wound e. Delayed healing due to cells dehydrating and dying f. Decreased effectiveness of the patient's normal immune process

c, f. Wound biofilms are the result of wound bacteria growing in clumps, embedded in a thick, self-made, protective, slimy barrier of sugars and proteins. This barrier contributes to decreased effectiveness of antibiotics against the bacteria (antibiotic resistance) and decreases the effectiveness of the normal immune response by the patient (Baranoski & Ayello, 2016; Hess, 2013). Necrosis (dead tissue) in the wound delays healing. Maceration or overhydration of cells related to urinary and fecal incontinence can lead to impaired skin integrity. Desiccation is the process of drying up, in which cells dehydrate and die in a dry environment.

11. A nurse is providing patient teaching regarding the use of negative pressure wound therapy. Which explanation provides the most accurate information to the patient? a. The therapy is used to collect excess blood loss and prevent the formation of a scab. b. The therapy will prevent infection, ensuring that the wound heals with less scar tissue. c. The therapy provides a moist environment and stimulates blood flow to the wound. d. The therapy irrigates the wound to keep it free from debris and excess wound fluid.

c. Negative pressure wound therapy (NPWT) promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid, while providing a moist wound healing environment. The negative pressure results in mechanical tension on the wound tissues, stimulating cell proliferation, blood flow to wounds, and the growth of new blood vessels. It is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or healing slowly.

10. A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation? a."I can expect to have more discomfort in the area where the cold is applied." b. "I should expect more drainage from the incision after the ice has been in place." c. "I should see less swelling and redness with the cold treatment." d. "My incision may bleed more when the ice is first applied."

c. The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues, decreases the local release of pain-producing substances, decreases metabolic needs, and capillary permeability. The resulting effects include decreased edema, coagulation of blood at the wound site, promotion of comfort, decreased drainage from wound, and decreased bleeding.

4.A patient was in an automobile accident and received a wound across the nose and cheek. After surgery to repair the wound, the patient says, "I am so ugly now." Based on this statement, what nursing diagnosis would be most appropriate? a.Pain b. Impaired Skin Integrity c.Disturbed Body Image d. Disturbed Thought Processes

c. Wounds cause emotional as well as physical stress.

Serous drainage

composed of clear, serous portion of the blood and from serous membranes

What does applying cold to a wound do?

constricts peripheral blood vessels, reduces muscle spasms, promotes comfort

Sanguineous Drainage:

containing or mixed with blood

5. A patient is admitted with a nonhealing surgical wound. Which nursing action is most effective in preventing a wound infection? a. Using sterile dressing supplies b. Suggesting dietary supplements c. Applying antibiotic ointment d. Performing careful hand hygiene

d. Although all of the answers may help in preventing wound infections, careful hand washing (medical asepsis) is the most important.

14. A nurse is developing a care plan related to prevention of pressure injuries for residents in a long-term care facility. Which action accurately describes a priority intervention in preventing a patient from developing a pressure injury? a. Keeping the head of the bed elevated as often as possible b. Massaging over bony prominences c. Repositioning bed-bound patients every 4 hours d. Using a mild cleansing agent when cleansing the skin

d. To prevent pressure injuries, the nurse should cleanse the skin routinely and whenever any soiling occurs by using a mild cleansing agent with minimal friction, and avoiding hot water. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible. Bony prominences should not be massaged, and bed-bound patients should be repositioned every 2 hours.

Necrosis

death of cells and tissue

Ischemia

deficiency of blood in a particular area

Desiccation

dehydration; the process of being rendered free from moisture

Exudate

fluid that accumulates in a wound; may contain serum, cellular debris, bacteria, and white blood cells

shear

force created when layers of tissue move on one another

What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing? transparent film hydrocolloid hydrogel alginate

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.

Dermis

layer of the skin below the epidermis

Hematoma

localized mass of usually clotted blood

Sanguineous drainage

mixture of serum and red blood cells

serosanguineous drainage

mixture of serum and red blood cells

Granulation tissue

new tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal

Friction

occurs when two surfaces rub against each other; the resulting injury resembles an abrasion and can also damage superficial blood vessels directly under the skin

List the common types of drains (open and closed)

open: infected wounds, after removal of hemorrhoids, abdominal surgery (incision and drainage of abscess) closed: after cardiac surgery, abdominal surgery, breast surgery, gallbladder surgery

Evisceration

protrusion of viscera through an incision

Erythema

redness of the skin

Dehiscence

separation of the layers of a surgical wound; may be partial, superficial, or a complete disruption of the surgical wound

Maceration

softening through liquid; overhydration

List and explain the stages of pressure injuries

stage 1: intact skin with a localized area of nonblanchable skin stage 2: Partial-thickness loss of skin with exposed dermis stage 3: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present stage 4: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer.

Epithelialization

stage of wound healing in which epithelial cells form across the surface of a wound; tissue color ranges from the color of "ground glass" to pink

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take? Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station. Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain. Rotate the swab several times over the wound surface to obtain an adequate specimen. Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen.

the nurse should press and rotate the swab several times over the wound surface. The swab should be inserted into the culture tube at the bedside, immediately after collection. Saline or any other fluid is not added to the tube and anesthetics are not applied prior to collection.

Eschar

thick, leathery scab or dry crust that is necrotic and must be removed for adequate healing to occur

Are pressure injuries painful?

yes

Can pressure injuries affect activities of daily living?

yes

Can pressure injuries affect body image?

yes

The nurse is caring for a client who has recently noted abnormal pigmentation in his skin. What is most likely deficient in the client's diet? Vitamin A Vitamin B12 Zinc Magnesium

zinc, Adequate intake of iron, copper, and zinc is important to prevent abnormal pigmentation and changes in nails and hair.