Chapter 48 Skin Integrity and Wound Care

A patient has a stage II pressure ulcer. Which dressings might the nurse plan to use for the patient? Select all that apply.

Hydrogel Hydrocolloid Composite film

A nursing instructor discusses with a nursing student the changes that occur in the skin with aging. Which of the student's statements indicates the need for further teaching?

"The collagen content of the skin increases with age."

What is the correct sequence of steps when performing a wound irrigation? 1. Use slow continuous pressure to irrigate wound. 2. Attach angio catheter to syringe 3. Fill syringe with irrigation fluid 4. Place water proof bag near bed 5. Position angio catheter over wound.

4, 3, 2, 5, 1

Which equipment should the nurse have available when irrigating a surgical wound?

A 35-mL syringe with a 19-gauge soft angiocathete

Which dressings are inappropriate for intact stage I pressure ulcers? Select all that apply.

Gauze Composite film Calcium alginate

What are the implications for healing of a surgical incision? Select all that apply.

Heals by epithelialization Clean and intact wound edges Heals quickly with minimal scar formation

The nurse is caring for a patient who is diagnosed with venous stasis ulcers. Which support surface should the nurse anticipate for this patient?

Lateral rotation

Which type of support surface should the nurse plan to use to treat and prevent pulmonary, venous stasis, and urinary complications associated with immobility?

Lateral rotation

Which support surface is useful for treating and preventing pulmonary, venous stasis, and urinary complications associated with immobility?

Lateral rotation surface

Which nursing actions are appropriate when removing tape from the patient's skin during wound care? Select all that apply.

Loosen the ends Pull the tape in the direction of hair growth Use adhesive remover to loosen the tape

Which nutrient is an antioxidant that promotes wound healing?

Vitamin C

A nurse discusses the purposes of wound dressings with a nursing student. Which of the nursing student's statements indicates the need for further learning?

"Dressings provide a dry environment to facilitate healing."

Which patient statement indicates understanding of the disadvantages of using moist applications for wound therapy?

"It causes maceration of the skin."

Which patient statement indicates understanding of the advantages of using dry applications for wound therapy?

"It reduces the risk of burns."

The nursing instructor is discussing the Braden Scale for pressure ulcer development risk with a nursing student. Which of the student's statements is incorrect?

"The Braden Scale has shown sufficient predictive validity and accuracy for all patients."

What amount of protein per kilogram of body weight a day should the nurse recommend a patient consume to support wound healing?

1.25 to 1.5 g

When an injury is a result of trauma from a dirty penetrating object, a tetanus antitoxin injection is necessary unless the patient's last shot was administered within the past _____ years. Record you answer using whole number.

10

What quantity of vitamin C is recommended for wound healing? Record your answer using a whole number. ______ mg/day

1000

What amount of retinol equivalents for vitamin A per day should the nurse recommend a patient to consume to support proper wound healing?

1600-2000

How many calories per kilogram per day should the nurse suggest a patient consume to promote proper wound healing?

30-35 kcal

What amount of fluid per kilogram per day should the nurse encourage the patient to drink for proper wound healing?

30-35 mL

What size syringe is used for irrigating an open wound? Record your answer using whole number. _______ mL

35

What might the nurse anticipate for a patient with new-onset bowel incontinence that is causing compromised skin integrity?

A change in dietary prescription.

Which of the following describes a hydrocolloid dressing?

A dressing that forms a gel that interacts with the wound surface.

Which factor does not put a patient at risk for burns during heat therapy?

Abscessed tooth

When performing any wound care procedure, which nursing action is appropriate for addressing the patient's pain and discomfort?

Administering pain medication 30 to 60 minutes before the procedure

Which action is involved in safely removing retention sutures?

Clip suture materials nearest to the skin edge on one side, and pull from the other side.

Which skin care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence?

Frequent position changes. Using an incontinence cleaner Applying a moisture barrier ointment

When cleaning a wound, which action is incorrect?

Cleaning from the surrounding skin to the site of incision

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?

Cleansed wound

The nurse is preparing a care plan for a patient who has a pressure ulcer on the coccyx. Which part of the plan is included to provide comfort to the patient?

Applying a moisture barrier ointment over the ulcer

A patient who has an acute wound due to trauma is admitted to the emergency unit. Which nursing action for wound care is the priority in this situation?

Applying a sterile dressing as per the health care provider's order

Under the supervision of the registered nurse, a nursing student is providing negative-pressure wound therapy to a patient who has a wound near the knee joint. Which nursing action indicates the need for further learning?

Applying adhesive remover at the affected site before the dressing

Which nursing action during removing tape from the patient's skin during wound care requires correction?

Applying hard traction to the skin next to the wound

Which nursing action evaluates patient and family knowledge related to a pressure-redistribution surface?

Asking the participants to discuss possible sensations associated with the prescription

Which nursing actions are appropriate when providing care to a patient who is diagnosed with a stage III, IV, or unstageable pressure ulcer? Select all that apply.

Avoid prolonged elevation of the head of the bed Consider the use of a wheelchair cushion Consider an alternating pressure support surface Place a pillow under the calves to decrease the risk of heel breakdown

Which sign is an early indication of pressure that resolves without tissue loss if the pressure is eliminated?

Blanchable erythema

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch?

Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.

What type of wound drainage is considered sanguineous?

Bright red, active bleeding

Which dressing will the nurse use for a patient with a clean stage III pressure ulcer?

Calcium alginate

The registered nurse is overseeing a nursing student who is providing a dressing change to a patient who had a cesarean section. Which nursing action indicates a need for further learning?

Choosing a dressing that keeps the periwound moist

The registered nurse is overseeing a nursing student who is collecting samples of wound drainage for culture. Which nursing action indicates a need for further learning?

Collecting wound culture samples from old drainage

What is the removal of devitalized tissue from a wound called?

Debridement

Which advantages should the nurse include in a teaching session on using dry applications when treating a wound? Select all that apply.

Decreases the risk for burns Retains temperature longer because evaporation does not occur

What intervention is not necessary for a patient who has impaired skin integrity related to limited mobility?

Demonstrate correct repositioning techniques.

Which condition warrants the use of cold therapy?

Direct trauma

What is the advantage of a moist application in wound healing?

Does not promote sweating

Which is characteristic of abnormal healing of a primary wound?

Drainage for more than 3 days after closure

Which is characteristic of abnormal healing in a primary-intention wound?

Drainage present more than three days after closure

A 76-year-old female patient who has osteoarthritis and mild hypertension develops redness and oozing of foul-smelling tan-colored drainage from her hip incision on postoperative day 4. Because of the pain at the incision site, she needs assistance in turning and transferring herself from her bed to the chair. What intervention will the nurse avoid?

Elevating the head of the bed to 45 degrees

Under the supervision of the registered nurse, the nursing student is repositioning a patient to reduce the risk of pressure ulcers. Which nursing action indicates a need for further learning?

Encouraging the patient to sit on a donut-shaped cushion

Which nursing actions are teaching strategies for patients and families who will be working with a pressure-redistribution surface? Select all that apply.

Explaining the reasons for the prescription Teaching common errors associated with the prescription Noting the minimum layers of linen to be used with the prescription

Which nursing action is appropriate when framing the periwound area with skin sealant?

Extending the sealant 3 to 5 cm (1.2 to 2 in) beyond the wound edges

Which piece of knowledge does a nurse not require for assessing a patient's risk for developing pressure ulcers?

Factors contributing to inflammation and infection

Arrange the steps for preparing an ice bag in order.

Fill the bag with water, and check it for leaks. Fill two thirds of the bag with crushed ice. Squeeze the bag's sides to release any air.. Cover the bag with a flannel cover, towel, or pillowcase.

Which statement is true regarding sutures?

Fine sutures cause minimal tissue injury.

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part?

Ice bag

A patient who has a stage III pressure ulcer develops a body temperature of 103° F. While changing the wound dressing, the nurse finds purulent discharge with an odor coming from the wound. What will the nurse suspect is occurring in the patient?

Infection

What step is a component of the planning phase for a patient who has impaired skin integrity?

Involve the patient and family in choosing interventions.

A patient with limited mobility develops a Stage III sacral pressure ulcer. Which nursing interventions are appropriate for reducing the risk of wound infection in this patient? Select all that apply.

Irrigating and cleansing the wound with saline twice a day Packing the open wound with antibiotic solution-moistened gauze

Which intervention is part of the nursing intervention classification?

Irrigating the wound with a saline solution two times per day

Which pressure ulcer site is found immediately distal to the buttock?

Ischium

What are the therapeutic benefits of heat application? Select all that apply.

It promotes the movement of waste products. It improves blood flow to injured body parts. It improves delivery of leukocytes to the wound site.

Which is the priority nursing action for any wound care procedure?

Managing pain prior to initiating care

In a supine position, which site is not at risk for a pressure ulcer?

Medial knee

Which action is inappropriate for maintaining an airtight seal in negative-pressure wound therapy?

Moistening the periwound area thoroughly

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions?

Notify the surgeon Cover the area with sterile, saline-soaked towels and immediately.

Which nursing intervention is appropriate for a patient who is at risk for infection due to a surgical incision at the right hip?

Obtaining a wound culture as needed

What intervention should the nurse plan for a patient who has a sacral pressure ulcer?

Pack open areas of the wound with gauze moistened with an antibiotic solution.

What is characteristic of stage III pressure ulcers?

Slough may be present with slough, but it does not obscure the depth of tissue loss.

The nurse performs the skin and risk assessment on a patient who has diabetes and limited mobility due to a fractured left hip and finds that the skin is intact without any skin disintegration. Which nursing intervention should the nurse provide to the patient?

Place a pillow under the patient's calves.

According to the Braden Scale for predicting pressure ulcer risk, which factor most puts the patient at risk for developing a pressure ulcer?

Poor nutrition

Which is characteristic of abnormal healing in a secondary-intention wound?

Presence of necrotic or slough tissue at the base of the wound

What is the role of vitamin A in wound healing?

Promotes wound closure

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound?

Provides support to abdominal tissues when coughing or walking Reduction of stress on the abdominal incision

A patient's wound drainage appears thick and yellow. Which type of drainage is this considered?

Purulent

Chronologically arrange the steps for using a syringe and needle to collect a sample for a wound culture.

Removing skin flora with a disinfectant solution Using a 10-mL disposable syringe with a 22-gauge needle Applying suction to the 10-mL mark Moving the needle back and forward at different angles for two to four explorations

Which interventions are part of the nursing intervention classification (NIC) of pressure management? Select all that apply.

Repositioning the patient every 90 minutes Avoiding the use of massage around the open area Elevating the head of the patient's bed to no more than 30 degrees

What does the Braden Scale evaluate?

Risk factors that place the patient at risk for skin breakdown

Which dressing is inappropriate for a patient with a clean stage II pressure ulcer?

Silver

Which type of ulcer can be dressed with a transparent or hydrocolloid dressing?

Stage I

Which stage of the pressure ulcer involves partial-thickness loss of the dermis and manifests as a red-pink, open ulcer without slough?

Stage II

For which pressure ulcers would the nurse include education related to both granulation and reepithelialization? Select all that apply.

Stage III Stage IV

How is the nursing care for a patient who has a stage IV pressure ulcer different from that for a patient who has a stage I pressure ulcer?

Stage IV requires the use of a low-air-loss, alternating pressure, or air-fluidized support surface.

Which adjuvant treatment is only considered for patients diagnosed with an unstageable pressure ulceration?

Surgical consultation for debridement

Arrange the events that occur during the proliferative phase of wound healing in chronological order.

Synthesis of collagen from fibroblasts Mixing of collagen with granulation tissue Contraction of the wound Migration of the epithelial cells from the wound edges

Which statement regarding the skin is true?

The dermis and the inner layer of the skin provide tensile strength.

While caring for a patient in the postsurgical unit, the nurse palpates the area around the surgical wound and asks the patient if there is tenderness. What is the rationale behind this nursing action?

To assess for the risk of periwound edema

A patient with an abdominal wound from a motor vehicle accident comes into the emergency room with evisceration. The nurse immediately places sterile gauze soaked in sterile saline over the extruding tissues. What is the rationale for this nursing action?

To prevent infection

When is an application of a warm compress to an ankle muscle sprain indicated?

To relieve edema To improve blood flow to an injured part

Which can cause an acute wound? Select all that apply.

Trauma Surgical incision

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient's pressure ulcer?

Unstageable

While assessing a patient who has a pressure ulcer, the nurse finds black wound tissue. In which stage is this pressure ulcer?

Unstageable

What should the nurse consider when developing a nursing plan for an immobile patient whose skin is intact but is at a high risk for impaired skin integrity? Select all that apply.

Use a pillow under the calves so that the heels are elevated to reduce the risk of heel breakdown. Use an active support surface, such as an overlay or mattress, when frequent manual repositioning is difficult. Avoid prolonged head-of-bed elevation and a slouched position that places pressure and shear on the sacrum and coccyx.

Which of the following are measures to reduce tissue damage from shear?

Use a transfer device, e.g. transfer board Have head of bed flat when re positioning patients Raise head of bed 30 degrees when patient positioned supine

Which nursing action is appropriate when providing care to a patient who exhibits no risk for skin breakdown?

Using a standard surface

Which nutrient helps healing by promoting epithelialization, wound closure, inflammatory response, and angiogenesis?

Vitamin A