PrepU Ch 30 Skin Integrity and Wound Healing

A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?

"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." rationale: The bulb-like drain allows removal of blood and drainage from the surgical wound. All the statements are factual and true; however, the name of the drain, how it works, when it will be removed, and measurement of the exudate are drain management skills and knowledge. Only, "the drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound" answers the clients question about why the drain is present.

The wound care nurse is performing skin assessments for clients at risk for the development of skin alterations. Which clients does the nurse identify as at greatest risk for skin alterations? Select all that apply.

A client with morbid obesity A client with reports of excessive perspiration A client that has a low BMI rationale: Very thin (low BMI) and very obese people tend to be more susceptible to skin irritation and injury. Excessive perspiration, often associated with being ill, predisposes the skin to breakdown, especially in skin folds. Jaundice, a condition caused by excessive bile pigments in the skin, results in a yellowish skin color. The skin is often itchy and dry, and clients with jaundice are more likely to scratch their skin and cause an open lesion with the potential for infection.

A nurse is caring for a client who has a pressure injury. Which documentation is an example of a complete assessment of the wound's physical appearance?

Stage V pressure injury on the client's left heel, 3 × 4 × 3 cm, pink wound base, no drainage, skin cool to touch, no redness, client denies pain rationale: Assessment and documentation should include wound type, wound location, wound size, wound classification (if it is a pressure injury it should be staged), wound base, wound drainage, the presence or absence of tunnelling, tubes and drains if present, signs and symptoms of infection, condition of surrounding skin, and pain. Measurement should include length, width, and depth in centimeters. Tunnelling measured using the clock method.

A nurse is performing negative pressure wound therapy on a client with a wound in his left ischial tuberosity area. Place in the correct order the steps that the nurse should perform during this dressing change.

Use sterile gloves. Cut the foam to the shape and measurement of the wound. Place the drape to cover the wound and an additional 3 to 5 cm. Cut a 2-cm hole in the drape. Apply a vacuum device to wound. Ensure that negative pressure has been achieved.

A nurse is inspecting the skin of a client and notes a wound with ragged edges and torn tissue. The nurse documents this wound as:

a laceration. rationale: A laceration is a wound with ragged edges with torn tissue. An abrasion is a wound involving friction of the skin. A contusion is a closed wound with bleeding in underlying tissues. A puncture is a wound involving penetration of the skin and underlying tissue.

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

an obese woman with a history of type 1 diabetes rationale: 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 are 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 nurse is caring for a client who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time?

assisting the client in moving to prevent strain on the suture line rationale: The proliferative phase of wound healing begins within 2 to 3 days of the injury. Collagen synthesis and accumulation continue, peaking in 5 to 7 days. During this time, adequate nutrition, oxygenation, and prevention of strain on the suture line are important client care considerations. Pain medication assists with the pain and not with the wound healing process. Fever is not a normal response. A scar will occur later in the wound healing process and usually does not limit the joint movement.

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?

proliferation phase rationale: The proliferation phase is characterized by the formation of granulation tissue (highly vascular red tissue that bleeds easily). During the proliferation phase, new tissue is built to fill the wound space. Hemostasis involves the constriction of blood vessels and the beginning of blood clotting immediately after the initial injury. The inflammatory phase lasts about 4 to 6 days; white blood cells and macrophages move to the wound. The maturation phase is the final phase of wound healing and involves remodeling of collagen that was haphazardly deposited in the wound; in addition, a scar forms.

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this?

secondary intention rationale: Healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue, and eventually epithelial cells migrate across the granulation base. Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the wound are approximated and the risk of infection is lower when a wound heals in this manner. Maturation is the final stage of full-thickness wound healing. Tertiary intention occurs when there is a delay between injury and wound closure. The delay may occur when a deep wound is not sutured immediately or is left open until no sign of infection is evident.

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of decubitus ulcers. What is the name given to the factor responsible for this risk?

shearing force rationale: A shearing force results when one layer of tissue slides over another layer. Clients who are pulled rather than lifted when being moved up in bed or from bed to chair to stretcher are at risk for injury from shearing forces.

A nurse is assessing a pressure injury on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound, 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound?

stage III rationale: Stage III wounds have full-thickness tissue loss. Subcutaneous tissue may be visible, but no bone, tendon, or muscle should be seen. Stage I involves intact skin with nonblanchable redness. Stage II involves a partial tissue loss, such as a blister. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle.

Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections?

thorough hand hygiene rationale: The single most important information on which to educate clients and caregivers about home wound care is the importance of thorough hand hygiene to prevent wound infections. Proper intake of fluids and fiber as well as adequate sleep and rest are general guidelines to promote health. Taking medications especially antibiotics are important if an infection occurs.