"Skin Integrity and Wound Care: Chapter 48"

patients who are unable to independently change position are at risk because they cannot change or shift off of bony prominences

impaired mobility

________ thickness will heal via the inflammatory response, epithelial proliferation, and migration with reestablishement of epidermal layers

partial

how often should you shift your patient to avoid pressure ulcers

1 to 2 hours as indicated

when possible maintain hemoglobin at

12 g/100 mL

The nurse is to collect a specimen for culture after assessing the client's wound drainage. The best technique for obtaining the culture is to: A) Cleanse the wound first. B) Send the soiled dressing to the laboratory. C) Swab from the outside skin edge inward. D) Collect the specimen from accumulated drainage.

A) Cleanse the wound first.

The nurse is caring for a patient with a large abrasion from a motorcycle accident. The nurse recalls that if the wound is kept moist, it can resurface in _____ day(s). A. 4 B. 2 C. 1 D. 7

A. 4 A partial-thickness wound repair has three compartments: the inflammatory response, epithelial proliferation and migration, and re-establishment of the epidermal layers. Epithelial proliferation and migration start at all edges of the wound, allowing for quick resurfacing. Epithelial cells begin to migrate across the wound bed soon after the wound occurs. A wound left open to air resurfaces within 6 to 7 days, whereas a wound that is kept moist can resurface in 4 days. One or 2 days is too soon for this process to occur, moist or dry.

Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence? A. Complaint by patient that something has given way B. Protrusion of visceral organs through a wound opening C. Chronic drainage of fluid through the incision site D. Drainage that is odorous and purulent

A. Complain by patient that something has given way Dehiscence occurs when a wound fails to heal properly and the layers of skin and tissue separate. It involves abdominal surgical wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. Patients often report feeling as though something has given way. Evisceration is seen when vital organs protrude through a wound opening. A fistula is an abnormal passage between two organs or between an organ and the outside of the body that can be characterized by chronic drainage of fluid. Infection is characterized by drainage that is odorous and purulent.

Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, which results in tissue ischemia and ultimately tissue death. There are four stages of pressure ulcer formation. The nurse observes partial-thickness skin loss involving the epidermis and possibly the dermis. What stage of ulcer will the nurse document? A) Stage I B) Stage II C) Stage III D) Stage IV

B) Stage II

The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. The nurse recognizes that the risk factors that predispose a patient to pressure ulcer development include: A. A diet low in calories and fat B. Alteration in level of consciousness C. Shortness of breath D. Muscular pain

B. Alteration in level of consciousness Patients who are confused or disoriented or who have changing levels of consciousness are unable to protect themselves. The patient may feel the pressure but may not understand what to do to relieve the discomfort or to communicate that he or she is feeling discomfort. Impaired sensory perception, impaired mobility, shear, friction, and moisture are other predisposing factors. Shortness of breath, muscular pain, and a diet low in calories and fat are not included among the predisposing factors.

The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. What would be the nurse's next best step? A. Remove the drain; a drain is no longer needed B. Call the physician; a blockage is present in the tubing C. Call the charge nurse to look at the drain D. As long as the evacuator is compressed, do nothing

B. Call the physician; a blockage is present in the tubing Because a drainage system needs to be patent, look for drainage flow through the tubing, as well as around the tubing. A sudden decrease in drainage through the tubing may indicate a blocked drain, and you will need to notify the physician. The health care provider determines the need for drain removal and removes drains. Notifying the charge nurse, although important for communication, is not the next step in providing care for this patient. The evacuator may be compressed when a blockage is present.

The home health nurse is caring for a patient with impaired skin integrity in the home. The nurse is reviewing dressing changes with the caregiver. Which intervention assists in managing the expenses associated with long-term wound care? A. Sterile technique B. Clean dressings and no touch technique C. Double bagging of contaminated dressings D. Ability of the caregiver

B. Clean dressings and no touch technique Clean dressings as opposed to sterile dressings are recommended for home use. This recommendation is in keeping with principles regarding nosocomial infection, and it takes into account the expense of sterile dressings and the dexterity required for application. The caregiver can use the same no touch technique for dressing changes that is used for changing surface dressings without touching the wound or the surface that might come in contact with the wound. Double bagging is required for the disposal of contaminated dressings. The dressings go in a bag, which is fastened and then placed in the household trash. The ability of the caregiver certainly is a component of the success of home treatment, but it does not influence the cost of supplies.

The nurse is updating the plan of care for a patient with a stage III pressure ulcer and a nursing diagnosis of Impaired skin integrity. Which of the following outcomes when met indicate progression toward goals? (Select all that apply.) A. Ask whether patient's expectations are being met B. Prevent injury to the skin and tissues C. Obtain the patient's perception of interventions D. Reduce injury to the skin E. Reduce injury to the underlying tissues F. Restore skin integrity

B. Prevent injury to the skin and tissues D. Reduce injury to the skin E. Reduce injury to the underlying tissues F. Restore skin integrity Optimal outcomes are to prevent injury to skin and tissues, reduce injury to skin, reduce injury to underlying tissues, and restore skin integrity. Asking the patient's perceptions and whether expectations are being met allows one to obtain information regarding the experience, but these are not actual measurable outcomes.

The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by: A. Tertiary intention B. Secondary intention C. Partial-thickness repair D. Primary intention

B. Secondary intention A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater. A clean surgical incision is an example of a wound with little loss of tissue that heals by primary intention. The skin edges are approximated or closed, and the risk for infection is low. Partial- thickness repair are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed until the risk of infection is resolved.

The nurse is caring for a patient after an open abdominal aortic aneurysm repair. The nurse requests an abdominal binder and carefully applies the binder. What is the best explanation for the nurse to use when teaching the patient the reason for the binder? A. The binder creates pressure over the abdomen B. The binder supports the abdomen C. The binder reduces edema at the surgical site D. The binder secures the dressing in place

B. The binder supports the abdomen The patient has a large abdominal incision. This incision will need support, and an abdominal binder will support this wound, especially during movement, as well as during deep breathing and coughing. A binder can be used to create pressure over a body part, for example, over an artery after it has been punctured. A binder can be used to prevent edema, for example, in an extremity but is not used to reduce edema at a surgical site. A binder can be used to secure dressings such as elastic webbing applied around a leg after vein stripping.

Postoperatively a client with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the nurse sees that the sutures are open and that pieces of small bowel are visible at the bottom of the now opened wound. The correct intervention would be to: A) Allow the area to be exposed to air until all drainage has stopped. B) Place several cold packs over the area, with care taken to protect the skin around the wound. C) Cover the area with sterile saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration. D) Cover the area with sterile gauze; place a tight binder over the areas; ask the client to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly.

C) Cover the area with sterile saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration.

The nurse applies a hydrogel dressing to a client with radiation-damaged skin. Why is a hydrogel dressing the best choice for this client? A) It provides a wicking action. B) It permits the nurse to view the wound. C) It is soothing and reduces pain in the wound. D) It can be used as a preventative dressing for high-risk friction areas.

C) It is soothing and reduces pain in the wound.

Application of a warm compress is indicated: A) To relieve edema B) For a client who is shivering C) To improve blood flow to an injured part D) To protect bony prominences from pressure ulcers

C) To improve blood flow to an injured part

The autolytic, mechanical, chemical, and surgical methods that are often used during wound management are all methods of accomplishing what? A) Wound dressing B) Wound cleansing C) Wound débridement D) Stimulation of growth factors

C) Wound débridement

The nurse is cleansing a wound site. As the nurse administers the procedure, what intervention should be included? A. Allowing the solution to flow from the most contaminated to the least contaminated B. Scrubbing vigorously when applying solutions to the skin C. Cleansing in a direction from the least contaminated area D. Utilizing clean gauge and clean gloves to cleanse a site

C. Cleansing in a direction from the least contaminated area Cleanse surgical or traumatic wounds by applying non-cytotoxic solution with sterile gauze or irrigations. Cleanse in a direction from the least contaminated area. Use gentle friction when applying solutions to the skin, and allow irrigation to flow from the least to the most contaminated area.

The nurse is caring for a postoperative medial meniscus repair of the right knee. To assist with pain management following the procedure, which intervention should the nurse implement? A. Monitor vital signs every 15 minutes B. Apply brace to right knee C. Elevate right knee and apply ice D. Check pulses in right foot

C. Elevate right knee and apply ice Ice assists in preventing edema formation, controlling bleeding, and anesthetizing the body part. Elevation assists in preventing edema, which in turn can cause pain. Monitoring vital signs every 15 minutes is routine postoperative care and includes a pain assessment but in itself is not an intervention that decreases pain. Applying a brace provides support and decreases the opportunity for additional trauma, which in turn assists in the healing process. Checking the pulses is important to monitor the circulation of the extremity but in itself is not a pain management intervention.

The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a pressure ulcer takes time to heal and is an example of: A. Primary intention B. Partial-thickness wound repair C. Full-thickness wound repair D. Tertiary intention

C. Full-thickness wound repair Pressure ulcers are full-thickness wounds that extend into the dermis and heal by scar formation because the deeper structures do not regenerate, hence the need for full-thickness repair. The full-thickness repair has three phases: inflammatory, proliferative, and remodeling. A wound heals by primary intention when wounds such as surgical wounds have little tissue loss; the skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges approximated. Wound closure is delayed until risk of infection is resolved.

The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair? A. Eschar B. Slough C. Granulation D. Purulent drainage

C. Granulation Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. Soft yellow or white tissue is characteristic of slough—a substance that needs to be removed for the wound to heal. Black or brown necrotic tissue is called eschar, which also needs to be removed for a wound to heal. Purulent drainage is indicative of an infection and will need to be resolved for the wound to heal.

The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How would the nurse stage this ulcer? A. Stage I pressure ulcer B. Healing stage II pressure ulcer C. Healing stage III pressure ulcer D. Stage III pressure ulcer

C. Healing stage III pressure ulcer When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage and is labeled with the words "healing stage." Once an ulcer has been staged, the stage endures even as the ulcer heals. This ulcer was labeled a stage III, it cannot return to a previous stage such as stage I or II. This ulcer is healing, so it is no longer labeled a stage III.

When a wound specimen is obtained for culture to determine whether infection is present, the specimen should to be taken from: A) Necrotic tissue B) Wound drainage C) Drainage on the dressing D) The wound after it has first been cleansed with normal saline

D) The wound after it has first been cleansed with normal saline

The patient has been provided a nursing diagnosis of Risk for skin impairment and has a 15 on the Braden scale upon admission. The nurse has implemented interventions for this nursing diagnosis. Upon reassessment, which Braden score would be the best sign that the risk for skin breakdown is decreasing? A. 12 B. 13 C. 20 D. 23

D. 23 The Braden scale is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The total score ranges from 6 to 23, and a lower total score indicates a higher risk for pressure ulcer development. The cutoff score for onset of pressure ulcer risk with the Braden scale in the general adult population is 18. The best sign is a perfect score of 23.

drainage flows onto the ______ but not directly onto the _____

barriers, skin

_____ assessments and __________ assessments provide valuable data that indicate skin integrity, as well as any risk for pressure ulcer development

baseline, continual

continual exposure of the skin to _____ _____ increases a patients risk for skin breakdown and pressure ulcer formation

body fluids

What parts of your body are the MOST at risk for a pressure ulcer

boney prominences

what scale do you use when assessing a patients risk for a pressure ulcer

braden scale

which of the following is an example of a wound or injury healing by secondary intention? a.) an open burn area b.) a bone fracture that is casted c.) a sprained ankle d.) a sutured surgical incision

a.) an open burn area

Who is at risk for pressure

any patient who is experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence, and/or poor nutrition

is the force of two surfaces moving across one another, such as the mechanical force exerted when the body is dragged across another surface

friction

_____ thickness wounds heal via inflammatory response, proliferation, and remodeling

full

Clarification of pressure ulcer Stage 4

full thickness tissue loss with exposed bone, muscle, or tendon

Clarification of pressure ulcer Stage 3

full thickness tissue loss with visible fat

a low _____ level decreases delivery of oxygen to the tissues and leads to further ischemia

hemoglobin

bleeding from the wound site

hemorrhage

is normal during and immediately after initial trauma

hemorrhage

complications of wound healing include

hemorrhage, infection, dehiscence, evisceration, and fistulas

a series of events designed to control blood loss, establish bacterial control, and seal the defect that results when an injury occurs

hemostasis

when positioning a patient with light skin, observe for normal reactive ________ and __________

hyperemia, blanching

An entry in a client chart states that the wound drainage is sanguineous. That means it is a.) watery in appearance b.) green tinged or yellow c.) bright red d.) foul-smelling

c.) bright red

Patients with pressure ulcers who are underweight or are loosing weight need enhanced

calories and protein supplementations

may use topical enzymes to induce changes in the substrate resulting in the breakdown of necrotic tissue depending on the type of enzyme used, the preparation digests or dissolves the tissue. these preparations require a health care providers order. Dakin solution breaks down and loosens dead tissue in a wound

chemical debridement

Patients with altered sensory perception for pain and pressure are at risk because they cannot feel their body sensations

impaired sensory perception

types of wound management (4)

mechanical, autolytic, chemical, or sharp/surgical

assessment includes documenting the level of _________ and the potential effects of impaired _______ on skin integrity.

mobility

the presence and duration of ______ on the skin reduce the skins resistance of other physical factors

moisture

Education: you need to impress on the patient and the patients family the importance of

nutrition, fluids, and body positioning

dehiscence is common in people who are

obese

what is the first thing that you should do if you suspect abnormal reactive hyperemia

outline the affected area with a marker (this makes reassessment easier)

Clarification of pressure ulcer Stage 2

partial thickness skin loss involving epidermis, dermis, or both

removal of nonviable, necrotic tissue

debridement

a partial or total separation of wound layers

dehiscence

a patient who is at risk for poor wound healing is at risk for

dehiscence

portable units exert a safe, constant, low-pressure vacuum to remove and collect drainage

drainage evacutors

when drainage interferes with healing, ___________ is achieved by using a drain alone or a drainage tube with continuous suction

evacuation

With the appearance of new blood vessels as _______ _______ , the proliferative phase begins and lasts from __ to ___ days

reconstruction progresses, 3 to 24

the wound is left open until it becomes filled by

scar tissue

________ _______ is a force that acts perpendicular to the plane of interaction

shearing force

the form the wound repair takes depends on the wounds

thickness

the edges of the wound appear inflamed.

wound infection

the second most common health care associated infection

wound infection

a patient care lose as much as _____ of protein per day from an open, weeping pressure ulcer

50g

What parts of your body are at risk for pressure ulcers

Anywhere on your body where there is pressure

For a client who has a muscle sprain, localized hemorrhage, or hematoma, application of which of the following helps to prevent edema formation, control bleeding, and anesthetize the body part? A) Binder B) Ice bag C) Elastic bandage D) Absorptive diaper

B) Ice bag

The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. What should the nurse do to decrease the patient's anxiety? A. Tell the patient to close his eyes B. Explain the procedure C. Turn on the television D. Ask the family to leave the room

B. Explain the procedure Explaining the procedure educates the patient regarding the dressing change and involves him in his care, thereby allowing the patient some control in decreasing anxiety. Telling the patient to close his eyes and turning on the television are distractions that do not usually decrease a patient's anxiety. If the family is a support system, asking support systems to leave the room can actually increase a patient's anxiety.

Serous drainage from a wound is defined as: A) Fresh bleeding B) Thick and yellow drainage C) Clear, watery plasma D) Beige to brown and foul-smelling drainage

C) Clear, watery plasma

There are three phases of wound healing. The nurse observes granulation tissue in a client's pressure ulcer. What phase of wound healing is represented by granulation tissue? A) Maturation phase B) Hemostasis phase C) Proliferative phase D) Inflammatory phase

C) Proliferative phase

who recommends nutritional assessments within 24 hours of admission

the joint commission 2008

Which type of pressure ulcer consists of an observable pressure-related alteration of intact skin that may show changes in skin temperature (warmth or coolness), tissue consistency (firm or beefy feel), and/or sensation (pain, itching) compared with an adjacent or opposite area on the body? A) Stage I B) Stage II C) Stage III D) Stage IV

A) Stage I

The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.) A. "Can you easily change your position?" B. "Do you have sensitivity to heat or cold?" C. "How often do you need to use the toilet?" D. "Is movement painful?" E. "What medications do you take?" F. "Have you ever fallen?"

A. "Can you easily change your position?" B. "Do you have sensitivity to heat or cold?" C. "How often do you need to use the toilet?" D. "Is movement painful?" Changing positions is important for decreasing the pressure associated with long periods of time in the same position. If the patient is able to feel heat or cold and is mobile, he can protect himself by withdrawing from the source. Knowing toileting habits and any potential for incontinence is important because urine and feces in contact with the skin for long periods can increase skin breakdown. Knowing whether the patient has problems with mobility such as pain will alert the nurse to any potential for decreased movement and increased risk for skin breakdown. Medications and falling are safety risk questions.

The nurse is caring for a patient with a healing stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse? A. Complete the head-to-toe assessment, and include current treatment, vital signs, and laboratory results B. Notify the charge nurse about the change in status and the potential for infection C. Notify the physician by utilizing Situation, Background, Assessment, and Recommendation (SBAR) D. Notify the wound care nurse about the change in status and the potential for infection

A. Complete the head-to-toe assessment, and include current treatment, vital signs, and laboratory results The patient is showing signs and symptoms associated with infection in the wound. It is serious and needs treatment but is not a life-threatening emergency, where care is needed immediately or the patient will suffer long-term consequences. The nurse should complete the assessment; gather all data such as current treatment modalities, medications, vital signs including temperature, and laboratory results such as the most recent complete blood count or white cell count. The nurse can then notify the physician and receive treatment orders for the patient. It is important to notify the charge nurse and consult the wound nurse on the patient's status and on any new orders.

The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial interventions should the nurse select to decrease this risk? A. Gentle cleaners and thorough drying of the skin B. Absorbent pads and garments C. Positioning with use of pillows D. Therapeutic beds and mattresses

A. Gentle cleaners and thorough drying of the skin Assessment and skin hygiene are two initial defenses for preventing skin breakdown. Avoid soaps and hot water when cleansing the skin. Use gentle cleansers with nonionic surfactants. After bathing, make sure to dry the skin completely, and apply moisturizer to keep the epidermis well lubricated. Absorbent pads and garments are controversial and should be considered only when other alternatives have been exhausted. Positioning the patient reduces pressure and shearing force to the skin and is part of the plan of care but is not one of the initial components. Depending on the needs of the patient, a specialty bed may be needed, but again, this does not provide the initial defense for skin breakdown.

The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers. The nurse has become competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage: A. I B. II C. III D. IV

A. I Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14 days do not require a dressing. This allows visual inspection and monitoring. A transparent dressing could be used to protect the patient from shear but cannot be used in the presence of excessive moisture. A composite film, hydrocolloid, or hydrogel can be utilized on a clean stage II. A hydrocolloid, hydrogel covered with foam, calcium alginate, gauze, and growth factors can be utilized with a clean stage III. Hydrogel, calcium alginate, gauze, and growth factors can be utilized with a clean stage IV. An unstageable wound cover with eschar should utilize a dressing of adherent film or gauze with an ordered solution of enzymes. In rare cases when eschar is dry and intact, no dressing is used, but this is an unstaged ulcer.

The nurse has collected the following assessment data: right heel with reddened area that does not blanch. What nursing diagnosis would the nurse assign? A. Ineffective tissue perfusion B. Risk for infection C. Imbalanced nutrition: less than body requirements D. Acute pain

A. Ineffective tissue perfusion The area on the heel has experienced a decreased supply of blood and oxygen (tissue perfusion), which has resulted in tissue damage. The most appropriate nursing diagnosis with this information is Ineffective tissue perfusion. Risk for infection, Acute pain, and Imbalanced nutrition may be part of this patient's nursing diagnosis, but the data provided do not support this nursing diagnosis.

A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, the next best step is to: A. Inspect the wound for bleeding B. Inspect the wound for foreign bodies C. Determine the size of the wound D. Determine the need for a tetanus antitoxin injection

A. Inspect the wound for bleeding After determining that a patient's condition is stable, inspect the wound for bleeding. An abrasion will have limited bleeding, a laceration can bleed more profusely, and a puncture wound bleeds in relation to the size and depth of the wound. Address any bleeding issues. Inspect the wound for foreign bodies; traumatic wounds are dirty and may need to be addressed. Determine the size of the wound. A large open wound may expose bone or tissue and be protected, or the wound may need suturing. When the wound is caused by a dirty penetrating object, determine the need for a tetanus vaccination.

The nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder. The nurse's responsibilities and activities before applying the bandage and binder include which of the following? (Select all that apply.) A. Inspecting the skin for abrasions and edema B. Covering exposed wounds C. Assessing condition of current dressings D. Assessing the skin at underlying areas for circulatory impairment E. Marking the sites of all abrasions F. Cleansing the area with hydrogen peroxide

A. Inspecting the skin for abrasions and edema B. Covering exposed wounds C. Assessing condition of current dressings D. Assessing the skin at underlying areas for circulatory impairment Before applying a bandage or a binder, the nurse has several responsibilities. The nurse would need to inspect the skin for abrasions, edema, and discoloration or exposed wound edges. The nurse also is responsible for covering exposed wounds or open abrasions with a sterile dressing and assessing the condition of underlying dressings and changing if soiled, as well as assessing the skin of underlying areas that will be distal to the bandage. This checks for signs of circulatory impairment, so that a comparison can be made after bandages are applied. Marking the sites of all abrasions is not necessary. Although it is important for the skin to be clean, and even though it may need to be cleaned with a non-cytotoxic cleanser, cleansing with hydrogen peroxide can interfere with wound healing.

The nurse is caring for a patient with wound healing by tertiary intention. Which factors does the nurse recognize as influencing wound healing? (Select all that apply.) A. Nutrition B. Evisceration C. Tissue perfusion D. Infection E. Hemorrhage F. Age

A. Nutrition C. Tissue perfusion D. Infection F. Age Normal wound healing requires proper nutrition. Oxygen and the ability to provide adequate amounts of oxygenated blood are critical for wound healing. Wound infection prolongs the inflammatory phase, delays collagen synthesis, prevents epithelialization, and decreases the production of pro-inflammatory cytokines, which leads to additional tissue destruction. As patients age, all aspects of wound healing are delayed. Hemorrhage and evisceration are complications of wound healing.

The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. The nurse is able to identify that the major element involved in the development of a decubitus ulcer is: A. Pressure B. Resistance C. Stress D. Weight

A. Pressure Pressure is the main element that causes pressure ulcers. Three pressure-related factors contribute to pressure ulcer development: pressure intensity, pressure duration, and tissue tolerance. When the intensity of the pressure exerted on the capillary exceeds 12 to 32 mm Hg, this occludes the vessel, causing ischemic injury to the tissues it normally feeds. High pressure over a short time and low pressure over a long time cause skin breakdown. Resistance (the ability to remain unaltered by the damaging effect of something), stress (worry or anxiety), and weight (individuals of all sizes, shapes, and ages acquire skin breakdown) are not major causes of pressure ulcers.

The nurse is completing an assessment of the skin's integrity, which includes: A. Pressure points B. All pulses C. Breath sounds D. Bowel sounds

A. Pressure points The nurse continually assesses the skin for signs of ulcer development. Assessment of tissue pressure damage includes visual and tactile inspection of the skin. Observe pressure points such as bony prominences and areas next to treatments such as a bi-nasal cannula and the nares. Assessment of pulses, breath sounds, and bowel sounds is part of a head-to-toe assessment and could influence the function of the body and ultimately skin integrity; however, this assessment is not a specific part of a skin assessment.

The nurse is caring for a patient with a stage II pressure ulcer and as the coordinator of care understands the need for a multidisciplinary approach. The nurse evaluates the need for several consults. Which of the following should always be included in the consults? (Select all that apply.) A. Registered dietitian B. Enterostomal and wound care nurse C. Physical therapist D. Case management personnel E. Chaplain F. Pharmacist

A. Registered dietitian B. Enterostomal and wound care nurse C. Physical therapist D. Case management personnel A registered dietitian is useful in working with the nurse to determine a meal plan that will support wound healing. An enterostomal or wound care nurse specializes in caring for the needs of the patient with wounds. Physical therapy is concerned about the mobility of the patient and can assist an immobile patient to progress toward mobility and decrease the risk for pressure ulcers. Pressure ulcers take a long time to heal and usually require continued therapy in the home. Case management personnel are useful in obtaining care for the patient outside the home. If the patient has a spiritual need, the chaplain can assist. If the patient has a need associated with medications, the pharmacist can assist. However, chaplains and pharmacists usually are not part of the wound care multidisciplinary team, unless a special need arises.

A patient has developed a decubitus ulcer. What laboratory data would be important to gather? A. Serum albumin B. Creatine kinase C. Vitamin E D. Potassium

A. Serum albumin Normal wound healing requires proper nutrition. Serum proteins are biochemical indicators of malnutrition, and serum albumin is probably the most frequently measured of these parameters. The best measurement of nutritional status is prealbumin because it reflects not only what the patient has ingested, but also what the body has absorbed, digested, and metabolized. Measurement of creatine kinase helps in the diagnosis of myocardial infarcts and has no known role in wound healing. Potassium is a major electrolyte that helps to regulate metabolic activities, cardiac muscle contraction, skeletal and smooth muscle contraction, and transmission and conduction of nerve impulses. Vitamin E is a fat-soluble vitamin that prevents the oxidation of unsaturated fatty acids. It is believed to reduce the risk of coronary artery disease and cancer. Vitamin E has no known role in wound healing.

Placement of a binder around a surgical client with a new abdominal wound is indicated for: A) Collection of wound drainage B) Reduction of abdominal swelling C) Reduction of stress on the abdominal incision D) Stimulation of peristalsis (return of bowel function) from direct pressure

C) Reduction of stress on the abdominal incision

Several instruments are available for assessing clients who are at high risk for developing a pressure ulcer. The Braden Scale is the most commonly used. What risk factors are assessed using the Braden Scale? A) Infection, hemorrhage, dehiscence, evisceration, and fistulas B) Physical condition, mental condition, activity, mobility, and incontinence C) Sensory perception, moisture, activity, mobility, nutrition, friction, and shear D) Nutrition, tissue perfusion, infection, age, shear force and friction, and moisture

C) Sensory perception, moisture, activity, mobility, nutrition, friction, and shear

The nurse is caring for a patient with potential skin breakdown. Which components would the nurse include in the skin assessment? (Select all that apply.) A. Mobility B. Hyperemia C. Induration D. Blanching E. Temperature of skin F. Nutritional status

B. Hyperemia C. Induration D. Blanching E. Temperature of skin Assessment of the skin includes both visual and tactile inspection. Assess for hyperemia and abnormal reactive hyperemia (when the skin turns red after an obstruction of blood flow returns and vasodilatation causes the tissue to turn red). Assess for indurated (hardened) areas on the skin and palpate reddened areas for blanching. Changes in temperature can indicate changes in blood flow to that area of the skin. Mobility and nutritional status are certainly part of the overall assessment for pressure ulcer risk but are not part of the actual skin assessment.

The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer would be staged as stage: A. I B. II C. III D. IV

B. II This would be a stage II pressure ulcer because it presents as partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin with nonblanchable redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be visible, but bone, tendon, and muscles are not exposed. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle.

The nurse is caring for a patient who has a stage IV pressure ulcer awaiting plastic surgery consultation. Which of the following specialty beds would be most appropriate? A. Standard mattress B. Non-powered redistribution air mattress C. Low-air-loss therapy unit D. Lateral rotation

B. Non-powered redistribution air mattress A low-air-loss therapy unit is utilized for stage IV pressure ulcers and when prevention or treatment of skin breakdown is needed. If the patient has a stage III or stage IV ulcer or a postoperative myocutaneous flap, the low-air-loss therapy unit would be an appropriate selection. A static air mattress or nonpowered redistribution is utilized for the patient at high risk for skin breakdown. A standard mattress is utilized for an individual who does not have actual or potential altered or impair skin integrity. Lateral rotation is used for treatment and prevention of pulmonary complications associated with mobility.

The nurse is caring for a medical-surgical patient. To decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility, which intervention is most important for the nurse to complete? A. Encourage the patient to sit up in the chair B. Provide analgesic medication as ordered C. Explain the risks of immobility to the patient D. Turn the patient every 3 hours while in bed

B. Provide analgesic medication as ordered Maintaining adequate pain control and patient comfort increases the patient's willingness and ability to increase mobility, which in turn reduces pressure ulcer risks. It is good to encourage a patient to move about but even better if the patient actually sits up in the chair. Explaining the risk of immobility is important for the patient because it may impact the patient's willingness but not his or her ability. Turning the patient is important for decreasing pressure ulcers but needs to be done every 2 hours, and again does not influence the patient's ability to increase mobility.

The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which of these actions should the nurse take first? A. Don sterile gloves B. Provide analgesic medications as ordered C. Avoid accidentally removing the drain D. Gather supplies

B. Provide analgesic medications as ordered Because removal of dressings is painful, if often helps to give an analgesic at least 30 minutes before exposing a wound and changing the dressing. The next sequence of events includes gathering supplies for the dressing change, donning gloves, and avoiding the accidental removal of the drain during the procedure.

The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. The nurse consults a: A. Respiratory therapist B. Registered dietitian C. Chaplain D. Case manager

B. Registered dietitian Assessment and a plan for the patient to optimize the diet are essential. Adequate calories, protein, vitamins, and minerals promote wound healing. The nurse is the coordinator of care, and collaborating with the dietitian would result in planning the best meals for the patient. The respiratory therapist can be consulted when a patient has issues with the respiratory system. Case management can be consulted when the patient has a discharge need. A chaplain can be consulted when the patient has a spiritual need.

Which nursing observation would indicate that the patient was at risk for pressure ulcer formation? A. The patient ate two thirds of breakfast B. The patient has fecal incontinence C. The patient has a raised red rash on the right shin D. The patient's capillary refill is less than 2 seconds

B. The patient has fecal incontinence The presence and duration of moisture on the skin increase the risk of ulcer formation by making it susceptible to injury. Moisture can originate from wound drainage, excessive perspiration, and fecal or urinary incontinence. Bacteria and enzymes in the stool can enhance the opportunity for skin breakdown because the skin is moistened and softened, causing maceration. Eating a balanced diet is important for nutrition, but eating just two thirds of the meal does not indicate that the individual is at risk. A raised red rash on the leg again is a concern and can affect the integrity of the skin, but it is located on the shin, which is not a high-risk area for skin breakdown. Pressure can influence capillary refill, leading to skin breakdown, but this capillary response is within normal limits.

The nurse observes all wounds closely. At what time is the risk of hemorrhage the greatest for surgical wounds? A) Between 48 and 60 hours after surgery B) Between 60 and 72 hours after surgery C) During the first 24 to 48 hours after surgery D) 7 days after surgery, when the client is more active

C) During the first 24 to 48 hours after surgery

Which of the following interventions is most appropriate in managing fecal and urinary incontinence in a client? A) Keeping the buttocks exposed to air at all times B) Applying a large absorbent diaper that is changed when completely saturated C) Using an incontinence cleanser, followed by application of a moisture barrier ointment D) Cleansing frequently, applying an ointment, and covering the areas with a thick absorbent towel

C) Using an incontinence cleanser, followed by application of a moisture barrier ointment

The nurse is completing an assessment on an individual who has a stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. The nurse determines that the patient is experiencing issues with self-concept when the patient states which of the following? A. "I think I will be ready to go home early next week." B. "I am so weak and tired, I want to feel better." C. "I am ready for my bath and linen change as soon as possible." D. "I am hoping there will be something good for dinner tonight."

C. "I am ready for my bath and linen change as soon as possible." The patient's psychological response to any wound is part of the nurse's assessment. Body image changes can influence self-concept. Factors that affect the patient's perception of the wound include the presence of scars, drains, odor from drainage, and temporary or permanent prosthetic devices. The wound is odorous, and a drain is in place. The patient who is asking for a bath and change in linens gives you a clue that he or she may be concerned about the smell in the room. The patient stating that he or she wants to feel better, talking about going home, and caring about what is for dinner could be interpreted as positive statements that indicate progress along the health journey.

The nurse is completing a skin risk assessment utilizing the Braden scale. The patient has some sensory impairment and skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. What would be the patient's Braden scale total score? A. 15 B. 17 C. 20 D. 23

C. 20 With use of the Braden scale, the patient receives 3 for slight sensory impairment, 4 for skin being rarely moist, 3 for walks occasionally, 3 for slightly limited mobility, 4 for intake of meals, and 4 for no problem with friction and shear. The total score is 20.

The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. The nurse recognizes that the next step in caring for this patient includes: A. Monitoring of the wound B. Irrigation of the wound C. Debridement of the wound D. Management of drainage

C. Debridement of the wound Debridement is the removal of nonviable necrotic tissue. Removal of necrotic tissue is necessary to rid the ulcer of a source of infection, to enable visualization of the wound bed, and to provide a clean base for healing. A wound will not move through the phases of healing if the wound is infected. Irrigating the wound with non-cytotoxic cleaners will not damage or kill fibroblasts and healing tissue and will help to keep the wound clean once debrided. When treating a pressure ulcer, it is important to monitor and reassess the wound at least every 8 hours. Management of drainage will help keep the wound clean.

The nurse is caring for a patient with a stage III pressure ulcer. The nurse has assigned a nursing diagnosis of Risk for infection. Which intervention would be most important for this patient? A. Teach the family how to manage the odor associated with the wound B. Discuss with the family how to prepare for care of the patient in the home C. Encourage thorough hand washing of all individuals caring for the patient D. Encourage increased quantities of carbohydrates and fats

C. Encourage thorough hand washing of all individuals caring for the patient The number one way to decrease the risk of infection by breaking the chain of infection is to wash hands. Encouraging fluid and food intake helps with overall wellness and wound healing, especially protein, but an increase in carbohydrates and fats does not relate to the risk of infection. If the patient will be discharged before the wound is healed, the family will certainly need education on how to care for the patient. Teaching the family how to manage the odor associated with a wound is certainly important, but these interventions do not directly relate to the risk of infection and breaking the chain of the infectious process.

The nurse is caring for a patient with a stage IV pressure ulcer. The nurse assigns which of the following nursing diagnoses? A. Readiness for enhanced nutrition B. Impaired physical mobility C. Impaired skin integrity D. Chronic pain

C. Impaired skin integrity After the assessment is completed and the information that the patient has a stage IV pressure ulcer is gathered, a diagnosis of Impaired skin integrity is selected. Readiness for enhanced nutrition would be selected for an individual with an adequate diet that could be improved. Impaired physical mobility and Chronic pain, as well as the nutrition nursing diagnosis, could well be the nursing diagnoses selected for this patient, but current data in the question strongly support Impaired skin integrity.

The nurse is caring for a patient with a healing stage III pressure ulcer. The wound is clean and granulating. Which of the following orders would the nurse question? A. Use a low-air-loss therapy unit B. Consult a dietitian C. Irrigate with hydrogen peroxide D. Utilize hydrogel dressing

C. Irrigate with hydrogen peroxide Clean pressure ulcers with non-cytotoxic cleansers such as normal saline, which will not kill fibroblasts and healing tissue. Cytotoxic cleansers such as Dakin's solution, acetic acid, povidone-iodine, and hydrogen peroxide can hinder the healing process and should not be utilized on clean granulating wounds. Consulting a dietitian for the nutritional needs of the patient, utilizing a low-air-loss therapy unit to decrease pressure, and applying hydrogel dressings to provide a moist environment for healing are all orders that would be appropriate.

The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair? A. At least 3 hours B. Not longer than 30 minutes C. Less than 2 hours D. As long as the patient remains comfortable

C. Less than 2 hours When patients are able to sit up in a chair, make sure to limit the amount of time to 2 hours or less. The chair sitting time should be individualized. In the sitting position, pressure on the ischial tuberosities is greater than in a supine position. Utilize foam, gel, or an air cushion to distribute weight. Longer than 2 hours can increase the chance of ischemia.

The nurse is collaborating with the dietitian about a patient with a stage III pressure ulcer. After the collaboration, the nurse orders a meal plan that includes increased: A. Fat B. Carbohydrates C. Protein D. Vitamin E

C. Protein Protein needs are especially increased in supporting the activity of wound healing. The physiological processes of wound healing depend on the availability of protein, vitamins (especially A and C), and the trace minerals of zinc and copper. A balanced diet of fat and carbohydrates, along with protein, vitamins, and minerals, is needed in any diet. Wound healing does not require increased amounts of fats or carbohydrates. Vitamin E has no known role in wound healing.

Which of the following would be the most important piece of assessment data to gather with regard to wound healing? A. Muscular strength assessment B. Sleep assessment C. Pulse oximetry assessment D. Sensation assessment

C. Pulse oximetry assessment Oxygen fuels the cellular functions essential to the healing process; the ability to perfuse tissues with adequate amounts of oxygenated blood is critical in wound healing. Blood flow through the pulmonary capillaries provides red blood cells for oxygen attachment. Oxygen diffuses from the alveoli into the pulmonary blood; most of the oxygen attaches to hemoglobin molecules within the red blood cells. Red blood cells carry oxygenated hemoglobin molecules through the left side of the heart and out to the peripheral capillaries, where the oxygen detaches, depending on the needs of the tissues. Pulse oximetry measures the oxygen saturation of blood. Assessment of muscular strength and sensation, although useful for fitness and mobility testing, does not provide any data with regard to wound healing. Sleep, although important for rest and for integration of learning and restoration of cognitive function, does not provide any data with regard to wound healing.

The nurse is caring for a patient with a stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. The nurse is completing the plan of care and is writing goals for the patient. What is the best goal for this patient? A. The patient's family will demonstrate specific care of the wound site B. The patient will state what to look for with regard to an infection C. The patient will remain free of an increase in temperature and of odorous or purulent drainage from the wound D. The patient's family members will wash their hands when visiting the patient

C. The patient will remain free of an increase in temperature and of odorous or purulent drainage from the wound Because the patient has an open wound and the skin is no longer intact to protect the tissue, the patient is at increased risk for infection. The nurse will be assessing the patient for signs and symptoms of infection, including an increase in temperature, an increase in white count, and odorous and purulent drainage from the wound. The patient is unconscious and is unable to communicate the signs and symptoms of infection; also, this is an intervention, not a goal for this diagnosis. It is important for the patient's family to be able to demonstrate how to care for the wound and wash their hands, but these statements are interventions, not goals or outcomes for this nursing diagnosis.

The nurse is caring for a postpartum patient. The patient has an episiotomy after experiencing birth. The physician has ordered heat to treat this condition, and the nurse is providing this treatment. This patient is at risk for: A. Infection B. Impaired skin integrity C. Trauma D. Imbalanced nutrition

C. Trauma Heat causes vasodilatation and is used to improve blood flow to an injured body part. The application of heat incorrectly when the treatment is too hot, or is applied too long or to the wrong place, can result in a burn for the patient and risk for additional trauma. The skin already has impaired integrity owing to the surgical procedure, and because of this has been at risk for infection since the surgical procedure was performed. This patient is of childbearing age and has had a child. Additional needs for nutrition are present during pregnancy and breastfeeding, but this is an established nursing diagnosis. Data are insufficient to support the nursing diagnosis of Imbalanced nutrition.

The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. What is the best method for repositioning the patient? A. Obtain assistance and use the drawsheet to place the patient into the new position B. Place the patient in a 30-degree supine position C. Utilize a transfer sliding board and assistance to slide the patient into the new position D. Elevate the head of the bed 45 degrees

C. Utilize a transfer sliding board and assistance to slide the patient into the new position When repositioning the patient, obtain assistance and utilize a transfer sliding board under the patient's body to prevent dragging the patient on bed sheets and placing the patient at high risk for shearing and friction injuries. The patient should be placed in a 30-degree lateral position, not supine position. The head of the bed should be elevated less than 30 degrees to prevent pressure ulcer development from shearing forces.

A 40-year-old client is a new paraplegic. The client is about to be discharged from the rehabilitation center. Prevention of pressure ulcers has been an important part of the client's education. In providing this education, the nurse should have included which of the following guidelines? A) The client should sit in chair for no longer than 3 hours. B) The client should use a donut-shaped chair cushion. C) The client should use a rigid cushion for full support. D) The client should shift the weight in a chair every 15 minutes.

D) The client should shift the weight in a chair every 15 minutes.

Which of the following is the best description of a hydrocolloid dressing? A) A dressing containing a seaweed derivative that is highly absorptive B) Premoistened gauze placed over a granulating wound C) A dressing containing a débriding enzyme that is used to remove necrotic tissue D) A dressing that forms a gel which interacts with the wound surface

D) A dressing that forms a gel which interacts with the wound surface

When repositioning an immobile client, the nurse notices redness over a bony prominence. When the area is assessed, the red spot blanches with fingertip touch, indicating: A) A local skin infection requiring antibiotics B) A stage III pressure ulcer needing the appropriate dressing C) Sensitive skin that calls for the use of special bed linen D) Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured area

D) Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured area

The nurse places an aquathermia pad on a client with a muscle sprain. The nurse informs the client that the pad should be removed in 30 minutes. Why will the nurse return in 30 minutes to remove the pad? A) A local response occurs. B) A systemic response occurs. C) Reflex vasodilation occurs. D) Reflex vasoconstriction occurs.

D) Reflex vasoconstriction occurs.

During the skin assessment of an older adult client who had a stroke, the nurse noted a reddened area over the coccyx. The next actions of the nurse for this client should include: A) Massaging the reddened area and repositioning the client B) Placing the client in Fowler's position and returning in 2 hours C) Inserting a urinary catheter to prevent accumulation of moisture from urinary incontinence D) Repositioning the client off the coccygeal area and reassessing the area in 1 hour

D) Repositioning the client off the coccygeal area and reassessing the area in 1 hour

The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which of the following would be used first to assist in staging an ulcer on this patient? A. Cotton-tipped applicator B. Disposable measuring tape C. Sterile gloves D. Halogen light

D. Halogen light When assessing a patient with darkly pigmented skin, proper lighting is essential to accurately complete the first step in assessment—inspection—and the whole assessment process. Natural light or a halogen light is recommended. Fluorescent light sources can produce blue tones on darkly pigmented skin and can interfere with an accurate assessment. Other items that could possibly be used during the assessment include gloves for infection control, a disposable measuring device to measure the size of the wound, and a cotton-tipped applicator to measure the depth of the wound, but these items not the first item used.

The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse recalls that this type of wound heals by: A. Tertiary intention B. Secondary intention C. Partial-thickness repair D. Primary intention

D. Primary intention A clean surgical incision is an example of a wound with little loss of tissue that heals with primary intention. The skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed until the risk of infection is resolved. A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater.

Which nursing observation would indicate that a wound healed by secondary intention? A. Minimal scar tissue B. Minimal loss of tissue function C. Permanent dark redness at site D. Scarring can be severe

D. Scarring can be severe A wound healing by secondary intention takes longer than one healing by primary intention. The wound is left open until it becomes filled with scar tissue. If the scarring is severe, permanent loss of function often occurs. Wounds that heal by primary intention heal quickly with minimal scarring. Scar tissue contains few pigmented cells and has a lighter color than normal skin.

The nurse is caring for a patient who has experienced a total hysterectomy. Which nursing observation would indicate that the patient was experiencing a complication of wound healing? A. The incision site has started to itch B. The incision site is approximated C. The patient has pain at the incision site D. The incision has a mass, bluish in color

D. The incision has a mass, bluish in color A hematoma is a localized collection of blood underneath the tissues. It appears as swelling, change in color, sensation, or warmth or a mass that often takes on a bluish discoloration. A hematoma near a major artery or vein is dangerous because it can put pressure on the vein or artery and obstruct blood flow. Itching of an incision site can be associated with clipping of hair, dressings, or possibly the healing process. Incisions should be approximated with edges together. After surgery, when nerves in the skin and tissues have been traumatized by the surgical procedure, it is expected that the patient would experience pain.

patients who are confused or disoriented or who have alterations in level of consciousness are unable to protect themselves

alterations in level of consciousness

use synthetic dressings over a wound to allow the eschar to be self-digested by the action of enzymes that are present in wound fluids

autolytic debridement

Later that day the client becomes confused and pulls off her surgical dressing. The nurse enters the room and finds the clients wound separated with viscera protruding. which of the following nursing interventions are appropriate? a.) repack the wound b.) call for help c.) assist the client to a chair d.) cover the wound with a sterile dressing moistened with 0.9% sodium chloride e.) stay with the client

b.) call for help d.) cover the wound with a sterile dressing moistened with 0.9% sodium chloride e.) stay with the client

An adolescent client who has diabetes mellitus is 2 days postoperative following an appendectomy. The client is tolerating a regular diet well. He has ambulated successfully around the unit with assistance and requests pain medication every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to 10 after medication is given. His incision is approximated and free of redness with scant serous drainage noted on the dressing. which of the following risk factors for poor wound healing does this client have? a.) extremes in age b.) impaired circulation c.) impaired/ suppressed immune system d.) malnutrition e.) poor wound care such as breaches in aseptic technique

b.) impaired circulation c.) impaired/ suppressed immune system

An older adult woman is 6 days postoperative following surgery for a bowel obstruction. During the last 24 h, she has reported nausea, and she vomited small amounts of clear liquid three times in the last 8 hr. Her vital signs are stable. Currently her incision is well approximated and free of redness, tenderness, or swelling. Which of the following findings would indicate development of a wound infection? a.) decreased pulse rate b.) increased pain c.) decreased WBC count d.) Increased Thirst

b.) increased pain

what surface support could you give to avoid pressure ulcers

decrease the amount of pressure exerted over bony prominences

with total separation of a wound _____ or _______ of visceral organs through a opening occurs. (requires surgical repair)

evisceration or protrusion

clots form a ____ _____ that later provides a framework for cellular repair

fibrin matrix

main activities during the proliferative phase include

filling of the wound with granulation tissue, contraction of the wound, and resurfacing of the wound by epithelialization

nursing interventions for reducing and treating pressure ulcers need to be evaluated to determine whether the patient

has met the identified outcomes or goals

a localized collection of blood underneath the tissues

hematoma

in the inflammatory stage, damaged tissue and mast cell secrete ____, resulting in _______ of surrounding capillaries and exudation of serum and white blood cells into damaged tissues

histamine, vasodilation

abnormal reactive hyperemia are early signs are indicators of

impaired skin integrity (but damage to the underlying tissue is sometimes more progressive)

what is a benefit of predictive measures when dealing with a pressure ulcer

improved early detection by nurses of patients at greatest risk for ulcer developed

Clarification of pressure ulcer Stage 1

intact skin with nonblanchable redness

if drainage is present in a wound what would you want to note about it

is it oborous and purulent and causes yellow, green, or brown color

surface support includs

mattresses, integrated bed systems, mattress replacement, and an overlay or set cushion

Education: a _______ environment supports the movement of epithelial cells and facilitates wound closure

moist

care of patients with a pressure ulcer or wound requires a

multidisciplinary team approach

increases the patients willingness and ability to increase mobility, which is turn reduces pressure ulcer risk

pain control and patient comfort

for surgical wounds that heal by ________ __________, it is common to remove dressings as soon as the drainage stops

primary intention

the surgical incision heals by

primary intention

_________ or _________ the final stage of healing, sometimes takes place for longer than a year, depending on the depth and extent of the wound

remodeling, maturation

a wound involving loss of tissue such as a burn, pressure ulcer, or severe laceration heals by

secondary intention

occurs when the wound heals with scar tissue

secondary intention

when dressing a wound that is healing by __________ __________, the dressing material becomes a means for providing moisture to the wound or assisting in debridement

secondary intention

which takes longer to heal: primary or secondary intention

secondary intention

is the force exerted parallel to skin, resulting from both gravity pushing down on the body and resistance (friction) between the patient and a surface

shear

Patients with dehiscence commonly states that they felt

something pop

what to look for when assessing a wound

source, how serious, external or internal, vital signs (heart rate faster, BP lower), distinction or swelling, discoloration, distention of the affected area, change in the amount or type of drainage

is the removal of devitalized tissue by using a scalpel, scissors, or other sharp instruments

surgical debridement

_____ enables you to use palpation to acquire further data about indurations and damage to the skin and underlying tissues

tactile assessment

what does color tell us about drainage in a wound infection

the causative organism