CH 32: Skin Integrity and Wound Care

How does nutrition affect the likelihood that a patient will develop a pressure injury?

Poorly nourished cells are easily damaged (e.g. vitamin C deficiency causes capillaries to become fragile, and poor circulation to the area results when they break)

The nurse notes swelling and pain occurring from an incision. These symptoms are most likely caused by an accumulation of -----.

Exudate

Precut halfway to fit around drains or tubes

Sof-Wick

Placed over the smaller gauze to absorb drainage and protect the wound from contamination or injury

ABDs, Surgipads

What are six major functions of the skin?

1) Protect the body; immunologic function 2) Regulate body temperature 3) Sense stimuli from the environment and transmit these sensations 4) Absorption and elimination 5) Help maintain water and electrolyte balance 6) Produce and absorb vitamin D

Goals for patients who are at risk for impaired skin integrity.

1) The patient will participate in the prescribed treatment regimen to promote wound healing 2) The patient will remain free of infection at the site of the pressure injury 3) The patient will demonstrate self-care measures necessary to prevent the development of a pressure injury

Strips of cloth, gauze, or elasticized material used to wrap a body part

Bandages

Phases of Wound Healing: Maturation

Begins about 3 weeks after injury, possibly continuing for months or years if wound is large. Collagen is remodeled, new collagen is deposited, and avascular collagen tissue becomes a flat, thin white line.

Phases of Wound Healing: Proliferative

Begins about day 2 or 3 up to 2 to 3 weeks. New tissue is built to fill the wound space (action of fibroblasts). Capillaries grow across the wound, fibroblasts from fibrin that stretches through the clot, a thin layer of epithelial cells forms across the wound, and blood flow is reinstitute. Granulation tissue forms the foundation for scar tissue

They may be made of cloth (flannel or muslin) or an elasticized material that fastens together with velcro

Binders

Wraps designed for a specific body part

Binders

Wounds that are covered with thick eschar, which is usually black but brown, gray, or tan

Black wounds

B = black = debride

Black wounds are covered with thick eschar, which is usually black but may also be brown, gray, or tan. The eschar must be derided before the wound can heal by using sharp, mechanical chemical, or autolytic debridement

How does immobility affect the likelihood that a patient will develop a pressure injury?

Causes prolonged pressure on body areas

The nurse anchors a bandage by wrapping it around the patient's body part with complete overlapping of the previous bandage turn. This procedure is the ----- method of bandage wrapping.

Circular turn

How does external pressure contribute to pressure injury development?

Compress blood vessels and causes friction

Natural act of healing of dermal and epidermal tissue in which a protective membrane from over a wound

Epithelial

Necrotic tissue

Eschar

The protrusion of viscera through the incisional area

Evisceration

The partial or total disruption of wound layers

Dehiscence

How does hydration affect the likelihood that a patient will develop a pressure injury?

Dehydration can interfere with circulation and subsequent cell nourishment.

Composed of fluid and cells that escape from the blood vessels and are deposited in or on tissue surfaces.

Exudate

The nurse is measuring the depth of a patient's wound and discovers an abnormal passage from an internal organ to the skin. This wound condition is known as a ------.

Fistula

Commonly used to cover wounds; they come in various sizes and are commercially packaged as single units or in packs

Gauze dressings

New tissue found in a wound that is highly vascular, bleeds easily, and is formed in the proliferative phase is known as ------ tissue.

Granulation

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

Granulation tissue

Phases of Wound Healing: Hemostasis

Hemostasis occurs immediately after the initial injury. Involved blood vessels constrict and blood clotting begins through platelet activation and clustering. After only a brief period of constriction, these same blood vessels dilate and capillary permeability increases, allowing plasma and blood components leak out into the area that is injured, forming a liquid called exudate.

The nurse is changing the dressing on a patient's incision. This type of wound is commonly known as an -----.

Intentional Wound

A patient's wound is in the inflammatory cellular phase, meaning that ------ or ------- cells arrive first to ingest bacteria and cellular debris.

Leukocytes, macrophages

How does moisture on the skin affect the likelihood that a patient will develop a pressure injury?

Moisture associated with urinary incontinence increases the risk for skin damage more than chemical irritation from the ammonia in the urine

How does age affect the likelihood that a patient will develop a pressure injury?

Older people are good candidates for pressure injuries because their skin is susceptible to injury

Wound drainage that is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria

Purulent wound drainage

Wounds in the proliferative stage of healing that are the color of granulation tissue

Red wounds

R = red = protect

Red wounds are in the proliferative stage of healing and are the color of normal granulation. They need protection by gentle cleansing, using moist dressings, applying a transparent or hydrocolloid dressing, and changing the dressing only when necessary

Wound drainage that consists of large numbers of red blood cells and looks like blood

Sanguineous wound drainage

Avascular collagen tissue that does not sweat, grow hair, or tan in sunlight

Scar

Wound drainage that is composed of the clear, serous portion of the blood and drainage from serous membranes

Serous wound drainage

When cleaning a wound, the nurse might choose sterile 9% ----- as the cleansing solution.

Sodium chloride solution

A special gauze that covers the incision line and allows drainage to pass through and be absorbed by the center absorbent layer

Telfa

Used to prevent outer dressings from adhering to the wound and causing further injury when removed

Telfa

Phases of Wound Healing: Inflammatory Phase

The inflammation phase follows hemostasis and lasts about 2 to 3 days. White blood cells, predominantly leukocytes and macrophages, move to the wound. About 24 hours after the injury, macrophages enter the wound area and remain for an extended period. Macrophages are essential to the healing process. they do not ingest debris, but also release growth factors that are necessary for the growth of epithelial cells and new blood vessels. These growth factors also attract fibroblasts that help to fill in the wound, which is necessary for the next stage of healing. Acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury.

How does mental status affect the likelihood that a patient will develop a pressure injury?

The more alert the patient is, the more likely it is that he or she will relieve pressure periodically and mange adequate skin hygiene

The type of dressing often used over intravenous sites, subclavian catheter insertion sites, and noninflected healing wounds

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

c. Wounds cause emotional as well as physical stress.

Wounds that are characterized by oozing from the tissue covering the wound, often accompanied by purulent drainage.

Yellow wounds

Y = yellow = cleanse

Yellow wounds are characterized by oozing from the tissue covering the wound, often accompanied by purulent drainage. They need to be cleansed using irrigation; wet-moist dressings; using non-adherent, hydrogel, or other absorptive dressings; and topical antimicrobial medication

A disruption in the normal integrity of the skin

Wound

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

May occur from a slipped suture a dislodged clot from stress at the suture line infection or the erosion of a blood vessel by a foreign body (such as a drain)

hemorrhage

A nurse assessing a patient's wound documents a localized area of tissue necrosis. This type of wound is known as -----.

pressure injury

How does friction and shearing force contribute to pressure injury development?

tear and injure blood vessels

Applied directly over a small wound or tube, these dressings are occlusive, decreasing the possibility of contamination while allowing visualization of the wound

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