ch 32 skin integrity and wound care

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

hydrocolloid Hydrocolloids are occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment, provide minimal to moderate absorption of drainage, maintain a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing. Hydrogels maintain a moist wound environment and are best for partial or full-thickness wounds. Alginates absorb exudate and maintain a moist wound environment. They are best for wounds with heavy exudate. Transparent films allow exchange of oxygen between wound and environment. They are best for small partial-thickness wounds with minimal drainage.

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?

Dehiscence of the wound Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that "something has suddenly given way." If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician.

The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room?

transparent

A nurse has applied a bandage to a client's arm from just above the wrist to just below the elbow. What finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply.

Fingers with quick capillary refill Warm hand No finger numbness or tingling

The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity?

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

The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate?

"Dehiscence is when a wound has partial or total separation of the wound layers."

When assessing the right heel of a client who is confined to bed, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse?

Off-load pressure from the heel.

A nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client?

Subcutaneous tissue

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?

The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

The nurse is performing pressure injury assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure injury?

a critical care client

Which client(s) is considered at risk for skin alterations? Select all that apply.

an adolescent with multiple body piercings a client receiving radiation therapy a client with diabetes

The nurse has delegated applying an elastic bandage with clips to the right knee of a 12-year-old client to the unlicensed assistive personnel (UAP). Which action will the nurse determine the UAP needs additional training?

applies wrap from proximal to distal direction

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury?

preventing the client from sliding in bed

The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include?

"It provides a way to remove drainage and blood from the surgical wound."

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."

A pediatric nurse is familiar with specific characteristics of skin across the life span. Which statement accurately describes skin characteristics?

An infant's skin and mucous membranes are easily injured and at risk for infection.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

Assess the client's wound and vital signs.

Which action should the nurse perform when applying negative pressure wound therapy?

Cut foam to the shape of the wound and place it in the wound.

When applying an external heating pad, which prescription from the health care provider would the nurse question?

Leave heating pad on for 45 minutes

A nurse caring for a client who has a surgical wound after a caesarean birth notes dehiscence of the wound, what is the main priority of nursing care?

Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide?

The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment.

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces?

a client sitting in a chair who slides down

A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for:

dehiscence. Manifestations of infection include redness, warmth, swelling, and fever. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents.

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?

desiccation

The nurse is caring for a client who had abdominal surgery 12 hours ago and notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse?

document the findings

The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action?

elevating and supporting the stump

An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as:

milia: sebaceous retention cysts seen as white, opalescent spots around the chin and nose.

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage? A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a pale pink drainage on the dressing. Which drainage type should the nurse document?

serosanguineous This describes serosanguineous wound drainage. Drainage that is pale yellow, watery, and like the fluid from a blister is called serous. Drainage that is bloody is called sanguineous. Drainage that contains white cells and microorganisms is called purulent.

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury?

use pillows to maintain a side-lying position as needed

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question?

"Do you experience incontinence?"

The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surgical wound during a dressing change. What instructions should the RN provide the LPN regarding this action?

"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator."

An obese client on the unit has demonstrated difficulty healing a large pressure injury. The nurse correctly recognizes that this is most likely because of which factor?

Adipose tissue is poorly vascularized.

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture?

Keep the swab and the inside of the culture tube sterile prior to collecting the culture.

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 client's risk for the development of a pressure injury is most likely due to which lab result?

albumin 2.5 mg/dL An albumin level of less than 3.2 mg/dL indicates that the client is nutritionally at risk for the development of a pressure injury. A hemoglobin A1C level greater than 8% puts the client at risk for the development of pressure injuries due to a prolonged high glucose level. Glucose levels greater than 120 mg/dL are a risk factor for the development of pressure injuries.

A client's hand was severely wounded upon coming in contact with a running lawn mower blade. The nurse notes that large amounts of flesh are missing and the bones of two fingers are visible. How will the nurse document this assessment finding?

avulsion An avulsion involves the stripping away of large areas of tissue, leaving cartilage and bone exposed. Therefore the nurse will document this assessment finding as an avulsion. A puncture is an opening of the skin caused by a narrow, sharp, pointed object. A laceration is the separation of skin and tissue with torn, irregular edges. A contusion is an injury to soft tissue. Therefore the nurse would not document the finding as a puncture, laceration, or contusion.

A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing?

confusion

A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider as an indication of infection?

foul-smelling drainage that is grayish in color

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

stage IV Stage I pressure injuries are characterized by intact but reddened skin that is unblanchable. stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage. Stage IV pressure injuries are characterized as exposing muscle and bone and may have slough and a foul odor.

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate?

"Your wound will heal slowly as granulation tissue forms and fills the wound."

The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips?

Apply a skin protectant to the skin around the incision.

A client comes to the emergency department reporting a painful left ankle, headache, and dizziness, after falling off a skateboard and sliding on the sidewalk. For what type of injuries would the nurse be alert? Select all that apply.

Broken left ankle, bruising, soft tissue damage, concussion, and abrasions

The nurse is caring for a client who has a stage IV pressure injury. Based on the nurse's understanding of wound healing, arrange the following four phases of wound healing in the correct order.

Hemostasis Inflammatory Proliferation Maturation

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action?

Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures.

A nurse is caring for a client with quadriplegia. Which intervention by the nurse will prevent a heel or ankle pressure injury for the client?

Placing the client in a side-lying position with a pillow between the mattress and the lower leg, and a pillow between the lower legs

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?

Rotate the swab several times over the wound surface to obtain an adequate specimen.

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury?

Stage II

A nurse is removing the staples from a client's surgical incision, as ordered. After removing the first few staples, the nurse notes that the edges of the wound pull apart as each staple is removed. What is the nurse's best action?

Stop removing staples and inform the surgeon

The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately?

a sterile, flexible applicator moistened with saline

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?

a surgical incision with sutured approximated edges

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use?

figure-of-eight turn

When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding?

incision

The nurse is caring for a bedridden client who is at risk for the development of pressure injuries. In which position can the nurse place the client to relieve pressure on the trochanter area?

oblique The oblique position, an alternative to the side-lying position, results in significantly less pressure on the trochanter area.

A nurse is teaching a nursing student about surgical drains and their purposes. The nursing student understands that the purpose for a T-tube drain is:

to provide drainage for bile.

The nurse and client are looking at a client's heel pressure injury. The client asks, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response?

"Necrotic tissue is devitalized tissue that must be removed to promote healing."

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include?

"Very little scar tissue will form."

A nurse is removing a client's surgical sutures. Place the following steps in the correct order. Use all options.

Clean the incision using the wound cleanser and gauze. Using the forceps, grasp the knot of the first suture and gently lift the knot up off the skin. Using the scissors, cut one side of the suture below the knot, close to the skin. Grasp the knot with the forceps and pull the cut suture through the skin. Remove every other suture to be sure the wound edges are healed. Apply adhesive closure strips.

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

Clean the wound from the top to the bottom and from the center to outside.

The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care?

The nurse works outward from the wound in lines parallel to it.

An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site?

a transparent film Transparent film dressings are semipermeable, waterproof, and adhesive, allowing visualization of the access site to aid assessment and protecting the site from microorganisms. Gauze dressings--precut, with an adherent coating, premedicated with antibiotics--do not allow the nurse to visualize the site without partially or completely removing the dressing.