Chapter 29: Skin Integrity and Wound Care

Which intervention should be initiated by the nurse caring for a patient with urinary or fecal incontinence? a. Using a heat lamp to dry the skin b. Changing the adult brief every 8 hours c. Cleansing frequently with hot water and a strong soap d. Using an incontinence cleanser and a moisture barrier ointment

Answer: d Skin care for the incontinent patient should include cleansing as needed using a mild, pH-neutral soap and warm (not hot) water, to prevent the stripping of oils from the skin and reduction in the skin's normally acidic pH. Application of a moisture barrier ointment protects the skin from the moisture and irritation that can result from urinary or fecal incontinence. An adult brief should be changed with every incontinence episode. A heat lamp could further damage delicate skin.

Which technique is used to collect an aerobic culture specimen from a wound? a. Collect the specimen immediately after removing the old dressing. b. Apply sterile gloves, then open the culture tube. c. Always be sure to culture any necrotic tissue. d. Irrigate the wound before collecting the culture material.

Answer: d The wound should be irrigated with normal saline before the culture is taken so the dressing is removed, then the wound is irrigated. Sterile gloves are not necessary because the hands will grasp the outside of the culture tube, which is not sterile, so clean gloves can be worn. The culture specimen is taken in draining tissue, not necrotic tissue, so that the swab is covered in exudate.

Which features are characteristic of a closed drainage system such as a Jackson-Pratt (JP) drain? (Select all that apply.) a. Works by gravity b. Provides for early discharge c. Usually is inserted in surgery d. Reduces the amount of antibiotics required e. Allows for accurate measurement of wound drainage f. Allows bacteria to migrate up the drain from the surrounding dressing

Answers: c, e JP drains usually are inserted at surgery. Unlike an open drainage device such as the Penrose drain, a JP drain does not allow drainage to soak into the surrounding dressing and allows for an accurate measurement of the drainage. JP drains work by suction, not gravity. Discharge and antibiotic use are not dependent on the type of drain. Bacteria migration from the dressing will not occur because a JP drain is a closed system.

What is the most appropriate dressing for a pressure ulcer that is draining a large amount of exudate, extends through the fascia and into the deeper tissues including muscles and bone, and has granulation tissue in the wound bed? a. Alginate dressing b. Damp to dry dressing c. Hydrocolloidal dressing d. Gauze dressing reinforced with ABD pads

ANS: A Alginate dressings absorb a large amount of drainage. A damp to dry dressing debrides and could harm healthy granulation tissues. Hydrocolloidal dressings could be used in this type of wound if the exudate was a small to moderate amount. A gauze dressing may dry out and cause damage when removed.

What does a Braden Score of 14 indicate to the nurse? a. High risk for the development of pressure ulcers b. Low risk for the development of pressure ulcers c. The need for a special mattress d. The presence of a pressure ulcer

ANS: A The lower the score the higher the risk of pressure ulcer formation. While research continues as to where the cut off for risk should be, it is generally accepted that a Braden of 16-18 indicates an increased risk for pressure ulcer development. The Braden score does not indicate which interventions, such as a special mattress, to use. It does not indicate whether an ulcer already exists.

In planning care on the hospital unit, the nurse prioritizes care for assigned patients with regard to skin integrity. Which patient would be the nurse's highest priority for skin issues? a. A 50-year-old female with diabetes who has an ulcer on her foot b. An 80-year-old man with incontinence due to clostridium difficile c. A 22-year-old cocaine addict with a compound fracture of the tibia d. A 75-year-old female with CHF and a history of breast cancer

ANS: A While all of the patients have potential for skin integrity issues, the diabetic who also has an ulcer on her foot is at greatest risk for complications from impaired skin integrity. Any patient who is incontinent should receive diligent nursing care with each incontinence episode. A cocaine addict may have problems that will impair healing, which the nurse can manage with nutritional counseling and substance abuse counseling. The CHF patient has no known skin issues.

Which can be delegated to the unlicensed personnel on the nursing unit? (Select all that apply.) a. Morning care including a bath, linen change, and application of a barrier ointment b. Dressing changes with application of an enzymatic ointment c. Turning and positioning a patient during dressing changes d. Assessment of the skin and wounds e. Obtaining a wound culture f. Removal of a simple drain

ANS: A, C Hygiene and applying a barrier ointment and turning and position are the only choices that fall within the scope of practice of an unlicensed member of the health care team. Enzymatic ointment is a medication and cannot be delegated. Assessment is a nursing activity that cannot be delegated. Obtaining a wound culture is not a task that can be delegated to UAP. Removal of a drain is done by a specially trained nurse or the surgeon.

Which is the most appropriate treatment choice for a wound with a shallow pink wound bed and minimal drainage? a. Use of an enzymatic debriding agent b. A moisture retentive dressing such as a hydrocolloid c. Gauze moistened with 0.9% normal saline d. An aginate covered with a foam dressing

ANS: B A pink moist wound bed would indicate the presence of granulation tissue. A moist wound environment is essential for the development of epithelial tissue and so a moisture retentive dressing is appropriate. Gauze is more labor intensive and does not provide the moisture retentive environment needed for wound healing. Debridement would harm healthy granulation tissue. Alginate is too absorbent for a minimally draining wound.

What does wound irrigation require? a. A bulb syringe and 0.9% normal saline b. Personal protective equipment including goggles c. Use of an antiseptic solution such as Betadine d. Twice daily dressing changes

ANS: B Splashing can occur during irrigation and therefore there is a need for PPE, including goggles. A bulb syringe does not provide sufficient psi to adequately irrigate a wound, and antiseptic solutions are toxic to cells and should be avoided. Dressings are changed when soiled or according to PCP order.

The nurse is planning care for patients on the hospital unit. For which patient will it be most appropriate to use cold therapy? a. For any patient who requests a cold compress b. For a male patient with a stage I pressure ulcer c. For a female patient with a sprained ankle with edema d. For stimulating vasodilatation and improved blood flow in an immobile patient

ANS: C Cold therapy causes vasoconstriction and decreases edema and pain. Like heat therapy, the application of cold therapy requires a doctor's order that includes the area to be treated, the length of time to be treated, and what device should be used. Vasoconstriction would be detrimental for the patient with a pressure ulcer since blood flow is decreased.

Which is correct concerning the use of pain medication in the care of a patient with a chronic wound such as a pressure ulcer? a. It is rarely needed as chronic wounds are not as painful as acute wounds due to nerve damage. b. It should not be used in the elderly as they are at risk for constipation, a side effect of many pain medications. c. It should only be considered if the pain score is greater than "5" on a regular basis during dressing changes. d. It should be incorporated into the overall treatment plan based on the patient's reported pain level and assessment of the patient.

ANS: D All wounds are potentially painful and all patients should have pain treated appropriately. Untreated pain has both a physiological and psychological impact on the individual experiencing pain. There are many treatment options including systemic and topical agents as well as complementary and alternative methods.

Which is the most important strategy in the prevention of wound infections? a. The use of sterile dressings at all times b. A high protein diet with vitamin C supplements c. The use of antibiotics in all patients with wounds d. Careful and consistent hand hygiene

ANS: D Many wounds do not require a sterile dressing or antibiotics. While nutrition is very important in wound healing, hand hygiene remains the most important method to prevent wound infections.

A patient who is on bed rest has a stage I pressure ulcer on the sacrum and is recovering from a pelvic injury sustained in a motor vehicle accident. What is the priority nursing diagnosis for this patient? a. Ineffective coping related to pelvic injury b. Risk for Infection related to open wound site c. Risk for impaired tissue integrity and pain related to motor vehicle accident d. Impaired skin Integrity related to pressure, secondary to immobility

ANS: D The patient has impaired skin integrity, which would be the priority. There is no information indicating that the patient is not coping or that there is an open wound. Nursing diagnoses are stated with one diagnosis in each statement.

Based on knowledge of areas at greatest risk for development of a pressure ulcer in the bedridden patient, the nurse identifies which position to minimize this risk? a. 30-degree side-lying b. Sitting with the head of the bed elevated 75 degrees c. 90-degree side-lying d. Lying supine with the bed flat at all times

Answer: a Although pressure ulcers can result in any anatomic area, the sacrum is at highest risk in the bedridden client owing to forces of pressure, friction, and shear. Turning the patient from side to side, while making sure the horizontal plane of the body is at a 30-degree angle to the bed, will keep the patient off the sacrum and also off the greater trochanter, which is another risk area. The head of the bed should not be raised more than 30 degrees if the patient is supine, because greater angles increase the risk of friction and shear on the sacrum. Sacral ulcers also may develop if the patient is supine and is not moved at all.

Which statement best describes the healing process for a surgical wound that has been closed with the use of sutures? a. The edges of the wound are approximated. b. New tissue fills the sides and base of the wound. c. The proliferate phase is longer with surgical wounds. d. Debridement aids in the surgical healing process.

Answer: a Approximated wounds have the edges brought together. Surgical incisions closed with sutures are approximated. Tissue filling in the sides and base of the wound would be an example of secondary intention. The proliferate phase is shorter in surgical wounds. Debridement would damage a surgical wound, causing delayed healing.

On initial assessment of a patient, the nurse notices an area of redness over the right trochanter that, when pressed lightly, does not blanch. What does this assessment finding indicate to the nurse? a. The presence of an infection in the area b. The presence of a stage I pressure ulcer c. An allergic reaction to the sheets d. The need to apply a cold compress to reduce inflammation

Answer: b Nonblanchable erythema over an area of pressure defines a stage I pressure ulcer. An infection is likely to occur in an open sore and would be associated with signs of redness, warmth, and green or yellow exudate. An allergic reaction would manifest as a rash or itchy area. Cold compresses would cause vasoconstriction and further damage because the blood flow has already been restricted.

Four days after abdominal surgery, the patient is getting out of bed and feels something "pop" in his abdominal wound. An increase in amount of drainage from the wound is seen, and further examination shows that the sutured incision is now partially open, with tissue protruding from the wound. What is the nurse's next action? a. Apply Steri-Strips to close the wound edges. b. Cover the wound with saline-moistened gauze, and notify the physician. c. Assure the patient that this is common, and document the findings. d. Apply a binder to pull the wound edges together and provide support to the edges.

Answer: b This is likely to be an evisceration of the surgical wound and, as such, may require surgical intervention. The normal saline keeps the wound and tissue moist until they can be evaluated by the physician. Steri-Strips can be used to reinforce a closed wound when sutures or staples are removed but are not used to try to close a wound that has opened and has tissue protruding through. False reassurance should not be given. A binder is used to support a closed incision and should not be applied to a wound with tissue protruding.

A patient has a stage III pressure ulcer on the coccyx. Which food will be most beneficial in improving the healing process? a. Food high in vitamin D b. Whole-grain carbohydrates c. High-calorie, high-protein drink d. Food high in fat and water content

Answer: c A stage III pressure ulcer takes months to heal, and nutrition is an important aspect of care. Important nutritional components related to healing are calories, protein, vitamins A and C, and minerals zinc and copper. Therefore, the supplements high in calories and protein would be most beneficial.

Which patient is at highest risk for impaired wound healing? a. A 22-year-old with a pelvic fracture incurred in a motor vehicle accident b. A 49-year-old with a history of smoking two packs a day who just had abdominal surgery c. A 72-year-old with diabetes and cardiovascular disease who had surgical repair of a broken hip d. A 90-year-old with no chronic health conditions with a small blistered burn on the hand

Answer: c Although all of these patients have risk factors for impaired healing, the 72-year-old patient has the most risk factors: increased age, comorbid conditions of diabetes and cardiovascular disease, and an injury that often affects the ability to move independently. The 22-year-old accident victim does not have any risk factors other than the pelvic fracture. The 49-year-old surgical patient who smokes is at risk for delayed healing due to vasoconstriction but would not have as great a risk as the 72-year-old. The burn with a blister is not a deep injury, and the patient has no risk factors other than age.

A patient who has suffered a stroke is unable to maintain his position while seated in a chair without sliding down. His physician has ordered him to be up in a chair for part of the day. What does the nurse recognize as the patient's greatest risk factor for development of pressure ulcers? a. Moisture from incontinence b. Nutritional deficiencies c. Pressure and shear d. Aging

Answer: c Sitting in a chair increases pressure on the seating surface and the inability to maintain position, resulting in sliding down adding the destructive element of shear. Nutritional deficits, moisture, and skin changes with age can be contributing factors for pressure ulcer development but do not relate to being up in the chair.