Chapter 31: Skin Integrity & Wound Care

The nurse and client are looking at a client's heel pressure injury. The client states, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response? "This is normal tissue." "That is called slough, and it will usually fall off." "You are seeing undermining, a type of tissue erosion." "Necrotic tissue is devitalized tissue that must be removed to promote healing."

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

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 a sinus tract for drainage. to provide drainage for bile. to decrease dead space by decreasing drainage. to divert drainage to the peritoneal cavity.

A T-tube is used to drain bile, such as after a cholecystectomy. A Penrose drain provides a sinus tract for drainage. Hemovac and Jackson-Pratt drains both decrease dead space by decreasing drainage. A ventriculoperitoneal shunt diverts drainage to the peritoneal cavity.

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? Exert equal, but not excessive, tension with each turn of the bandage. Wrap distally to proximally. Elevate and support the stump. Keep bandage free from gaps between each turn.

Elevate and support the stump.

What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing? transparent films hydrocolloid dressings hydrogels alginates

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.

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

IV Stage IV pressure injuries are characterized as exposing muscle and bone, and may have slough and a foul odor. 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.

The nurse prepares to irrigate a wound and apply antiseptic. The nurse will follow which guideline for performing this procedure? If the wound is closed, clean technique may be used instead of sterile technique. Sterile water is often the solution of choice when irrigating wounds. When the solution from the wound turns light pink, the irrigation should be stopped. If bleeding that was not previously there is noted, the nurse should continue irrigation and then notify the health care provider

If the wound is closed, clean technique may be used instead of sterile technique.

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? Cleanse the wound after obtaining the wound culture. Stroke the culture swab on surrounding skin first. Utilize the culture swab to obtain cultures from multiple sites. Keep the swab and the inside of the culture tube sterile.

Keep the swab and the inside of the culture tube sterile.

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage types should the nurse document? Serous Sanguineous Serosanguineous Purulent

Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink in color. Serous drainage is a clear drainage consisting of the serous portion of the blood. Sanguineous drainage consists of red blood cells and looks like blood. Purulent drainage has various colors such as green or yellow; this drainage indicates infection.

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

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

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? The nurse uses wet-to-dry dressings continuously. The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown. The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. The nurse packs the wound cavity tightly with dressing material.

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

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. True False

True

A nurse is caring for a client who has a pressure injury on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-black (RYB) Wound Classification System, which classification should the nurse document? Red classification Yellow classification Black classification Unstageable

black red = dressing changes yellow=cleansing of the wound related to the drainage or slough in the wound. Unstageable is not a classification in the RYB Wound Classification System

A postoperative client describes the following during a transfer, "I feel like something just popped." The nurse immediately assesses for: infection. herniation. dehiscence. evisceration.

dehiscence Dehiscence is a total or partial disruption in wound edges.

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 Maceration Necrosis Evisceration

desiccation Desiccation is localized wound dehydration. Maceration is localized wound overhydration or excessive moisture. Necrosis is death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area.

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use? circular turn spiral-reverse turn spica turn figure-of-eight turn

figure-of-eight turn (for joints)

A client fell from a truck and required abdominal surgery to repair lacerations of the abdomen and bowel. The client now has constant drainage from a wound that will not heal on the surface of the abdomen. What does the nurse identify has occurred with the client's wound? There is an infection present. The client has wound dehiscence. There is evidence of evisceration. The client has fistula formation.

the client has fistula formation A fistula is an abnormal tubelike passageway that forms from one organ to outside the body. There is no information that would lead to a suspicion that the wound is infected. Wound dehiscence would be indicated by separation of the wound and evisceration would be evidenced by protrusion of abdominal contents through the wound.

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? Contact the surgeon for debridement. Using sterile technique, debride the wound. Off-load pressure from the heel. Place a TED hose on the client's leg.

Off-load pressure from the heel.

A client's risk for the development of a pressure injury is most likely due to which lab result? albumin 2.5 mg/dL glucose 110 mg/dL hemoglobin A1C 7% sodium 135 mEq/L

An albumin level of less than 3.2 mg/dL indicates the client is nutritionally at risk for the development of a pressure injury. Hemoglobin A1C levels greater than 8% place the client at risk for the development of pressure injuries due to prolonged high glucose levels. Glucose levels greater than 120 mg/dL are a risk factor for the development of pressure injuries. Sodium of 135 mEq/L is normal and would not place the client at risk for the development of a pressure injuries.

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes a Penrose drain intact. Which statement is true about Penrose drains? A Penrose drain promotes drainage passively into a dressing. A Penrose drain is a closed drainage system that is connected to an electronic suction device. A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. A Penrose drain has a round collection chamber with a spring that is kept under negative pressure.

A Penrose drain promotes drainage passively into a dressing. A Penrose drain is an open drainage system that promotes drainage of fluid passively into a dressing. Additional drains include the Jackson-Pratt drain that has a small bulblike collection chamber that is kept under negative pressure. A Hemovac is a round collection chamber with a spring inside that also must be kept under negative pressure.

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? avulsion abrasion incision laceration

An incision.. of skin and tissue with smooth, even edges. Therefore, the nurse documents the finding as an incision. An avulsion has stripped away of large areas of skin and underlying tissues. An abrasion involves stripped surface layers of skin. A laceration involves separation of skin and tissue with torn, irregular edges. Therefore, the nurse does not document the finding as an avulsion, abrasion, or laceration.

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? An infant's skin and mucous membranes are easily injured and at risk for infection. In children younger than 2 years, the skin is thicker and stronger than in adults. A child's skin becomes less resistant to injury and infection as the child grows. An individual's skin changes little over the life span.

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

A client recovering from abdominal surgery sneezes, and then screams, "My insides are hanging out!" What is the initial nursing intervention? Contact the surgeon. Apply sterile dressings with normal saline over the protruding organs and tissue. Assess for impaired blood flow to the area of evisceration. Monitor for pallor and mottle appearance of the wound.

Apply sterile dressings with normal saline over the protruding organs and tissue.

A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion? Tearing of the skin and tissue with some type of instrument; tissue not aligned Cutting with a sharp instrument with wound edges in close approximation with correct alignment Tearing of a structure from its normal position Puncture of the skin

Tearing of a structure from its normal position An avulsion involves tearing of a structure from its normal position on the body. Tearing of the skin and tissue with some type of instrument with the tissue not aligned is a laceration. Cutting with a sharp instrument with wound edges in close approximation and correct alignment is an incision. A puncture of the skin is simply a puncture.