Chapter 35: Skin Integrity & Wound Healing

VENOUS STASIS ULCERS

A venous stasis ulcer is an open lesion of the skin and subcutaneous tissue of the lower leg, usually above the inside ankle and below the knee, and not necessarily over a bony prominence. Venous stasis or insufficiency results when: -Valves in the veins are permanently damaged from a deep vein thrombosis (blood clot), previous trauma (e.g., broken leg or sprained ankle), pregnancy, or obesity. -Poor calf muscle function (e.g., in patients with impaired mobility) causes blood to pool in the lower legs, increasing pressure in the veins and leading to edema as fluid is forced out into the tissues of the lower leg. Any injury, such as a scratch or blister, can lead to a venous ulcer. The increased pressure in the tissues, swelling, and drainage keep the sore from healing. A venous stasis ulcer is superficial and appears "beefy" red and granular (although it is not healing). Wound edges are usually flat and irregular without undermining. The skin of the lower leg will have varicosities, edema, dermatitis, and scarring from past ulcers.

What Are the Main Points in This Chapter?

-The layers of the skin are the epidermis (outermost), the dermis, and the subcutaneous layer (innermost). -The major functions of the skin are protection of the internal organs, unique identification of an individual, thermoregulation, metabolism of nutrients and metabolic waste products, and sensation. -Age, mobility, nutrition, hydration, moisture underlying conditions, medications, contamination or infection, diminished sensation, cognitive impairment, hygiene, and lifestyle are factors that influence the ability to maintain intact skin and heal wounds. -If there are no breaks in the skin a wound is described as closed. A wound is considered open if there is a break in the skin or mucous membranes. -Acute wounds may be intentional (e.g., surgical incisions) or unintentional (e.g., from trauma) and are expected to be of short duration. -Wounds that exceed the anticipated length of recovery are classified as chronic wounds. Chronic wounds include pressure, arterial, venous, and diabetic ulcers. A chronic wound may linger for months or years. -Clean wounds are uninfected wounds with minimal inflammation. Clean-contaminated wounds are surgical incisions that enter the gastrointestinal, respiratory, or genitourinary tracts. Contaminated wounds include open, traumatic wounds or surgical incisions in which a major break in asepsis occurred. Infected wounds are wounds with evidence of infection, such as presence of microorganisms. -A wound that involves minimal or no tissue loss and has wound edges that are approximated are said to heal by primary intention. -A wound that involves extensive tissue loss and has margins that cannot be approximated, or is infected, heals by secondary intention. -Tertiary intention healing, or delayed primary closure, occurs when two surfaces of granulation tissue are brought together. Initially the wound is allowed to heal by secondary intention. -Healing occurs in three stages. The inflammatory phase lasts from 1 to 5 days and consists of two major processes: hemostasis and inflammation. The proliferative phase occurs from days 5 to 21. It is characterized by cell development aimed at filling the wound defect and resurfacing the skin. The maturation phase begins in the second or third week and continues until the wound is completely healed. -Wound closure methods include adhesive strips (Steri-Strips), absorbent sutures, surgical staples, and surgical glue. -Drainage is the flow of fluids from a wound or cavity. It is often referred to as exudate (fluid that oozes as a result of inflammation). -Complications of wound healing include hemorrhage, infection, dehiscence, evisceration, and fistula formation. -Pressure ulcers are caused by unrelieved pressure over time that compromises blood flow to tissue, resulting in ischemia in the underlying tissue. -A stage I pressure ulcer is an area of persistent redness and does not blanch. -Stage II pressure ulcers involve partial-thickness skin loss of the epidermis, dermis, or both. -A stage III pressure ulcer is characterized by full-thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to, but not through, the underlying fascia. The ulcer appears as a deep crater. -Stage IV pressure ulcers involve full-thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or support structures. Undermining and sinus tracts (blind tracts underneath the epidermis) are common. -Extrinsic factors leading to pressure ulcers are those that alter the skin and tissue integrity and blood supply (e.g., aging, low blood pressure, neurological injury, poor nutrition, edema, and fever). -Extrinsic factors include friction and shearing, and exposure to moisture and pressure. -Not all lower extremity ulcers are related to pressure. Some are caused by poor perfusion, such as venous stasis ulcers, diabetic foot ulcers, and arterial ulcers. -An eschar is a black leathery covering of necrotic tissue. An ulcer covered by an eschar cannot be classified because it is impossible to determine the depth. -The Braden, Norton, and PUSH scales evaluate risk for problems with skin integrity. -When assessing a wound, note the following: the type of wound, the color of the wound and surrounding skin, the condition of the wound bed, drainage and odor, and the level of pain associated with the wound or wound care. -Preventing pressure ulcers focuses on skin care, nutrition, turning and positioning, using therapeutic mattresses and cushions, and patient/family teaching. -Five types of debridement are used sharp, mechanical, enzymatic, autolytic, and biotherapy (maggot debridement). -Wound care therapies to promote healing might include negative pressure wound therapy (NPWT), electrical stimulation, tissue growth factors, ultrasound, bioengineered skin substitutes, and surgical options. -Primary dressings are ones that are placed in the wound bed and touch the wound. A secondary dressing covers or holds a primary dressing in place. Many dressings can act as both. -Types of wound dressings are absorption, alginate, antimicrobial, collagen, gauze, FOAM dressings, hydrocolloid, hydrogel, skin sealants, and moisture barriers. -Ideal wound irrigation pressures range from 4 pounds per square inch (psi) to 15 psi. Current recommendations are to use a 35-mL syringe attached to a 19-gauge angiocatheter. This will deliver the solution at approximately 8 psi. -Heat application promotes vasodilatation, increases tissue metabolism, increases capillary permeability, reduces blood viscosity, and reduces muscle tension. -The application of cold causes vasoconstriction, local anesthesia, reduced cell metabolism, increased blood viscosity, and decreased muscle tension.

DIABETIC FOOT ULCERS

Diabetic foot ulcers, often painless, occur mainly on the plantar surface of the foot, at the ball of the foot over the metatarsal heads, or on the top or bottom of the toes. The wounds are usually deep with even margins. The wound bed may be necrotic or tunneled. The wound and/or the surrounding skin may be calloused and macerated (depending on amount of drainage). Because people with diabetes lose protective sensation, those with neuropathy often walk on blisters or sores, continuously damaging tissues. Narrowing of the arteries (stenosis) caused by diabetes decreases blood flow to the foot, delaying healing or allowing for further progression of an ulcer. Diabetic foot ulcers are common and are responsible for 125,000 lower leg amputations a year. Within 5 years, these clients either will lose their other leg or will die.

ARTERIAL ULCERS

An arterial ulcer results from a non-pressure-related blockage of arterial blood flow to an area that causes tissue necrosis (e.g., from a clot or narrowing of the arterioles). Arterial ulcers usually occur over the lower part of the leg, ankle, or bony areas of the foot (e.g., top of the foot or toe, outside edge of the foot) or shin, where arterial flow is the least. The wound bed is frequently dry and pale with little drainage. The affected foot will have all the signs of peripheral arterial disease: diminished pulses, cool to the touch, blanching on elevation, minimal hair on the foot or toes, and toenail thickening. These wounds are very painful, which may be relieved when the leg is dependent. Clients with moderate to severe peripheral arterial disease, inflammatory, or autoimmune diseases (e.g., sickle cell anemia, vasculitis) are at high risk for ulcers.

Explain the difference between an acute and a chronic wound.

Answer: -Acute and chronic wounds have different durations and causes. Acute wounds are expected to be of short duration. Acute wounds may be intentional (surgical incisions) or unintentional (trauma). -Wounds are classified as chronic when they exceed the anticipated length of recovery. Chronic wounds include pressure, arterial, venous, and diabetic ulcers. These wounds are frequently colonized with bacteria, and healing is very slow because of the underlying disease process. A chronic wound may linger for months or years.

Three days after a patient had abdominal surgery, the nurse notes a 4-cm periwound erythema and swelling at the distal end of the incision. The area is tender and warm to the touch. Staples are intact along the incision, and there is no obvious drainage. Heart rate is 96 beats/min and oral temperature 100.8°F (38.2°C). The nurse would suspect that the patient has what kind of complication? 1) Infection at the incision site 2) Dehiscence of the wound 3) Hematoma under the skin 4) Formation of granulation tissue

Answer: 1) Infection at the incision site Rationale: Infection is a complication of wound healing that causes warmth, pain, inflammation of the affected area, and changes in vital signs (i.e., elevated pulse and temperature). Dehiscence is the rupture of a suture line, whereas evisceration is the protrusion of internal organs through the rupture. A hematoma is a collection of blood that forms under the skin. It is usually tender or painful to the touch, and usually swollen. Granulation tissue is new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process. It is beefy red in appearance but would not be warm or tender to the touch.

When performing an assessment for a patient with a 2-week-old wound, the nurse notes the formation of granulation tissue in the wound bed and recognizes the wound is most likely in which phase of wound healing? 1) Proliferative 2) Maturation 3) Aggregation 4) Inflammatory

Answer: 1) Proliferative phase Rationale: The proliferative phase occurs from days 5 to 21. It is characterized by cell development aimed at filling the wound defect and resurfacing the skin. Granulation tissue forms during this stage, as fibroblasts migrate to the wound to form collagen, and new blood and lymph vessels sprout from the existing capillaries at the edge of the wound.

An older adult has a 3 cm × 2 cm eschar on the right heel. The initial treatment choice for this wound is to: 1) elevate the right heel off the surface of the bed. 2) request a surgical consult for debridement of the area. 3) apply a hydrocolloid to promote autolytic debridement of the wound. 4) request an order for an enzymatic debridement medication.

Answer: 1) elevate the right heel off the surface of the bed. Rationale: A black wound (eschar) requires debridement of the necrotic tissue except at the heel. The Agency for Healthcare Research and Research (AHRQ) does not recommend debridement of this site. Therefore, your best treatment choice would be elevation of the heel off of the bed. A heel suspension device might be used to relieve pressure to the affected area.

To obtain the most accurate culture information of a chronic wound, the nurse would recommend: 1) tissue biopsy. 2) swab culture. 3) sterile culture. 4) needle aspiration culture.

Answer: 1) tissue biopsy. Rationale: A tissue biopsy, in which a piece of tissue is removed from the wound bed and analyzed, provides the most definitive information about infection status of a chronic wound. Chronic wounds are frequently colonized with bacteria; therefore, surface culture (swab) would not be accurate.

Match the following terms and descriptions: Terms 1. Montgomery straps 2. Jackson-Pratt 3. Maceration 4. Autolysis 5. Fistula Descriptions A. Abnormal passage between two body cavities B. Tie tapes used for dressings that require frequent changing C. Type of surgical drain D. Softening of the skin E. Occurs under a transparent, nonocclusive dressing

Answer: 1, B 2, C 3, D 4, E 5, A

The patient with a new colostomy refuses to participate in the care of her colostomy or meet with a support member from the ostomy society. She will not look at the site and describes the colostomy as disgusting. Based on these data, the priority nursing diagnosis is: 1) Anxiety related to colostomy. 2) Disturbed Body Image related to colostomy. 3) Disturbed Body Image related to incontinence of stool. 4) Impaired Skin Integrity related to fecal drainage.

Answer: 2) Disturbed Body Image related to colostomy. Rationale: The patient is having difficulty adjusting to her colostomy. The colostomy is covered by a collection device, so there is no incontinence. There is no evidence of either anxiety or actual skin impairment.

The nurse applying a bioocclusive, transparent dressing on the abdomen of an elderly frail women is concerned about damaging her fragile skin when removing the dressing at a later time. What action should the nurse take to safegaurd the skin? 1) Gently cleanse the skin with soap and water first. 2) Use a skin sealant before applying the dressing. 3) Remove hair from the site using scissors or clippers. 4) Change the dressing frequently to avoid excessive adhesion.

Answer: 2) Use a skin sealant before applying the dressing. Rationale: The junction between the epidermis and dermis on the older adult is not as strong as it is in a younger person. Skin sealant preparations may be used under adhesives to reduce the pressure or tension needed to break those bonds and cause skin damage. Soap has a drying effect on skin and should not be used, particularly on fragile, dry skin of an elderly person. Typically, an elderly woman's abdomen would not have enough hair to warrant trimming. Removing the dressing can be traumatic, especially with the thin, fragile skin of a frail, older adult.

The nurse is assessing an ischial pressure ulcer on a client. She observes that the pressure ulcer is 3 cm × 2 cm × 1 cm and involves only subcutaneous tissue. The nurse also notes an area extending 3 cm from 12 o'clock to 3 o'clock under the wound edges. The nurse would document this as: 1) stage IV pressure ulcer with undermining of 3 cm from 12:00 to 3:00. 2) stage III pressure ulcer with undermining of 3 cm from 12:00 to 3:00. 3) stage IV pressure ulcer with sinus tract from 12:00 to 3:00. 4) tage III pressure ulcer with sinus tract from 12:00 to 3:00.

Answer: 2) stage III pressure ulcer with undermining of 3 cm from 12:00 to 3:00. Rationale: A stage III pressure ulcer is characterized by full-thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to, but not through, the underlying fascia. Undermining is deeper-level damage of adjacent tissue. Sinus tracts are narrow, blind tracts underneath the epidermis.

The most appropriate nursing diagnosis for a patient with a draining wound would be: 1) Risk for Infection related to dehiscence of wound. 2) Body Image Disturbance related to nonhealing surgical wound. 3) Risk for Impaired Skin Integrity related to wound drainage. 4) Pain related to surgical incision.

Answer: 3) Risk for Impaired Skin Integrity related to wound drainage. Rationale: The drainage from a wound places the patient at an increased risk for skin breakdown because of the dampness and presence of enzymes in the drainage. The risk of infection is present, but the data provided do not indicate this is a problem. There are no data indicating the patient is having a problem with body image or that he is in pain.

A postsurgical patient who is morbidly obese informs the nurse that as she was coughing, she felt a "pop" at her abdominal incision site. Upon inspection, the nurse notes the sutures to the incision are intact; however, there is an increase in the amount of serosanguineous drainage. The nurse would suspect wound: 1) Evisceration 2) Fistula 3) Hemorrhage 4) Dehiscence

Answer: 4) Dehiscence Rationale: Wound dehiscence is a rupture of one or more layers of a wound and usually occurs in the inflammatory phase before large amounts of collagen have been deposited in the wound to strengthen it. Dehiscence is usually associated with abdominal wounds, and patients often report feeling a pop or tear, especially with sudden straining from coughing, vomiting, or changing positions in bed. Usually, there is an immediate increase in serosanguineous drainage. Patients with obesity are more likely to experience wound dehiscence because fatty tissue does not heal readily, and the patient's body mass increases the strain on the suture line.

An older adult had a colon resection 1 week ago. When assessing the abdominal incision, the nurse notes foul-smelling brown drainage seeping from the middle of the incision site. The nurse suspects he has: 1) an infected wound. 2) wound dehiscence. 3) a hematoma. 4) a fistula.

Answer: 4) a fistula. Rationale: A fistula is an abnormal passage connecting two body cavities or a cavity and the skin. Based on the type of surgery and drainage present, the nurse would suspect fistula formation.

The nurse will know ostomy care teaching is most likely successful when the patient with a new ostomy device: 1) demonstrates the proper method of cleansing her skin. 2) demonstrates proficiency when providing treatment to excoriated skin. 3) states she will start caring for the colostomy after she gets home. 4) proficiently performs colostomy care prior to discharge.

Answer: 4) proficiently performs colostomy care prior to discharge. Rationale: By performing colostomy care, the patient's behavior reflects acceptance of her colostomy. There is no information to suggest that her skin is excoriated. Waiting until she gets home to start care is delaying acceptance and will not allow her to get assistance or further instruction. Demonstrating correct skin cleansing does not ensure that the client is actually performing colostomy care or has accepted her condition.

Place the steps the nurse will take to irrigate a wound in the proper order of performance. Mark the options in rank order (priority rating) with 1 being the first thing you would do, and 8 last. 1) Don clean nonsterile gloves. 2) Set up a sterile field with supplies. 3) Pour irrigation solution into sterile bowl. 4) Remove soiled dressing. 5) Don sterile gloves. 6) Gently irrigate wound. 7) Fill the irrigation syringe. 8) Administer pain medication.

Answer: 8) Administer pain medication. 1) Don clean nonsterile gloves. 4) Remove soiled dressing. 2) Set up a sterile field with supplies. 3) Pour irrigation solution into sterile bowl. 5) Don sterile gloves. 7) Fill the irrigation syringe. 6) Gently irrigate wound. Rationale: The nurse administers pain medication before the procedure; then the nurse helps the patient to a comfortable position. The nurse then dons nonsterile gloves to remove the soiled dressing. After removing the dressing, the nurse disposes of the dressing and gloves in a biohazard receptacle. The sterile field and supplies are assembled, and irrigation fluid is poured in the bowl. The nurse dons sterile gloves. Then, the nurse fills the sterile syringe with sterile irrigating fluid, and finally the wound is gently irrigated.

What should be included in a wound assessment?

Answer: A wound assessment should include the following parameters: -The type of wound -Location of the wound -The color of the wound and surrounding skin -The condition of the wound bed and surrounding skin -The color, consistency, amount, and odor of exudate or drainage -Pain or discomfort related to the wound or wound care

The nurse is ambulating Mr. Sanchez, who had a bowel resection yesterday. Suddenly, Mr. Sanchez states, "It feels like I've popped open." The nurse observes that the abdominal incision has opened 3 inches and a small section of the bowel is protruding. In addition to calling the physician immediately, the nurse would do which of the following? A. Place the patient supine in bed, knees flexed, and cover the wound with sterile gauze soaked with sterile saline. B. Position the patient prone to put pressure on the area, and instruct him not to cough. C. Place the patient supine in bed, legs flat, and cover the wound with dry, sterile dressings. D. Position the patient in Trendelenburg's position, knees flexed, and cover the wound with an occlusive dressing.

Answer: A. Place the patient supine in bed, knees flexed, and cover the wound with sterile gauze soaked with sterile saline. Rationale: This wound likely has eviscerated, which is a total separation of the layers of a wound in which internal viscera protrude through the incision. This is a rare complication and is a surgical emergency. Immediately cover the wound with sterile towels or dressings soaked in sterile saline solution to prevent the organs from drying out and becoming contaminated with environmental bacteria. Have the patient stay in bed supine with knees bent to minimize strain on the incision. Notify the surgeon and ready the patient for a surgical procedure (see Chapter 39 for perioperative care).

Describe four types of wound closures.

Answer: Answers may include any four of the following types of wound closure: -Adhesive strips (Steri-Strips) are used to close superficial low-tension wounds, such as skin tears or lacerations, or to close the skin on a wound that has been closed subcutaneously. They may also be used to give additional support to a wound after sutures or staples have been removed. The strips extend at least 2 to 3 cm on either side of the wound to ensure closure and are placed 2 to 3 cm apart along the wound. -Sutures are the most traditional wound-closure technique. They are available in a variety of sizes and materials. Absorbent sutures are used deep in the tissues. They may be used to close an organ or anastomose (connect) tissue. Absorbent sutures are made of material that will gradually dissolve; there is no need to remove these sutures. Nonabsorbent sutures are placed in superficial tissues. These sutures require removal. Nurses often remove sutures. -Surgical staples are made of lightweight titanium and may be used as an alternative wound-closure technique. Staples are easy to use and provide a rapid way to close an incision. Removal requires a staple remover. -Surgical glue is a relatively new method for wound closure. It is safe for use in clean, low-tension wounds. It is an ideal wound-closure method for skin tears. -Negative-pressure wound closure uses a piece of open-cell foam in the wound that is attached with a tube to a negative-pressure pump to remove wound drainage, provide subatmospheric pressure for improved wound healing, create a clean and moist environment, and form a barrier to bacterial infection. The negative-pressure device is computerized and can be programmed for continuous or intermittent negative pressure. -Compression stockings are used with venous stasis ulcers on the lower extremities. They apply continuous pressure to the veins, which facilitate venous return and helps the ulcers to heal.

Identify three types of laboratory data that may be associated with a delay in wound healing.

Answer: Answers may include any three of the following lab data that may be associated with a delay in wound healing: -A low WBC count -A low serum protein, albumin, or pre-albumin level -Prolonged coagulation times -Needle aspiration result indicative of infection

Identify three nursing responsibilities when caring for a client with a wound drain.

Answer: Answers may include any three of the following nursing responsibilities for wound drains: -Monitoring wound drains. The surgeon will describe the number and type of drains present. -Describe drain placement using the positions on the clock face. Consider the patient's head to be at the 12 o'clock position (e.g., "Penrose drain at 3 o'clock"). -Label the drains numerically with a marker or by placing tape on the collection apparatus, so that each caregiver provides consistent care. Some patients have more than one drainage device in a wound. -When removing dressings or irrigating wounds, take care to avoid dislodging drains. Remember, many drains are not sutured in place. -Monitor the amount and character of the drainage and the condition of the collection apparatus. Record this information in your nursing notes and on the I&O record. -Report to the surgeon any change in the amount or character of the drainage. -If you suspect that a drain is occluded, check the drain line from the insertion site to the collection device. Remove any kinks in the tubing. If this does not correct the problem, notify the physician of the blockage. -Empty the collection apparatus at a designated volume to maintain suction. As the device fills, suction pressure decreases. If there is significant drainage, you may need to empty the device several times during your shift.

Describe three signs of internal hemorrhage.

Answer: Answers may include any three of the following signs of internal bleeding: -Swelling of the affected body part -Pain -Changes in vital signs -A hematoma (a red-blue collection of blood under the skin). A hematoma often forms as a result of internal bleeding. The amount of blood in a hematoma varies. A large hematoma causes pressure on surrounding tissues. When the hematoma is located near a major artery or vein, it may impede blood flow.

What effect does aging have on skin?

Answer: As adults age, aging has the following effects on the skin: -The activity of the sebaceous and sweat glands diminishes, resulting in drier skin. -The subcutaneous tissue layer thins, giving the individual a sharp, angular appearance. Excess caloric intake and weight gain can offset this change of appearance. -The strong bond between the epidermal and dermal layers decreases as the dermal layer loses elasticity. -These changes make the skin prone to breakdown and slow the healing of a wound.

Which of the following is a complication of wound healing? A. Three centimeters of sanguineous fluid on a surgical dressing B. Hypotension and increased pain at the surgical site C. Presence of beefy red tissue in the center of a closing wound D. Low-grade temperature

Answer: B. Hypotension and increased pain at the surgical site Rationale: Falling blood pressure and increasing pain may indicate internal hemorrhage. Responses A and C, sanguineous fluid and red tissue, are normal findings. Response D, low-grade temperature, has other potential causes.

Mr. Smith had a small basal cell carcinoma lesion removed from his back. The plastic surgeon removed an area of skin 3 inches (7.5 cm) in diameter and ½ inch (1.2 cm) deep around and under the lesion and left the wound open to heal. The wound will heal by: A. primary intention. B. secondary intention. C. third intention. D. tertiary intention.

Answer: B. secondary intention.

Differentiate between dehiscence and evisceration.

Answer: Dehiscence and evisceration have the following differences: -Dehiscence is the separation of one or more layers of the wound. -Evisceration is the total separation of the layers of a wound with internal viscera protruding through the incision.

Identify the factors that affect skin integrity.

Answer: Eleven factors affect skin integrity: 1. Age 2. Mobility status 3. Nutrition 4. Hydration 5. Sensory and cognitive status 6. Circulation 7. Medications, tobacco 8. Exposure to moisture 9. Exposure to harmful microorganisms 10. Fever 11. Lifestyle

Serosanguineous drainage on a surgical dressing is an abnormal finding and should be reported to the physician immediately.

Answer: False Rationale: Serosanguineous drainage is a common finding during the immediate postoperative period.

Identify five types of wound complications.

Answer: Five types of complications can occur with wounds: -Hemorrhage -Infection -Dehiscence -Evisceration -Fistula

For how long should heat or cold be applied to an area?

Answer: Heat or cold should be applied intermittently, leaving either on for no more than 15 minutes at a time to avoid tissue injury.

What form of dressing is appropriate for a wound with an eschar that needs to be eliminated?

Answer: Hydrogel is most appropriate for a wound with an eschar that needs to be eliminated. Some students may state that a wet-to-wet dressing is also appropriate, but this dressing type is difficult to maintain and may cause damage to surrounding tissue.

What is the preferred method of wound culture that may be performed by a registered nurse?

Answer: Needle aspiration of a wound is the preferred method for a culture obtained by nursing staff. Nurses can culture wounds by swabbing and aspirating with a needle, but not biopsy, unless certified as advanced practice.

Identify goals for wound care before applying a dressing to a wound.

Answer: Nursing interventions have the following goals for wound care: -Protect wounds from further injury and infection. -Cleanse wounds to prevent infection. -Drain wounds to aid in the healing process and prevent infection. -Debride to aid in the healing process and reduce scarring.

What effect does immobility have on skin?

Answer: Patients with impaired mobility often cannot reposition themselves, leading to pressure over bony prominences, which can lead to skin breakdown.

A wound with approximated edges

Answer: Primary and tertiary intention

A wound that is sutured and has minimal or no tissue loss

Answer: Primary intention

What nursing diagnosis is most appropriate for a patient at risk for pressure ulcer development?

Answer: Risk for Impaired Skin Integrity

Identify the purposes of a wound dressing.

Answer: The primary purposes of dressings are as follows: -Protect from contamination and heat loss -Aid hemostasis -Absorb drainage -Debride the wound -Splint the wound site -Prevent drying of the wound bed -Keep the surrounding tissue dry and intact -Provide comfort to the patient -Eliminate dead space -Control odor

Identify the major functions of the skin.

Answer: The skin has five major functions: -Protection of the internal organs -Thermoregulation -Metabolism of nutrients and metabolic waste products -Sensation -Unique identification of an individual

What is the function of the stratum corneum, the outermost layer of the skin?

Answer: The stratum corneum serves as a barrier, which has three functions: -Restrict water loss -Prevent entry of fluids into the body -Protect the body against the entry of pathogens and chemicals

What is the function of the subcutaneous layer?

Answer: The subcutaneous layer, which is primarily connective and adipose tissues, has three functions: -Insulation -Protection -Reserve of calories in the event of severe malnutrition

When applying an Ace wrap (roller bandage) to a limb, it is important to begin at the most distal point and wrap toward the body.

Answer: True Rationale: This prevents blood and fluid from becoming trapped in the most distal area.

Deeper level tissue damage, known as undermining, may be present in a stage IV pressure ulcer.

Answer: True. Stage IV pressure ulcers involve full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or support structures. Undermining and sinus tracts (blind tracts underneath the epidermis) are common. Exposed bone/tendon is visible or directly palpable. Slough or eschar may be present.

What should you consider when choosing a dressing?

Answer: When choosing a dressing, ask yourself these questions: Will the dressing provide a moist wound environment? Will it contain all the wound drainage and keep it off the surrounding skin? Can it be removed without damaging fragile skin or the wound itself? Will it protect the wound from outside contamination or infection? How long should it stay in place, or how often does it need to be changed?

Describe the wound categorization system based on the level of contamination.

Answer: Wounds are categorized based on four levels of contamination: -Clean wounds are uninfected wounds with minimal inflammation. They may be open or closed and do not involve the gastrointestinal, respiratory, or genitourinary tracts (these systems frequently harbor bacteria). There is very little risk of infection for these wounds. -Clean-contaminated wounds are surgical incisions that enter the gastrointestinal, respiratory, or genitourinary tracts. There is an increased risk of infection for these wounds, but there is no obvious infection. -Contaminated wounds include open, traumatic wounds or surgical incisions in which a major break in asepsis occurred. The risk of infection is high for these wounds. -Infected wounds are wounds with evidence of infection, such as purulent drainage or necrotic tissue. Wounds are considered infected when bacteria counts in the wound tissues are above 100,000 organisms per gram of tissue or in which there is the presence of beta-hemolytic streptococci in any number.

What solutions are used to cleanse a wound?

Answer: Wounds may be cleansed with the following solutions: -Saline -Water -Dilute antimicrobial solutions -Commercially prepared wound cleansers

How do the Langerhans cells protect the skin from injury? Langerhans cells: 1) contain protein that gives the skin strength and elasticity. 2) are able to filter out beta ultraviolet light waves. 3) are mobile to phagocytize foreign material. 4) are located in the dermal layer of the skin.

Answer: 3) are mobile to phagocytize foreign material. Rationale: Langerhans cells are located in the epidermal layer of the skin. They are mobile to phagocytize (consume) foreign material and trigger an immune response. Keratinocytes are protein-containing cells that give the skin strength and elasticity. Melanocytes provide protection from ultraviolet light.

Which of the following factors puts the patient at greatest risk for impaired skin integrity? A. Peripheral vascular disease B. Tanning once a week C. An 1,800-calorie diet D. A temperature of 101.5°F

Answer: A. Peripheral vascular disease Rationale: Although tanning and a high fever are risk factors for impaired skin integrity, arterial peripheral vascular disease directly affects the delivery of oxygen and nutrients to the skin and the removal of waste products. An 1,800-calorie diet is not, in and of itself, a risk factor.

Jan is an RN, and today she is working with Mary, the new nursing assistant. The nursing supervisor knows that Jan understands proper delegation in relationship to wound care when she asks Mary to: A. debride a clean wound healing by primary intention. B. evaluate how treatment is working for a decubitus ulcer. C. turn a comatose patient every 2 hours. D. irrigate an open wound using vigorous flushing.

Answer: C. turn a comatose patient every 2 hours. Rationale: Responses A and B, debridement and treatment evaluation, are the responsibility of the licensed nurse. Response D, vigorous flushing of a wound, may cause damage to healing tissue.

The Braden scale is a way to measure the depth of a decubitus (pressure) ulcer.

Answer: False Rationale: The Braden scale is used to calculate a patient's risk for skin breakdown.

What types of dressing may be used for wounds with a large amount of exudate?

Answer: Gauze, foam, alginates, or absorption dressings are best used for a wound with a large amount of exudate.

Identify the type of wound healing (primary, secondary, or tertiary intention): A wound that heals from inner layer to the surface

Answer: Secondary intention

A wound that heals by approximating two surfaces of granulation tissue

Answer: Tertiary intention

What is the effect of adding moisture to heat or cold treatments?

Answer: The addition of moisture amplifies the intensity of the treatment.

How can you control the amount of force applied for wound irrigation?

Answer: The amount of force applied during wound irrigation is controlled by the size of the syringe and Angiocath used. Ideal irrigation pressures range from 4 to 15 pounds per square inch (psi). Pressures below 4 psi may not adequately cleanse the wound. Pressures above 15 psi increase the risk of impaling bacteria into the tissues and causing mechanical damage. Current recommendations are to use a 35-mL syringe with a 19-gauge Angiocath attached. This will deliver the solution at approximately 8 psi. Commercial irrigation systems are available. Closely evaluate the amount of pressure delivered before you use these devices.

Describe the five types of wound debridement.

Answer: The five types of wound debridement are sharp, mechanical, enzymatic, autolysis, and biotherapy, or maggot debridement: -Sharp debridement is the use of a sharp instrument, such as scalpel or scissors, to remove devitalized tissue. -Mechanical debridement may be performed via the use of wet-to-dry dressings, hydrotherapy (whirlpool), or lavage. -Enzymatic debridement is the application of a topical enzymatic agent to the wound. -Autolysis is the use of an occlusive moisture-retaining dressing and the body's own mechanisms for ridding itself of necrotic tissue. -Biotherapy, or maggot debridement therapy, is the use of medical-grade larvae to dissolve dead and infected tissue from wounds.

What stage pressure ulcer does Mr. Harmon (Meet Your Patient, in Volume 1) have? Answer: A stage I pressure ulcer What factors have contributed to its development?

Answer: The following factors contributed to the development of Mr. Harmon's pressure ulcer: -Weight loss -Age -Altered mobility -Presence of another wound that required body reserves for healing Students may also mention low protein reserves. This is likely based on his weight, height, and limited appetite.

Identify the major interventions for preventing pressure ulcers.

Answer: The following major interventions prevent pressure ulcers: -Inspect skin daily -Manage moisture -Adequate nutrition and hydration -Frequent position changes -Use of therapeutic mattresses and cushions to minimize pressure -Adjunctive wound care therapies -Patient and family teaching

What precautions should you take before using heat or cold therapy?

Answer: The following precautions should be taken before heat or cold therapy: -Avoid direct contact with the heating or cooling device. Cover the hot or cold pack with a washcloth, towel, or fitted sleeve. -Apply hot or cold intermittently, leaving either on for no more than 15 minutes at a time in an area. This helps prevent tissue injury (e.g., burns, impaired circulation). It also makes the therapy more effective by preventing rebound phenomenon: At the time the heat or cold reaches maximum therapeutic effect, the opposite effect begins. -Check the skin frequently for extreme redness, blistering, cyanosis (turning blue), or blanching. When heat or cold is first applied, the thermal receptors react strongly and the person feels the temperature intensely. During about 30 minutes, the receptors adapt to the new temperature, and the person notices it less. Caution clients not to change the temperature when this occurs because this can cause tissue injury.

How does wound depth affect healing?

Answer: Wound depth is a major determinant of healing time. As wound depth increases, healing time also increases.

What nutritional components are essential to maintain skin?

Answer: Adequate intakes of five nutritional components are essential to maintain skin: -Protein -Calories -Fluid -Vitamin C -Minerals

Differentiate among the different categories of dressings.

Differentiate among the different categories of dressings. Answer: -Absorption dressings are used to soak up drainage from a wound. -Alginate dressings are highly absorbent dressing made of fibers from brown seaweed and kelp. -Antimicrobial dressings are topical antifungal and antibiotic agents that are available as ointments, impregnated gauzes, pads, gels, foams, hydrocolloids, and alginates. -Collagen dressings are made from bovine or porcine sources and made into sheets, pads, powders, and gels to absorb wound drainage. -Gauze dressings absorb wound drainage with woven and nonwoven fibers of cotton, rayon, polyester, or a combination of these.