Fundamentals Chapter 31 (Skin Integrity and Wound Care)

A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate?

"I respect your wish not to look at it right now."

Which is an example of a closed wound? A) Abrasion B) Ecchymosis C) Incision D) Puncture wound

Ecchymosis A closed wound results from a blow, force, or strain caused by trauma (such as a fall, an assault, or a motor vehicle crash). The skin surface is not broken, but soft tissue is damaged, and internal injury and hemorrhage may occur. Examples include ecchymosis and hematomas. An open wound occurs from intentional or unintentional trauma. The skin surface is broken, providing a portal of entry for microorganisms. Bleeding, tissue damage, and increased risk for infection and delayed healing may accompany open wounds. Examples include incisions and abrasions.

The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a client with diabetes. The wound care nurse determines that damage has occurred to the subcutaneous tissues; how would she document this wound?

Stage III pressure ulcer A) Stage I pressure ulcer B) Stage II pressure ulcer C) Stage III pressure ulcer D) Stage IV pressure ulcer Damage to the subcutaneous tissue indicates a stage III ulcer. Extensive destruction associated with full-thickness skin loss is categorized as a stage IV pressure ulcer. A stage I ulcer is a defined area of persistent redness in lightly pigmented skin and a persistent red, blue, or purple hue in darker pigmented skin. A stage II pressure ulcer is superficial and may present as a blister or abrasion.

Sanguineous

bloody

Stage 4 pressure ulcer

full-thickness skin loss with extensive destruction (visible bone, muscle or ligament)

Serous drainage

yellow or clear (honey)

A nurse working in long-term care is assessing residents at risk for the development of a decubitus ulcer. Which one would be most at risk? A) A client 83 years of age who is mobile B) A client 92 years of age who uses a walker C) A client 75 years of age who uses a cane D) A client 86 years of age who is bedfast

A client 86 years of age who is bedfast Most pressure ulcers occur in older adults as a result of a combination of factors, including aging skin, chronic illness, immobility, malnutrition, fecal and urinary incontinence, and altered level of consciousness. The bedfast resident would be most at risk in this situation.

When a wound splits open, what is that called?

dehiscence

When there is an organ falling out of a wound, that is called

evisceration

Stage 3 pressure ulcer

full-thickness skin loss, not involving underlying fascia

Stage 2 pressure ulcer

partial-thickness skin loss (blister)

Serosanguineous

pink, yellowish pink

purulent

pus (green, yellow, brown)

Stage 1 pressure ulcer

skin intact, reddened, non-blanchable area

Unstageable

slough and or eschar

A nurse is teaching a client on home care about how to apply hot packs to an infected leg ulcer. What statement by the client indicates the need for further education? A "I understand the rebound effect of heat." B) "I will put the heat packs only on the sore on my leg." C) "I will only leave the heat packs on for 20 minutes." D) "I will leave the heat packs on for an hour.

"I will leave the heat packs on for an hour." Initially, temperature receptors in the skin are strongly stimulated. This response decreases rapidly for the first few seconds after being stimulated and more slowly for the next 30 minutes as the receptors adapt to the temperature. Be sure to tell clients that increasing the temperature or lengthening the time of application can seriously damage tissues.

A nurse is educating a postoperative client on essential nutrition for healing. What statement by the client would indicate a need for more information? A) "I will drink a lot of orange juice and drink milk, too." B) "I will take the zinc supplement the doctor recommended." C) "I will restrict my diet to fats and carbohydrates." D) "I will drink 8 to 10 glasses of water every day."

"I will restrict my diet to fats and carbohydrates." Wound healing requires adequate proteins, carbohydrates, fats, vitamins, and minerals. Calories and proteins are necessary to rebuild cells and tissues. Vitamins C and D, zinc, and adequate fluids are also necessary for wound healing.

When applying hot or cold compresses, what is the general rule to follow?

20 minutes on, 20 minutes off

A nurse caring for a female client notes a number of laceration wounds around the cervix of the uterus due to childbirth. How could the nurse describe the laceration wound in the client's medical record? A) A clean separation of skin and tissue with a smooth, even edge B) A separation of skin and tissue in which the edges are torn and irregular C) A wound in which the surface layers of skin are scraped away D) A shallow crater in which skin or mucous membrane is missing

A separation of skin and tissue in which the edges are torn and irregular Guidelines include: Place a heating pad anteriorly or laterally to, not under, the body part. If the heating pad is between the client and the mattress, heat dissipation may be inadequate, leading to burning of the client or the bed linens. Avoid using pins to secure a heating pad because there is a danger of electric shock if a pin touches a wire. Do not cover the heating pad with anything that might be heavy; heat may accumulate and burn the client when it cannot dissipate normally from the pad. Use a heating pad with a selector switch that cannot be turned up beyond a safe temperature.

Which of the following clients would be considered at risk for skin alterations? Select all that apply. A) A teenager with multiple body piercings B) A homosexual in a monogamous relationship C) A client receiving radiation therapy D) A client undergoing cardiac monitoring E) A client with diabetes

A teenager with multiple body piercings A client receiving radiation therapy A client with diabetes Body piercings, radiation therapy, and diabetes place clients at risk for skin alterations. Having a homosexual relationship with multiple partners would also place a client at risk for HIV and skin alterations. Cardiac monitoring and respiratory disorders are not risk factors.

A home health nurse has a caseload of several postoperative clients. Which one would be most likely to require a longer period of care? A) An infant B) A young adult C) A middle adult D) An older adult

An older adult An older adult heals more slowly than do children and adults as a result of physiologic changes of aging, resulting in diminished fibroblastic activity and circulation. Older adults are also more likely to have one or more chronic illnesses, with pathologic changes that impede the healing process.

Which of the following is an accurate step when applying a saline-moistened dressing on a client's wound? A) Do not use irrigation to clean the wound before changing the dressing. B) Hold the fine-mesh gauze over the basin and pour the ordered solution over the mesh to saturate it. C) Exert light pressure to pack the wound tightly with moistened dressing. D) Apply several dry, sterile gauze pads over the wet gauze and place the ABD pad over the gauz

Apply several dry, sterile gauze pads over the wet gauze and place the ABD pad over the gauze. Answer D is the correct step in the procedure. The wound should be cleaned, if needed, using sterile forceps. Irrigation may be used as ordered or required. The wound should be cleaned from the top to the bottom, and from the center to the outside. The fine-mesh gauze should be placed into the basin and the ordered solution poured over the mesh to saturate it. The dressing should be gently and loosely packed inside the wound.

A nurse is caring for a client who is two days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time? A) Administer pain medications on a p.r.n. and regular basis. B) Assist in moving to prevent strain on the suture line. C) Tell the client that a mild fever is a normal response. D) If a scar forms over a joint, it may limit movement.

Assist in moving to prevent strain on the suture line. The proliferative phase of wound healing begins within two to three days of the injury. Collagen synthesis and accumulation continue, peaking in five to seven days. During this time, adequate nutrition, oxygenation, and prevention of strain on the suture line are important client care considerations.

When describing drainage, what acronym should we refer to?

Color Amount Type Odor

A nurse is applying cold therapy to a client with a contusion of the arm. Which of the following is an effect of cold therapy? Select all that apply. A) Constricts peripheral blood vessels B) Reduces muscle spasms C) Increases blood flow to tissues D) Increases the local release of pain-producing substances E) Reduces the formation of edema and inflammation

Constricts peripheral blood vessels Reduces muscle spasms Reduces the formation of edema and inflammation The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues and decreases the local release of pain-producing substances such as histamine, serotonin, and bradykinin. This action in turn reduces the formation of edema and inflammation. Decreased metabolic needs and capillary permeability, combined with increased coagulation of blood at the wound site, facilitate the control of bleeding and reduce edema formation. Cold also reduces muscle spasms, alters tissue sensitivity (producing numbness), and promotes comfort by slowing the transmission of pain stimuli

The plan of care for a postoperative client specifies that sterile 0.9% sodium chloride solution be used to clean the wound. What should the nurse do after reading this information? A) Question the physician about the accuracy of this agent. B) Refuse to use 0.9% normal saline on a wound. C) Document the rationale for not changing the dressing. D) Continue with the dressing change as planned

Continue with the dressing change as planned. Although various antiseptic cleaning agents could be used to clean a wound, sterile 0.9% normal saline is usually the agent of choice. Other agents may be caustic to skin and tissues.

Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the physician and doing which of the following? A) Covering the wound area with sterile towels moistened with sterile 0.9% saline B) Closing the wound area with Steri-Strips C) Pouring sterile hydrogen peroxide into the abdominal cavity and packing with gauze D) Holding the wound together until the physician arrives

Covering the wound area with sterile towels moistened with sterile 0.9% saline If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% saline. The client should also be placed in the low Fowler's position, and the exposed abdominal contents should be covered as previously discussed. Notify the physician immediately because this is a medical emergency. Do not leave the client alone.

What are the two major processes involved in the inflammatory phase of wound healing? A) Bleeding is stimulated, epithelial cells are deposited B) Granulation tissue is formed, collagen is deposited C) Collagen is remodeled, avascular scar forms D) Blood clotting is initiated, WBCs move into the wound

D Blood clotting is initiated, WBCs move into the wound The inflammatory phase of wound healing begins at the time of injury and prepares the wound for healing. The two major physiologic activities are blood clotting (hemostasis) and the vascular and cellular phase of inflammation.

A nurse is treating the pressure ulcer of an African American client. How would the nurse assess for deep tissue injury in this client? A) Upon inspection the nurse would notice a purple or maroon localized area of discolored, intact skin. B) Upon inspection, the nurse would see a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. C) Upon palpation, the nurse determines that the area preceded by deep tissue injury is painful, firm, boggy, warmer or cooler as compared with adjacent tissue. D) Upon inspection the nurse notes partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.

Deep tissue injury may be difficult to detect in individuals with dark skin tones. The area may be preceded by tissue that is painful, firm, boggy, warmer or cooler as compared with adjacent tissue. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by a thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.

A nurse is assessing a client with a stage IV pressure ulcer. What assessment of the ulcer would be expected? A) Full-thickness skin loss B) Skin pallor C) Blister formation D) Eschar formation

Full-thickness skin loss

A physician orders a dressing to cover a wound that is shallow with minimal drainage. What would be the best type of dressing for this wound? A) Saline-moistened dressing B) Dressing secured with Montgomery straps C) Hydrocolloid dressing D) Foam dressing

Hydrocolloid dressing Hydrocolloid dressings are used for wounds that are shallow to moderate depth with minimal drainage. Saline-moistened dressing is often used with chronic wounds and pressure wounds. Montgomery straps are recommended to secure dressings on wounds that require frequent dressing changes, such as wounds with increased drainage. Foam dressings are recommended for chronic wounds.

What intervention should be included on a plan of care to prevent pressure ulcer development in health care settings? A) Change position at least once each shift. B) Implement a turning schedule every two hours. C) Use ring cushions for heels and elbows. D) Do not turn; use pressure-relieving support surface.

Implement a turning schedule every two hours. To protect clients at risk from the adverse effects of pressure, implement turning using an every-2-hour schedule in the health care setting. More frequent position changes may be necessary. Never use ring cushions or "donuts.

During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution? A) Document the assessments and intervention. B) Reinforce the dressing with additional layers. C) Administer pain medications intramuscularly. D) Notify the physician and prepare for surgery.

Notify the physician and prepare for surgery. Protrusion of the intestines through an opened wound indicates evisceration. After covering the wound with towels soaked in sterile normal saline, the nurse should immediately notify the physician. Immediate surgical repair is required.

The nurse would recognize which of these devices as an open drainage system?

Penrose drain A Penrose drain is an open system that lacks a collection device. Jackson-Pratt drains, Hemovacs, and negative pressure dressings all utilize a suction device or collection reservoir and are considered to be closed systems.

When measuring the size, depth, and wound tunneling of a client's stage IV pressure ulcer, what action should the nurse perform first? A) Penrose drain B) Jackson-Pratt drain C) Hemovac D) Negative pressure dressing

Perform hand hygiene.

Which of the following is a recommended guideline nurses follow when using an electric heating pad on a client? A) Secure the heating pad to the client's clothing with safety pins. B) Place a heavy towel or blanket over the heating pad to maximize heat effects. C) Use a heating pad with a selector switch that can be turned up by the client if needed. D) Place a heating pad anteriorly or laterally to, not under, the body part.

Place a heating pad anteriorly or laterally to, not under, the body part. Guidelines include: Place a heating pad anteriorly or laterally to, not under, the body part. If the heating pad is between the client and the mattress, heat dissipation may be inadequate, leading to burning of the client or the bed linens. Avoid using pins to secure a heating pad because there is a danger of electric shock if a pin touches a wire. Do not cover the heating pad with anything that might be heavy; heat may accumulate and burn the client when it cannot dissipate normally from the pad. Use a heating pad with a selector switch that cannot be turned up beyond a safe temperature.

Which of the following is an indication for the use of negative pressure wound therapy? A) Bone infections B) Malignant wounds C) Wounds with fistulas to body cavities D) Pressure ulcers

Pressure ulcers Negative pressure wound therapy (NPWT) is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or wounds healing slowly. Examples of such wounds include pressure ulcers; arterial, venous, and diabetic ulcers; dehisced surgical wounds; infected wounds; skin graft sites; and burns. NPWT is not considered for use in the presence of active bleeding; wounds with exposed blood vessels, organs, or nerves; malignancy in wound tissue; presence of dry/necrotic tissue; or with fistulas of unknown origin (Hess, 2008; Preston, 2008; Thompson, 2008).

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue easily bleeds when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?

Proliferation phase The proliferation phase is characterized by the formation of granulation tissue (highly vascular, red tissue that bleeds easily). During the proliferation phase, new tissue is built to fill the wound space. Hemostasis involves the constriction of blood vessels and the beginning of blood clotting immediately after the initial injury. The inflammatory phase lasts about four to six days, and white blood cells and macrophages move to the wound. The maturation phase is the final phase of wound healing and involves remodeling of collagen that was haphazardly deposited in the wound; in addition, a scar forms.

Which of the following are functions of the skin? Select all that apply A) Protection B) Temperature regulation C) Sensation D) Vitamin C production E) Immunological

Protection Temperature regulation Sensation Immunological

A student has been assigned to provide morning care to a client. The plan of care includes the information that the client requires partial care. What will the student do? A) Provide total physical hygiene, including perineal care. B) Provide total physical hygiene, excluding hair care. C) Provide supplies and orient to the bathroom. D) Provide supplies and assist with hard-to-reach areas.

Provide supplies and assist with hard-to-reach areas. Morning care is often identified as either self-care, partial care, or complete care. Clients requiring partial morning care most often receive care at the bedside or seated near the sink in the bathroom. They usually require assistance with body areas that are difficult to reach.

When assessing and describing a wound, what acronym should be use?

Redness Edema Erythema Drainage Approximation

What nursing diagnosis would be a priority for a client who has a large wound from colon surgery, is obese, and is taking corticosteroid medications? A) Self-care Deficit B) Risk for Imbalanced Nutrition C) Anxiety D) Risk for Infection

Risk for Infection Clients who are taking corticosteroid medications are at high risk for delayed healing and wound complications such as infections, because corticosteroids decrease the inflammatory process that may in turn delay healing.

A nurse caring for a post-operative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as which of the following? A) Serous B) Sanguineous C) Serosanguineous D) Purulent

Serosanguineous The nurse should document the drainage as serosanguineous, which is pale pink-yellow, thin, and contains plasma and red cells. Serous drainage is pale yellow and watery, like the fluid from a blister. Sanguineous drainage is bloody, as from an acute laceration. Purulent drainage contains white cells and microorganisms and occurs when infection is present. It is thick and opaque and can vary from pale yellow to green or tan, depending on the offending organism.

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. Which of the following is the correct name of this wound? A) Stage II pressure ulcer B) Stage I pressure ulcer C) Stage III pressure ulcer D) Stage IV pressure ulcer

Stage II pressure ulcer Stage I is defined as intact skin with a localized area of nonblanchable redness, usually over a bony prominence. Stage II is defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed. Stage III is defined as full-thickness loss without exposed bone, tendon, or muscle. Stage IV is defined as full-thickness tissue loss with exposed bone, tendon, and muscle.

A nurse inspecting a client's pressure ulcer documents the following: full-thickness tissue loss; visible subcutaneous fat; bone, tendon, and muscle are not exposed. This pressure ulcer is categorized to be at which of the following stages?

Stage III In stage III there is full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. In stage I there is intact skin with nonblanchable redness of a localized area, usually over a bony prominence. In stage II there is partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. In stage IV, there is full-thickness tissue loss with exposed bone, tendon, or muscle.

Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections? A) Taking medications as prescribed B) Proper intake of food and fluids C) Thorough hand hygiene D) Adequate sleep and rest

Thorough hand hygiene the single most important information on which to educate clients and caregivers about home wound care is the importance of thorough hand hygiene to prevent wound infections.

An older adult client has edema of the right lower extremity with redness and clear drainage. This is most likely related to what? A) Beta-hemolytic streptococcus B) Age C) Venous insufficiency D) Hemangioma

Venous insufficiency Leg and foot ulcers occur from various causes, but the most common are ulcers secondary to venous insufficiency, arterial insufficiency, and neuropathy.

A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage? A) Clear, watery blood B) Large numbers of red blood cells C) Mixture of serum and red blood cells D) White blood cells, debris, bacteria

White blood cells, debris, bacteria 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. Serous drainage is composed primarily of the clear, serous portion of the blood and from 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. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to