fundamentals chapter 32 : Skin integrity and wound care

A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response?

"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound."

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

"Very little scar tissue will form."

Braden Scale for Predicting Pressure Sore Risk

19-23 not at risk 15-18 low risk 13-14 moderate risk 10-12 high risk Less than or equal to 9 very high risk mental status, continence, mobility, activity, and nutrition

stage 1 pressure injury

An area of intact skin that is red, deep pink, or mottled skin that does not blanch with fingertip pressure

The nurse is performing a sterile dressing change. After donning sterile gloves, the nurse drops the dressing on the bed and does not have a replacement. What is the appropriate action at this time?

Ask the patient to press the call bell to summon a co-worker to obtain another dressing.

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

Fingers with quicl capillary refill -Warm Hand -No finger numbness or tingling

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

Hydrocolloids

Which of the following sign(s) and symptom(s) would the nurse expect in a patient with chronic venous insufficiency?

Lower extremity edema Wound exudate

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

Notify the surgeon, apply a sterile saline-moistened dressing to the open areas, and support the wound during coughing or abdominal movement Explaination With dehiscence, there is an unintentional separation of wound edges, especially in a surgical wound. Dehiscence is not a medical emergency. However, the nurse will notify the surgeon and protect the open wound areas with a sterile saline-moistened dressing. Also, the nurse will implement preventative measures such as splinting the wound with a pillow during movement to prevent further dehiscence or evisceration. Approximating the wound edges and applying wound closure tapes may cause the client undue pain and trap bacteria in the wound. Irrigating the open wound may cause unwanted bacteria from the surrounding area to wash into the wound.

Norton Scale

Physical and mental condition, activity, mobility, and continence

Functions of the skin

Protection Body temperature regulation Cutaneous sensations Metabolic functions Blood reservoir Excretion of wastes

The nurse is reviewing a patient's laboratory results to determine the current nutritional status. Which of the following will negatively affect wound healing?

Protein definciency , vitiam B excess

RYB wound classification

Red - protect Yellow - cleanse Black - debride

mixture of serum and red blood cells light pink to blood-tinged.

Serosanguineous drainage

A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain?

The status of the client's tetanus immunization

collection of infected fluid that has not drained

abscess

Waterlow Scale

age and gender (sex), build and weight, continence, skin type, mobility, nutrition, and special population-specific risks

piece of gauze or other material used to cover a wound

bandage

a thick grouping of microorganisms

biofilm

what is not considered a skin appendage ?

connective tissue

cleaning away devitalized tissue and foreign matter from a wound

debridement

separation of the layers of a surgical wound; may be partial, superficial, or a complete disruption of the surgical wound

dehiscence

the layer of skin below the epidermis

dermis

dehydration; the process of being rendered free from moisture

desiccation

protective covering placed over a wound

dressing

superficial layer of the skin

epidermis

stage of wound healing in which epithelial cells form across the surface of a wound ; tissue color ranges from the color of " ground glass:" to pink

epithelialization

redness of the skin

erythema

thick, leathery scab or dry crust that is necrotic and must be removed for adequate healing to occur

eschar

protrusion of viscera through an incision

evisceration

fluid that accumulates in a wound ; may contain serum , cellular debris , bacteria , and white blood cells

exudate

an abnormal passage from a internal organ to the skin or from one internal organ to another

fistula

occurs when two surfaces rub against each other; the resulting injury resembles an abrasion and can also damage superficial blood vessels directly under the skin

friction

new tissue that is pink /red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal

granulation tissue

stage 3 pressure injury

has a shallow skin crater that extends to the subcutaneous tissue

localized mass of usually clotted blood

hematoma

deficiency of blood in a particular area

ischemia

softening through liquid; overhydration

maceration

dealth of cells and tissue

necrosis

activity that promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid

negative pressure wound therapy (NPWT)

stage 2 pressure injury

partial thickness skin loss with exposed dermis and present as a shallow crater

(1) localized damage to the skin and underlying tissue that usually occurs over a bony prominence or is related to the use of a (medical or other) device; (2) any lesion caused by unrelieved pressure that results in damage to underlying tissue; formerly known as pressure ulcer

pressure injury

comprised of white blood cells, liquefied dead tissue debris, and both dead and live bacteria assesses yellow, foul-smelling drainage

purulent drainage

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

removing dead or infected tissue to promote wound healing

containing or mixed with blood bright red and looks like blood

sanguineous drainage

connective tissue that fills a wound area

scar

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this?

secondary intention Explanation: Healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue, and eventually epithelial cells migrate across the granulation base. Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the wound are approximated and the risk of infection is lower when a wound heals in this manner. Maturation is the final stage of full-thickness wound healing. Tertiary intention occurs when there is a delay between injury and wound closure. The delay may occur when a deep wound is not sutured immediately or is left open until no sign of infection is evident.

composed of clear, serous portion of the blood and from serous membranes

serous drainage

stage 4 pressure injury

severe; the tissue is deeply ulcerated and exposes muscle and bone with the presence of necrotic tissue likely

force created when layers of tissue move on one another

shear

hair , the sebaceous gland , and eccrine sweat glands are

skin appendages

underlying layer that anchors the skin layers to the underlying tissues of the body

subcutaneous tissue

injury that results in a disruption in the normal continuity of a body tissue

wound