(PrepU) Chapter 32: Skin Integrity and Wound Care

The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective?

"I will put a layer of cloth between my skin and the ice pack." Teaching has been effective when the client understands that a layer of cloth is needed between the ice pack and skin to preserve skin integrity. The ice pack should be removed if the skin becomes mottled or numb; this indicates that the cold therapy is too cold. The ice pack can be in place for no more than 20-30 minutes at a time, and a minimum of 30 minutes should go by before it is reapplied.

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate?

"Your wound will heal slowly as granulation tissue forms and fills the wound." This statement is correct, because it provides education to the client: "Your wound will heal slowly as granulation tissue forms and fills the wound." Large wounds with extensive tissue loss may not be able to be closed by primary intention, which is surgical intervention. Secondary intention, in which the wound is left open and closes naturally, is not done if less of a scar is necessary. Third intention is when a wound is left open for a few days and then, if there is no indication of infection, closed by a surgeon.

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. An infant's skin and mucous membranes are easily injured and at risk for infection. In children younger than 2 years, the skin is thinner and weaker than in adults. The structure of the skin changes as a person ages. A child's skin becomes more resistant to injury and infection as the child grows.

Which is not considered a skin appendage?

Connective tissue Hair, the sebaceous gland, and eccrine sweat glands are skin appendages that are formed with the enfolding of the epidermis into the dermis. The dermis is composed of connective tissue.

The nurse is caring for a client who needs blood drawn for analysis. When gathering supplies, which dressing will the nurse select to cover the site where the needle was inserted to gather blood?

gauze Gauze dressings absorb blood or drainage. Transparent dressings are used to protect intravenous insertion sites. Hydrocolloid dressings are used to used keep a wound moist. Adhesive strips with eyelets are used to secure a gauze dressing that needs frequent changing.

The client twisted his ankle while hiking in an isolated area. The client reports pain and is unable to bear weight on the ankle. A nurse who is present has conducted an assessment and recommended the client rest and elevate the leg while waiting for rescue. The nurse is applying to the ankle a commercially prepared ice pack that contains a chemical. What precautions would the nurse employ when applying cold therapy to the client's ankle? Select all that apply.

squeeze the nonfrozen chemical pack to activate assess the client's ankle skin frequently ask the client about numbness and pain related to the cold therapy place a cloth between the ice pack and the skin Commercially prepared ice packs that contain a chemical are activated by squeezing the ice pack. During an application of cold therapy, the nurse assesses the skin and asks the client about pain and numbness. The nurse places a cloth between the ice pack and the skin to prevent injury caused by the cold pack. The ice pack is applied for 30 minutes and removed for 1 hour prior to reapplication.

A nurse is admitting a client to a long-term care facility. What should the nurse plan to use to assess the client for risk of pressure injury development?

Braden scale The Braden scale is an assessment tool used to assess the client's risk for pressure injury development. The Glasgow scale is used to assess a client's neurologic status quickly. This is typically used in emergency departments and critical care units. The FLACC scale is used to evaluate pain in clients. The Morse scale is used to assess the client's risk for falls.

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 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.

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly?

The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly. The nurse would keep the heating pad in place for 20 to 30 minutes, assessing it regularly. The nurse would not use a safety pin to attach the pad to the bedding. The pin could create problems with this electric device. The nurse would not place the heating pad directly under the client's neck. The nurse would not cover the heating pad with a heavy blanket.

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

True A Penrose drain is an open drainage system that exits the skin through a stab wound. The purpose a Penrose drain is to provide a sinus tract for drainage.

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?

corticosteroids Clients who are taking corticosteroids or require postoperative radiation therapy are at high risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing. Antihypertensive drugs, potassium supplements, and laxatives do not delay wound healing.

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 Debridement is the act of removing debris and devitalized tissue in order to promote healing and reduce the risk of infection. Debridement does not directly stimulate the wound bed, and the goal is neither assessment nor the prevention of maceration.

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury?

use pillows to maintain a side-lying position as needed Using pillows to maintain a side-lying position allows the nursing staff to change position to alleviate and alternate pressure on client's bony prominences. The client's position should be changed a minimum of every 2 hours. In addition, incontinent care should be performed a minimum of every 2 hours and as needed to decrease moisture and irritation of the skin. A foot board prevents foot drop but does not decrease the risk for pressure injury.

A client has undergone abdominal surgery for the treatment of cancer and is recovering with a Hemovac drain in place. When caring for this device, which interventions should the nurse perform? Select all that apply.

Administer analgesia before changing the dressing around the drain, if needed. Use a gauze pad to clean the drain outlet after emptying it. Fasten the drain to the client's gown using a safety pin after emptying and recompressing it. Analgesia can be provided before drain care, if necessary. A gauze pad is used to cleanse the outlet after emptying and the drain is secured to the client's gown with a safety pin. Goggles are not normally necessary. The drain does not require 5 to 7 minutes in order to become fully empty.

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the bestaction by the nurse at this time?

Discontinue the therapy and assess the client. The best action by the nurse at this time is to discontinue the therapy and assess the client; this should be done before notifying the health care provider or documenting the event. Gently rubbing the area or massaging it would not be appropriate at this time.

After 30 minutes, the nurse is preparing to remove the cold therapy application when the client asks if it can be left on a little longer. What is the best action by the nurse?

Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis. The best response by the nurse is to explain the possible complications of leaving cold therapy in place for too long, including cell death and tissue necrosis. This response not only answers the client's question but teaches at the same time the rationale and reason for limiting the cold therapy. Leaving the therapy on for 10 more minutes places the client at increased risk of tissue injury. Assisting the client out of bed ignores the client's request. Using the health care provider's prescription as the reason displays lack of understanding by the nurse and does not aid the client in understanding the rationale for the time limit.

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury?

Stage II A stage II pressure injury involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II injury could present as a blister, abrasion, or shallow crater. A stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III injury presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Injuries at this stage may include undermining and tunneling. Stage IV injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling.

The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately?

a sterile, flexible applicator moistened with saline A sterile, flexible applicator is the safest implement to use. A small plastic ruler is not sterile. A sterile tongue blade lubricated with water soluble gel is too large to use in a wound bed. An otic curette is a surgical instrument designed for scraping or debriding biological tissue or debris in a biopsy, excision, or cleaning procedure and not flexible.

The nurse would recognize which client as being particularly susceptible to impaired wound healing?

an obese woman with a history of type 1 diabetes Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process. This is a greater risk factor for impaired healing than are smoking and sedentary lifestyle. Large incisions in and of themselves do not necessarily complicate the healing process. Short-term lack of food intake is not as significant as longer-term lack of nutrition.

The health care provider prescribes negative-pressure wound therapy for a client with a pressure injury. Before initiating the treatment, it is important for the nurse to implement which nursing assessment?

assessing the wound for active bleeding Negative-pressure wound therapy (NPWT) promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed. NPWT is not considered for use in the presence of active bleeding. The nurse needs to assess for the use of anticoagulants, not antihypertensives, because these can cause bleeding. Mental status and the presence of claustrophobia are not significant when negative-pressure wound therapy is to be initiated.

A skin infection caused by beta-hemolytic streptococci common in children is:

impetigo Impetigo, which usually is caused by beta-hemolytic streptococci, is the most common bacterial skin infection.

A nurse is caring for a client on a medical-surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which type of debridement does the nurse understand has been ordered on this client?

mechanical debridement Mechanical debridement involves physical removal of necrotic tissue, such as surgical debridement. Biosurgical debridement utilizes fly larvae to clear the wound of necrotic tissue. This is accomplished through an enzyme the larvae release. Autolytic debridement involves using the client's own body to break down the necrotic tissue. Enzymatic debridement involves the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed.

A nurse is evaluating a client who was admitted with partial-thickness (second-degree) burns. Which describes this type of burn?

moist with blisters, which may be pink, red, pale ivory, or light yellow-brown Partial-thickness (second-degree) burns are moderate to deep burns that may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. Superficial (first-degree) burns may be pinkish or red with no blistering. Full-thickness (third-degree) burns vary from brown or black to cherry-red or pearly-white; bullae may be present; can appear dry and leathery.

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 III Stage III wounds have full-thickness tissue loss. Subcutaneous tissue may be visible, but no bone, tendon, 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 muscle.

A nurse is caring for a client in a wound care clinic. The client has a wound on the right heel that is 2 cm × 4 cm. The wound is a maroon color and looks like a blood-filled blister. Which stage should the nurse document for this wound?

suspected deep tissue injury A maroon blood-filled blister is staged as a suspected deep tissue injury. It is often preceded by a boggy or painful area. A stage II wound is a partial-thickness loss of dermis that often presents as an open blister. A stage III pressure injury is a full-thickness tissue loss in which subcutaneous tissue is visible. An unstageable wound is covered by slough or eschar. The depth of the wound is unknown because of this covering.

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?

transparent The nurse should use a transparent dressing to cover the IV insertion site, because such dressings allow the nurse to assess a wound without removing the dressing. In addition, they are less bulky than gauze dressings and do not require tape, since they consist of a single sheet of adhesive material. Gauze dressing is ideal for covering fresh wounds that are likely to bleed or wounds that exude drainage. A hydrocolloid dressing helps keep the wound moist. A bandage is a strip or roll of cloth wrapped around a body part to help support the area around the wound.

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 bulb-like drain allows removal of blood and drainage from the surgical wound. All the statements are factual and true; however, the name of the drain, how it works, when it will be removed, and measurement of the exudate are drain management skills and knowledge. Only, "the drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound" answers the clients question about why the drain is present.

The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surgical wound during a dressing change. What instructions should the RN provide the LPN regarding this action?

"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." The nurse should apply any topical medications, foams, gels, and/or gauze to the wound as prescribed; ensuring that the product stays confined to the wound and does not impact on intact surrounding tissue/skin. Applying the medicated gel with an applicator allows for better control over the application, thus minimizing any additional trauma to wound. The procedure should be preformed using sterile technique, but clean technique can be used when proving care to chronic or pressure injury wounds. To manage contamination risk, cleansing of a wound should be done from top to center to outside.

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." Very little scar tissue is expected to form in a minor surgical wound. Second-intention healing involves a complex reparative process in which the margins of the wound are not in direct contact. Third-intention healing takes place when the wound edges are intentionally left widely separated and later brought together for closure.

The nurse is providing education to a client recently diagnosed with psoriasis. The client questions the nurse about the potential for curing the condition. What response by the nurse is most appropriate?

"You will likely experience periods of increased skin outbreaks and periods of remissions." Psoriasis is a chronic condition. It may be managed with lifestyle changes and medications. There is no permanent cure. Periods of remission are followed by exacerbations, which can be triggered by stress, infection, or environmental factors.

A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline, then inserting it gently into the wound at a 90-degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method?

Depth When measuring the depth of a wound, the nurse moistens a sterile, flexible applicator with saline and inserts it gently into the wound at a 90-degree angle, with the tip down. The nurse then marks the point on the swab that is even with the surrounding skin surface, or grasps the applicator with the thumb and forefinger at the point corresponding to the wound's margin. Finally, the nurse removes the swab and measures the depth with a ruler. Size is measured with a ruler on the outside of the wound. Tunneling is measured by a finger probe or sterile probe instrument. Direction is a visual inspection.

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 drainage for bile. 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.

A nurse is caring for clients on a medical-surgical unit. On the basis of known risk factors, the nurse understands that which client has the highest risk for developing a pressure injury?

65-year-old incontinent client, who eats over half the meals, with a hip fracture on bed rest The 65-year-old client who is incontinent with a hip fracture would be at highest risk for developing a pressure injury, even though the client has adequate nutrition. This client has several risk factors: age, incontinence, and decreased mobility related to the hip fracture. The client who had a motor vehicle accident and has bilateral casts does have decreased mobility and is on a liquid diet but does not have as many risk factors as the client with the hip fracture. The client with cancer has a weakened immune system and is incontinent. However, the client has no immobility issues noted and more than likely uses incontinent appliances so the skin is rarely exposed to moisture. The client with Alzheimer disease is ambulatory and has decreased nutrition. The risk for this client is not as great as that of the client with the hip fracture because of the mobility.

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing?

Fish To promote wound healing, the nurse should ensure that the client's diet is high in protein, vitamin A, and vitamin C. The fish is high in protein and is therefore the most appropriate choice to promote wound healing. Pasta salad has a high carbohydrate amount with no protein. Banana has a high amount of vitamin C but no protein. Green beans have some protein but not as much as fish.

A nurse assessing the wound healing of a client documents that the wound formed a clean, straight line with little loss of tissue. This wound healed by:

primary intention. Wounds healing by primary intention form a clean, straight line with little loss of tissue. Wounds healing by secondary intention are large wounds with considerable tissue loss. The edges are not approximated. Healing occurs by formation of granulation tissue. Wounds healing by delayed primary intention or tertiary intention are left open for several days to allow edema or infection to resolve or exudates to drain. They are then closed. Dehiscence is wound separation, not wound healing.

A nurse is caring for an adult who had Mohs surgery on the nose. The client asks, "Is there anything I can do to prevent getting skin cancer again?" How should the nurse respond?

"There are preventative measures you should take to limit exposure to UVA and UVB rays, such as using sunscreen and wearing protective clothing; however, since you have already had skin cancer you are at a higher risk and should continue to inspect you skin for suspicious findings and see your dermatologist as recommended." The client should be educated about the importance of preventing skin cancer by limiting exposure to UVA and UVB rays. The use of clothing, such as long-sleeve shirts, wide-brimmed hats, and sunglasses, in addition to the use of sunscreen should be encouraged. Preventative measures are not an absolute guarantee that a client will not get skin cancer, and someone who has been diagnosed previously with skin cancer is at greater risk. UVA and UVB rays can penetrate clouds, only going out on cloudy days will not protect the skin from exposure.

An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site?

a transparent film Transparent film dressings are semipermeable, waterproof, and adhesive, allowing visualization of the access site to aid assessment and protecting the site from microorganisms. Gauze dressings--precut, with an adherent coating, premedicated with antibiotics--do not allow the nurse to visualize the site without partially or completely removing the dressing.