3101 Skills: Chap. 48 skin and wound

The patient should be informed that a change in sensation is normal. The patient should be within the reach of the call light. The position of the patient should allow him to move away from the cold source. Rationale The nurse should be aware of the safety measures that need to be used when applying heat or cold therapy. The patient should be told about sensations that he will feel during the procedure. The patient should report changes in sensation or discomfort immediately; the call light should be within the patient's reach to call for help if needed. The patient should be positioned so that he can move away from the source for safety. The patient cannot adjust the temperature setting. The patient should not be allowed to move an application or place hands on the wound site. p. 1219

A 36-year-old man is admitted to the hospital following a motor vehicle accident. He has sustained multiple injuries on the forehead, right elbow, and left knee. An x-ray of the knee shows a hairline fracture of the left patella. When giving cold therapy to this patient, what should the nurse keep in mind? Select all that apply. The patient has to adjust the temperature settings whenever required. The patient should be informed that a change in sensation is normal. The patient should be within the reach of the call light. The position of the patient should allow him to move away from the cold source. The patient should remove the application if he becomes uncomfortable.

The skin color remains unchanged on application of pressure. The localized area of the skin appears purple. Rationale Dark-skinned patients have different characteristics of skin when integrity is lost. The color of the skin remains unchanged on application of pressure. The localized area of the skin appears purple or blue instead of red. Blanching of the skin does not occur in dark-skinned patients. The area of the skin with a pressure ulcer appears lighter than the surrounding area. In addition, as the tissue changes color, the intact skin becomes cool. p. 1186

A dark-skinned hospitalized patient is bedridden. While examining the patient, which characteristics will determine that the patient has developed a pressure ulcer? Select all that apply. The skin color remains unchanged on application of pressure. The localized area of the skin appears purple. There is blanching of the skin. The area of the skin with a pressure ulcer appears darker. As the tissue changes color, the intact skin becomes warm.

The Braden Scale Rationale The Braden Scale is a widely used tool for risk assessment of pressure ulcer development and is composed of six subscales that are moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. The GNASC tool is used to assess stage I pressure ulcers in patients with dark skin tone. The Bates-Jensen tool is used to assess the wound status. WOCN ® or the Wound, Ostomy, and Continence Nurses Society™ does not provide any measurement or assessment tools. pp. 1189, 1192-1193, 1205

A long-term care facility encourages nurses to assess patients at risk of developing pressure ulcers based on six subscales: moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. What tool is the facility using for risk assessment of pressure ulcer development? The Gaskin's Nursing Assessment of Skin Color (GNASC) tool The Braden Scale The Bates-Jensen tool The Wound, Ostomy, and Continence Nurses Society™ (WOCN ®) scale

Assess the patient for symptoms of shock. Contact the surgical team for emergency surgery. Place sterile gauzed soaked in saline over the wound. Rationale The patient should be assessed for signs and symptoms of shock as eviscerating injuries can lead to shock. An eviscerating wound is a surgical emergency, and the nurse should contact the surgical team for emergency surgery and prepare the patient for the same. Meanwhile, the nurse should soak sterile gauzed in saline and place them over the extruding tissues to prevent bacterial infection and drying of tissues. The patient also should not have anything by mouth (NPO), and not even antibiotics should be administered orally. Keeping the wound open could lead to a potential bacterial infection that could cause further insult to the injured body part. Test-Taking Tip: Do not choose two answers in multiple-response questions that contradict each other or that are not compatible. For instance in this question, contacting the surgical team and administering anything orally are choices that are not compatible. p. 1192

A patient presents to the emergency department with severe injuries. The nurse notices that the wound on the abdomen is so deep that the liver has been eviscerated. What prompt actions does the nurse take in such a case? Select all that apply. Assess the patient for symptoms of shock. Administer oral antibiotics to prevent infection. Contact the surgical team for emergency surgery. Place sterile gauzed soaked in saline over the wound. Keep the wound open to examine the extent of injury.

Infection Rationale A patient who has a stage III pressure ulcer has full-thickness skin loss. Purulent drainage with a characteristic odor and a fever are indications of wound infection. Skin discoloration to bluish and purplish color are manifestations of bruising. Internal bleeding manifests as swelling and bluish discoloration at the affected part. Blanchable erythema is visible skin redness that becomes white when pressure is applied and reddens when pressure is relieved, but it does not come with fever and purulent discharge. p. 1197

A patient who has a stage III pressure ulcer develops a body temperature of 103° F. While changing the wound dressing, the nurse finds purulent discharge with an odor coming from the wound. What will the nurse suspect is occurring in the patient? Bruising Infection Internal bleeding Blanchable erythema

Applying a sterile dressing as per the health care provider's order Rationale An acute wound due to trauma needs an immediate intervention, such as the application of a sterile dressing to reduce bleeding and prevent sepsis. The nurse may educate the patient about hygiene and wound care, have the patient change positions to prevent pressure ulcers, and encourage the patient to drink 6 to 8 L of water to promote cell function, but these are all secondary to stopping the bleeding. p. 1203

A patient who has an acute wound due to trauma is admitted to the emergency unit. Which nursing action for wound care is the priority in this situation? Educating the patient about wound care Positioning the patient in different angles Encouraging the patient to drink 6 to 8 L of water Applying a sterile dressing as per the health care provider's order

To prevent infection Rationale Evisceration is a medical emergency in which the visceral organs protrude through a wound opening. Immediate application of sterile gauzed soaked in sterile saline over the extruding tissues helps to prevent bacterial invasion, infection, and drying of the tissues. Analgesics will be used to reduce pain. Pressure ulcer prevention will not be a primary concern in an emergency situation such as this. Saline-soaked gauze will not prevent edema. Test-Taking Tip: Multiple choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response. p. 1194

A patient with an abdominal wound from a motor vehicle accident comes into the emergency room with evisceration. The nurse immediately places sterile gauze soaked in sterile saline over the extruding tissues. What is the rationale for this nursing action? To reduce pain To prevent infection To prevent pressure ulcers To prevent periwound edema

Irrigating and cleansing the wound with saline twice a day Packing the open wound with antibiotic solution-moistened gauze Rationale Cleansing the wound and packing it with medicated gauze will reduce the risk for infection. Repositioning the patient at least every 90 minutes is appropriate for this patient, but it is done to improve mobility and prevent the risk for other ulcers developing. Obtaining a wound culture as needed will assess for infection but will not prevent it. Initiating antibiotic therapy is indicated in the presence of a confirmed infection. Antibiotics will not prevent an infection from occurring, and can lead to resistance or undesired side effects. p. 1205

A patient with limited mobility develops a Stage III sacral pressure ulcer. Which nursing interventions are appropriate for reducing the risk of wound infection in this patient? Select all that apply. Obtaining a wound culture as needed Irrigating and cleansing the wound with saline twice a day Repositioning the patient at least every 90 minutes Packing the open wound with antibiotic solution-moistened gauze Requesting an order for a prophylactic antibiotic

-Blanching is not a conclusive sign in these patients. -Differentiate skin color changes with reference to baseline skin tone. -Use the Gaskin's Nursing Assessment of Skin Color (GNASC) tool for assessment of patients with dark skin. Rationale Assessing the development of pressure ulcers in a patient with a dark skin tone can be challenging. Blanching may not be distinctly visible in a patient with dark skin, and the students should be taught to first determine the baseline skin tone and check skin color changes in the affected area. The nurse should inform the students that the GNASC is a useful tool in assessing pressure ulcers in dark-skinned patients. Dark skin is not more vulnerable to tans and sunburns. The nurse should be aware that Mongolian spots may be present on the sacral area of African, Asian, and Native American patients and should not be confused with a skin lesion. pp. 1186, 1189

A senior nurse is teaching a group of students to assess skin changes related to development of pressure ulcers. What should the students keep in mind when assessing dark-skinned patients? Select all that apply. Darker skin is more vulnerable to tans and sunburns. Blanching is not a conclusive sign in these patients. Differentiate skin color changes with reference to baseline skin tone. Mongolian spots may not be present in dark-skinned patients due to sun exposure. Use the Gaskin's Nursing Assessment of Skin Color (GNASC) tool for assessment of patients with dark skin.

Poor nutrition Rationale Of these factors, the patient's poor nutrition carries the highest risk for the patient developing a pressure ulcer. The better the nutrition, the lower the risk. Moist, not dry, skin puts a patient at a greater risk for developing a pressure ulcer. Although frequent, rather than occasional, activity is ideal for reducing the risk for developing a pressure ulcer, the more immobile the patient is, the greater the chance of pressure ulcer development. Slightly limited sensory perception puts a patient at less of a risk than does very limited or completely limited sensory perception.

According to the Braden Scale for predicting pressure ulcer risk, which factor most puts the patient at risk for developing a pressure ulcer? Dry skin Walks occasionally Poor nutrition Slightly limited sensory perception

Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration. Rationale If a patient has an opening in the surgical incision and a portion of the small bowel is noted, the small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus, sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist. p. 1192

After surgery, the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first? Allow the area to be exposed to air until all drainage has stopped. Place several cold packs over the area, protecting the skin around the wound. Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration. Cover the area with sterile gauze, place a tight binder over it, and ask the patient to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly.

Medial knee Rationale The medial knee may be at risk for a pressure ulcer in a patient who is in a side-lying position, but not in a supine position. The ischium, elbow, and occipital bone are all sites at risk for pressure ulcers in an immobilized supine patient. p. 1199

In a supine position, which site is not at risk for a pressure ulcer? Ischium Elbow Occipital bone Medial knee

Unstageable Rationale To determine the stage of a pressure ulcer you examine the depth of the tissue involvement. Since the assessed pressure ulcer was covered with necrotic tissue, the depth could not be determined. Thus, this pressure ulcer cannot be staged. A stage II pressure ulcer would show partial thickness skin loss and a stage IV full thickness. A suspected deep tissue injury is an area of purplish, maroon, intact skin or a blood-filled blister. p. 1187

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient's pressure ulcer? Stage II Stage IV Unstageable Suspected deep tissue damage

Primary intention Rationale Primary intention is the use of sutures or other wound closures to approximate the edges of an incision or a clean laceration. This reduces the risk of infection. Granulation tissue is formed to fill the gap between the edges of a wound and eventually fills in the surface of the wound. Healing by tertiary intention occurs with ulcers and wounds and results in scar formation. Secondary intention wound healing occurs more slowly than primary intention. Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct answer. pp. 1189-1190

The edges of a patient's appendectomy incision are approximated, and no drainage is noted. Which type of healing should be applied? Granulation Primary intention Tertiary intention Secondary intention

The wound is filled with granulation tissue. The wound contracts to reduce the area that requires healing. There is reepithelialization of the wound surface. Rationale In the proliferative phase, fibroblasts and the cells that synthesize collagen provide the matrix for granulation. The wound contracts to reduce the area that requires healing during the proliferative phase. The epithelial cells migrate to the edges to resurface the wound, thus causing reepithelialization. Vasodilatation of the surrounding capillaries and exudation of serum happens during the inflammatory phase. The inflammatory phase is also characterized by localized redness, edema, warmth, and throbbing. p. 1191

The nurse assesses a patient's abdominal wound and finds that the wound is in the proliferative phase of healing. Which changes in the wound might have led the nurse to this conclusion? Select all that apply. The wound is filled with granulation tissue. There is localized redness, edema, warmth, and throbbing. The wound contracts to reduce the area that requires healing. There is vasodilation of the surrounding capillaries and exudation of serum. There is reepithelialization of the wound surface.

The patient has urinary incontinence. The patient is immobilized due to a leg fracture. The patient has impaired sensory perception. Rationale Patients with urinary incontinence who cannot take care of personal hygiene have prolonged exposure to moisture. This can soften the skin, making it more susceptible to ulcer formation. Immobility also puts a patient at a risk for developing pressure ulcers because the patient cannot move voluntarily to relieve pressure on affected body parts, which causes prolonged pressure. Patients with impaired sensory perception are not able to feel or express pain and discomfort in the areas under pressure. Hypertension does not put a patient at risk for pressure ulcer development. A patient who can express pain and discomfort is at a low risk of developing ulcers as he or she can verbalize the painful areas. pp. 1186-1187

The nurse assesses an elderly patient admitted to the hospital after a fall. What assessment findings could place the patient at risk for developing pressure ulcers? Select all that apply. The patient has urinary incontinence. The patient suffers from hypertension. The patient is immobilized due to a leg fracture. The patient has impaired sensory perception. The patient is confused but can express pain and discomfort.

The color remains unchanged when pressure is applied. The circumscribed area of intact skin may be warm to touch. Inflammation may be detected when compared with the surrounding skin. Rationale Assessing the development of pressure ulcers in a patient with dark skin may be difficult. If the skin color remains unchanged when pressure is applied, or the skin is warm to the touch, it indicates a potential for the development of pressure ulcers. These skin changes should be compared with the surrounding skin, looking for signs of inflammation. Intact, unaffected skin appears flabby, whereas skin areas that appear taut and shiny may have the potential to develop pressure ulcers. Instead of red, the affected area of skin may appear purple/blue or violet in dark-skinned patients. p. 1186

The nurse is attending to a patient who is bedridden after a prolonged illness. The patient has darkly pigmented skin, which makes it difficult for the nurse to detect pressure ulcers. What characteristics will alert the nurse to the possibility the patient may develop pressure ulcers? Select all that apply. The skin appears flabby. Localized areas of skin may appear red. The color remains unchanged when pressure is applied. The circumscribed area of intact skin may be warm to touch. Inflammation may be detected when compared with the surrounding skin.

Diminished inflammatory response Loss of collagen and thinning of muscles Rationale With age the skin loses elasticity, has decreased collagen, and the underlying muscles thin out, causing the skin to be easily torn with shearing and friction trauma. This leads to development of pressure ulcers. The decreased inflammatory response in older adults results in poor healing processes due to slow epithelialization. In old age, the hypodermis decreases in size and there is little padding in the skin over bony prominences, causing easy skin breakdown. Test-Taking Tip: Be sure to note whether a question requires a single-answer (multiple choice) or a multiple-response ("Select all that apply") question! If you think there is just one answer, and it is really a multiple-response question, you might submit just the first answer you know to be true and miss the additional correct responses. p. 1185

The nurse is caring for older adult patients in a nursing home. The nurse understands that older adults are susceptible to development of pressure ulcers and other wounds. What makes older adults more vulnerable to developing pressure ulcers? Select all that apply. Increased skin elasticity Increased inflammatory response Increase of the hypodermis in size with age Diminished inflammatory response Loss of collagen and thinning of muscles

Warm, edematous skin The area is cooler than the adjacent tissue. It has localized nonblanchable erythema. Rationale A stage I pressure ulcer is described as a localized area of nonblanchable erythema, more often over a bony prominence. The skin in the affected area can be warm, edematous, hard, firm, or painful. The adjacent tissue may be cooler or warmer than the affected area. The nurse should pinch the skin to check whether the edema blanches and check the skin changes in relation to the adjacent tissue. Cyanotic or blue-colored skin may indicate necrosis of the underlying tissue, which is not associated with a stage I pressure ulcer. Generalized blanchable erythema usually resolves without tissue loss and is an early indication of a pressure ulcer. p. 1187

The nurse is performing an admission assessment on a patient who is paralyzed due to a stroke. The nurse notices a redness of the skin in the sacral area. What characteristics of the skin and surrounding tissues help the nurse to classify the wound as a stage I pressure ulcer? Select all that apply. Cyanotic skin changes Warm, edematous skin The area is cooler than the adjacent tissue. It has generalized blanchable erythema. It has localized nonblanchable erythema.

Applying a moisture barrier ointment over the ulcer Rationale Ointments may decrease friction with the sheets and cover the affected area, encouraging healing and moisture in open ulcers and minimizing patient discomfort. The patient should be repositioned every 90 minutes to reduce pressure over vulnerable areas of the body, but this does not necessarily relieve the patient's discomfort. Elevation of the patient's head of the bed is avoided to minimize further pressure on the sacrum and coccyx. Rubbing or massaging the affected areas may cause tissue damage, so this is avoided. p. 1204

The nurse is preparing a care plan for a patient who has a pressure ulcer on the coccyx. Which part of the plan is included to provide comfort to the patient? Repositioning the patient every 90 minutes Cleaning and massaging around the affected area Elevating the head of the patient's bed to 30 degrees Applying a moisture barrier ointment over the ulcer

They have antioxidant properties. They help in collagen synthesis. They provide fuel for cell energy. Rationale Citrus fruits are rich in vitamin C, which has antioxidant properties and helps in collagen synthesis, thus helping to heal the wound. Citrus fruits also contain calories for cell energy. Zinc-rich foods help in protein synthesis. Water provides an essential fluid environment for healing cells. p. 1194

The nurse is preparing a diet plan for a patient admitted to a wound care unit. After the nurse explains the diet plan to the patient, the patient asks the reason for an increase in the intake of citrus fruits. What should the nurse explain to the patient? Select all that apply. They have antioxidant properties. They help in collagen synthesis. They help in protein synthesis. They provide an essential fluid environment. They provide fuel for cell energy.

Protein needs are increased and are essential for tissue repair and growth. Trace elements are required for epithelialization and collagen fiber linking. Calories provide the energy source needed for cellular activities involved in wound healing. A balanced intake of protein, fat, carbohydrates, vitamins, and minerals is critical to support wound healing. Rationale A balanced nutritional intake promotes wound healing. Protein needs especially are increased and are essential for tissue repair and growth. Collagen is a protein and is a critical component in wound healing. Calorie requirements are high to provide the energy for cellular activity in wound healing. If calories are deficient, the body starts breaking down fats for energy, which may be detrimental to wound healing. A balanced intake of various nutrients such as protein, fat, carbohydrates, vitamins, and minerals is important for wound healing. Trace elements such as zinc and copper are required for epithelialization and collagen fiber linking. Fats have no role in wound healing. pp. 1194-1195

The nurse is teaching a group of nursing students about the role of nutrients in wound healing. Which statements are correct? Select all that apply. Fats are the most essential elements for tissue repair and growth. Protein needs are increased and are essential for tissue repair and growth. Trace elements are required for epithelialization and collagen fiber linking. Calories provide the energy source needed for cellular activities involved in wound healing. A balanced intake of protein, fat, carbohydrates, vitamins, and minerals is critical to support wound healing.

Hemorrhage Rationale The increased amount of red drainage from the surgical drain is indicative of hemorrhage or internal bleeding from the underlying tissues. Hemorrhage also results in swelling and warmth in the area around the incision. Infection is suspected if purulent drainage is drained, and the patient develops fever and an elevated white blood cell count. Evisceration is rarely encountered in surgical incisions, and it involves exposure of visceral organs through the wound. Full-thickness repair does not have any associated drainage. p. 1191

The nurse notices an increased amount of red-colored fluid from the drain in a postoperative patient who had undergone abdominal surgery 2 days ago. The nurse inspects the incision site and notices some swelling and warmth over the incision. The patient is otherwise afebrile and has stable vital signs. Of what are these findings indicative? Infection Evisceration Hemorrhage Full-thickness repair

Serum albumin Serum transferrin Serum prealbumin Rationale Serum albumin is a biochemical indicator of protein deficiency and malnutrition. Serum transferrin levels also indicate protein status in the body. Serum prealbumin is the best indicator of nutritional status. It not only reflects what the patient has ingested but also what the body has metabolized. Hemoglobin levels indicate the oxygen carrying capacity of the blood. Serum creatinine levels indicate kidney function. p. 1194

The nurse understands that a protein deficiency can adversely affect wound healing. What parameters should be measured to determine this deficiency in the patient? Select all that apply. Serum albumin Serum transferrin Serum prealbumin Hemoglobin levels Serum creatinine levels

A malnourished patient An obese patient A patient with wound infection Rationale A malnourished patient may have poor wound healing, which may lead to wound dehiscence. Obesity may increase strain on surgical incisions. In addition, fat tissue has poor wound healing. Infection interferes with the wound healing process and may increase the risk of wound dehiscence. A young adult may have a better wound healing and has less risk of wound dehiscence. Gender does not affect wound healing and dehiscence. pp. 1191-1192

The nurse understands that dehiscence of a wound may occur if there is partial or total separation of the wound layers. Which patients would be at increased risk of wound dehiscence? Select all that apply. A malnourished patient An obese patient A young adult A female patient A patient with wound infection

Vitamin A Vitamin C Rationale Vitamin A helps in epithelialization and closure of the wound. It helps in angiogenesis and promotes collagen formation. Vitamin C promotes collagen synthesis. It also enhances fibroblast function and immunological function. Vitamin B, Vitamin D, and Vitamin E do not have a role in wound healing. p. 1194

The nurse understands that the nutritional status of a patient is an important factor in wound healing. Which vitamins should be provided to the patient to promote wound healing? Select all that apply. Vitamin A Vitamin B Vitamin C Vitamin D Vitamin E

A patient with a spinal cord injury A comatose patient A patient with urinary incontinence An immobile patient with excessive wound drainage Rationale The patient with a spinal injury is immobile and is dependent on the health care team for changes in position. This patient is at risk of developing pressure ulcers due to remaining in the same position for a long time. A comatose patient has impaired perception of pain and pressure, is immobile, and is at increased risk of developing pressure ulcers. The patient with urinary incontinence is at risk of impaired skin integrity due to the urine irritating the skin. The patient may develop pressure ulcers due to constant exposure to moisture. The patient who is immobile and has excessive wound drainage may be at an increased risk due to the skin being exposed to moisture. The patient who underwent laparoscopic cholecystectomy is active and not immobile. The patient is not at risk of developing pressure ulcers. pp. 1186-1187

The nurse works in a long-term care unit. Which patients would be at high risk of developing pressure ulcers? Select all that apply. A patient with a spinal cord injury A comatose patient A patient with urinary incontinence An immobile patient with excessive wound drainage A postoperative patient after a laparoscopic cholecystectomy

It has full-thickness tissue loss. The subcutaneous fat may be visible. The bone, tendon, or muscle is not exposed. Rationale A stage III pressure ulcer has a full-thickness tissue loss involving the epidermis and dermis. Because of this, the subcutaneous fat may be visible. However, the wound is not deep enough to expose the bone, tendon, or the muscle. A wound with an open, serum-filled blister or one having a reddish pink wound bed with slough is a stage II pressure ulcer. p. 1187

The patient has a stage III pressure ulcer. Which findings are characteristic of this type of pressure ulcer? Select all that apply. It has full-thickness tissue loss. The subcutaneous fat may be visible. It may present as an open, serum-filled blister. It may have a reddish pink wound bed without slough. The bone, tendon, or muscle is not exposed.

Collecting wound culture samples from old drainage Rationale The nursing student should never collect a wound culture sample from old drainage, because these organisms may not be the organisms that caused the infection. The other actions are correct. Cleaning a wound with normal saline helps to remove skin flora. The nursing student should use a different method of specimen collection for each type of organism. The nursing student should use a 10-mL disposable syringe with a 22-gauge needle to aspirate the wound drainage for culture. p. 1201

The registered nurse is overseeing a nursing student who is collecting samples of wound drainage for culture. Which nursing action indicates a need for further learning? Cleaning a wound with normal saline Using a different method of specimen collection for each type of organism Collecting wound culture samples from old drainage Using a 10-mL disposable syringe with a 22-gauge needle

Choosing a dressing that keeps the periwound moist Rationale The nurse providing wound care should choose a dressing that keeps the periwound skin dry and the surgical wound bed moist to promote healing. The dressing used for wound care should control exudate from the wound, but it should not desiccate the wound bed. Application of pressure while cleaning the periwound and wound may deepen the wound bed. Using sterile normal saline and a sterile gauze to clean the surgical wound reduces the incidences of infection. p. 1211

The registered nurse is overseeing a nursing student who is providing a dressing change to a patient who had a cesarean section. Which nursing action indicates a need for further learning? Choosing a dressing that keeps the periwound moist Applying a dressing that controls exudates from the wound Cleaning the periwound and wound without applying pressure Using sterile normal saline and a sterile gauze to clean the surgical wound

Applying adhesive remover at the affected site before the dressing Rationale Application of adhesive remover at the affected area may leave a residue that hinders dressing film adherence the remaining actions are correct. The periwound should be thoroughly dried before dressing, because it promotes wound healing. Hydrocolloid dressing may result in contact dermatitis, so it is necessary to cover the skin near and under the areas of suction. Dressing the wound with hydrocolloid film 3 to 5 cm away from the wound ensures proper wound care. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong, and then call on your knowledge, skills, and abilities to choose from the remaining responses. p. 1215

Under the supervision of the registered nurse, a nursing student is providing negative-pressure wound therapy to a patient who has a wound near the knee joint. Which nursing action indicates the need for further learning? Drying the periwound thoroughly before dressing Covering the skin near the suction line with at hydrocolloid dressing Applying adhesive remover at the affected site before the dressing Dressing the wound with a hydrocolloid film 3 cm away from the wound

Encouraging the patient to sit on a donut-shaped cushion Rationale Rigid and donut-shaped cushions reduce blood supply to the vulnerable areas, resulting in wider areas of ischemia. Therefore, the patient who is at risk of pressure ulcers should avoid such cushions. The remaining actions are correct. If the patient can shift his or her weight every 15 minutes, this can help prevent pressure ulcers. The pressure on the ischial tuberosities, areas at risk for ulcers, can be reduced to a certain extent by allowing the patient to rest in a supine position. Using a foam, gel, or air cushion can help redistribute weight away from the ischial areas. Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the options are similar. This can be helpful, because it may mean that one of these look-alike answers is the best choice and the other is a good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur. p. 1207

Under the supervision of the registered nurse, the nursing student is repositioning a patient to reduce the risk of pressure ulcers. Which nursing action indicates a need for further learning? Teaching the patient to shift his or her weight every 15 minutes Encouraging the patient to sleep in a supine position Encouraging the patient to sit on a donut-shaped cushion Encouraging the patient to place the ischial areas on an air-filled pillow

Type of force Involvement of tissue Presentation of the injury Rationale A friction injury is different from a shear injury because of the type of force, involvement of tissue and presentation of injury. In a shear injury, underlying muscle and tissue are involved, whereas in a friction injury the epidermis of the skin is affected. Shear injury presents as necrosis in the deep tissues with intact skin, while a friction injury presents as denuded epidermis and torn skin. Redness and pain is observed in affected areas. Shear force is a sliding movement of the skin and subcutaneous tissue while the underlying muscles and bones remain stationary. Frictional force is the force between two surfaces moving against each other, such as skin and a bedsheet, when the patient is being transferred. Shear injuries and friction injuries are not differentiated by the condition of the patient or the location of the injury. Study Tip: Remember that intelligence plays a vital role in your ability to learn. However, being smart involves more than just intelligence. Being practical and applying common sense are also part of the learning experience. pp. 1186-1187

What characteristics differentiate a friction injury from a shear injury? Select all that apply. Type of force Location of the injury Involvement of tissue Condition of the patient Presentation of the injury

Risk factors that place the patient at risk for skin breakdown Rationale The Braden Scale measures factors in six subscales that can predict the risk of pressure ulcer development. It does not assess skin or wounds. pp. 1192-1193

What does the Braden Scale evaluate? Skin integrity at bony prominences, including any wounds Risk factors that place the patient at risk for skin breakdown The amount of repositioning that the patient can tolerate The factors that place the patient at risk for poor healing

Bedsore Pressure sore Pressure ulcer Decubitus ulcer Rationale A bedsore, pressure sore, pressure ulcer, and decubitus ulcer are the terms used to describe loss of or deteriorated skin condition due to pressure. A pressure ulcer is the most current terminology used. A skin tag is not a result of deteriorated skin condition. A skin wound is a general term used to describe any wound of the skin, be it pressure-related or any other abnormality in the skin. Test-Taking Tip: The "Select all that apply" statement at the end of a question tells you there are at least two correct responses. Be sure to check for this statement before submitting an answer. If you have only chosen one response, then you need to look again, because at least two, but possibly three or more responses are correct. p. 1185

What terms are used to describe deteriorated skin condition related to prolonged, unrelieved pressure on a body part? Select all that apply. Skin tag Bedsore Skin wound Pressure sore Pressure ulcer Decubitus ulcer

Cleaning from the surrounding skin to the site of incision Rationale The nurse should clean away from the wound to prevent contamination. Two separate swabs are to be used: one to clean from the top of the incision toward the draining site and another to clean from the bottom of the incision toward the draining site. Irrigation fluid should flow from the least to most contaminated area to prevent transmission of bacteria. Application of pressure while cleaning the wound should be avoided, but gentle friction may be applied while cleaning the traumatic wound with the noncytotoxic solution. p. 1215

When cleaning a wound, which action is incorrect? Using two separate swabs to clean the affected site Irrigating from the least to most contaminated area Applying noncytotoxic solutions using gentle friction Cleaning from the surrounding skin to the site of incision

Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode Rationale When repositioning an immobile patient, it is important to assess all bony prominences for the presence of redness, which can be the first sign of bed sores. Pressing over the area compresses the blood vessels in the area; and, if the integrity of the vessels is good, the area turns lighter in color and then returns to the red color. However, if the area does not blanch when pressure is applied, tissue damage is likely. A stage III pressure ulcer is open and has full-thickness skin loss. p. 1186

When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when a reddened area blanches on fingertip touch? A local skin infection requiring antibiotics Sensitive skin that requires special bed linen A stage III pressure ulcer needing the appropriate dressing Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

Macrophages Rationale Macrophages are called garbage cells because they ingest bacteria, dead cells, and debris from wounds. Neutrophils ingest bacteria and small debris. Erythrocytes are red blood cells. T-lymphocytes are cells that play an important role in immunity. p. 1193

Which blood cells are known as garbage cells? Neutrophils Erythrocytes Macrophages T-lymphocytes

Reduced local tissue defenses Rationale Reduced local defenses may prevent any counter activity against the microorganisms infecting the wound. Absence of necrotic tissue decreases the risk of infection by improving the blood supply. A foreign body in the wound increases the risk of infection by acting as a port of entry for the microorganisms. An adequate blood supply is important for preventing infection. Test-Taking Tip: Even if you are sure you do not recall the answer, stay calm, and use your best judgment or common sense to evaluate each option. For this question, you eliminate the incorrect options and are left with the remaining correct response. p. 1191

Which factor increases the risk of wound infection? Absence of necrotic tissue Absence of foreign body in the wound Reduced local tissue defenses Adequate blood supply

Drainage for more than 3 days after closure Rationale If a primary-intention wound has drainage for more than 3 days after closure, this is a sign of abnormal healing. Slough tissue in the wound base, a fruity, earthy, or putrid odor, and a dry or moist granulation tissue bed are signs of abnormal healing of a secondary-intention wound. p. 1200

Which is characteristic of abnormal healing of a primary wound? Slough tissue in the wound base A fruity, earthy, or putrid odor A dry or moist granulation tissue bed Drainage for more than 3 days after closure

Vitamin A Rationale One role of vitamin A in healing is to promote wound closure. Protein promotes collagen formation and immunity, vitamin C promotes collagen synthesis and immunity, and zinc promotes collagen formation and protein synthesis. p. 1196

Which nutrient supports healing by promoting wound closure? Protein Vitamin A Vitamin C Zinc

Stage II Rationale A stage II pressure ulcer involves partial-thickness loss of the dermis and manifests as a red-pink, open ulcer without slough. A stage I pressure ulcer presents as intact, nonblanchable, red skin, often over a bony prominence. A stage III pressure ulcer involves full-thickness tissue loss so that subcutaneous fat is visible. A stage IV pressure ulcer involves full-thickness tissue loss extending to and exposing bone, tendon, and/or muscle. pp. 1189-1190

Which stage of the pressure ulcer involves partial-thickness loss of the dermis and manifests as a red-pink, open ulcer without slough? Stage I Stage II Stage III Stage IV

The dermis and the inner layer of the skin provide tensile strength. Rationale The dermis and the inner layer of the skin provide tensile strength and mechanical support to the muscles, bones, and inner organs. The stratum corneum promotes, not prevents, absorption of topical medications. Fibroblasts, not the basal layer of the epidermis, are responsible for collagen formation. The skin has two layers only: the epidermis and the dermis. p. 1187

Which statement regarding the skin is true? The stratum corneum prevents entrance of topical medications. The dermis and the inner layer of the skin provide tensile strength. The basal layer of the epidermis is responsible for collagen formation. The three layers of the skin are the epidermis, dermis, and endodermis.

Lateral rotation surface Rationale A lateral rotation support surface is useful in treating and preventing pulmonary, venous stasis, and urinary complications associated with immobility. Low-air-loss and nonpowered support surfaces help in preventing and treating skin breakdown. An air-fluidized bed support surface prevents skin breakdown and may also be used to protect newly flapped or grafted surgical sites. p. 1208

Which support surface is useful for treating and preventing pulmonary, venous stasis, and urinary complications associated with immobility? Low-air-loss surface Nonpoweredsurface Lateral rotation surface Air-fluidized bed

Stage I Rationale A stage I pressure ulcer does not have a break in the skin but has a redness that does not blanch. Depending on the skin color, there may be a discoloration; the area may feel warm because of the vasodilation or cool if blood is constricted in the area; and the tissue may feel firm if there is edema in the area or may feel soft if the blood flow is compromised. The patient may report pain in the area. Stages II, III, and IV all have breaks in the skin at different degrees of depth. Study Tip: To memorize the characteristics of each stage of a pressure ulcer, write the stage on one side of a notecard and list the characteristics on the other. If possible, print a small color photograph of that stage and affix it next to the characteristics, or draw a picture of the characteristics to help your visual memory. Recognition of these stages is vital to your nursing ability and prevention of suffering. It's worth it to memorize the stages! p. 1187

Which type of pressure ulcer is noted to have intact skin and may include changes in skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain? Stage I Stage II Stage III Stage IV

Stage I Rationale A stage I pressure ulcer is an intact ulcer that can be dressed with a transparent or hydrocolloid dressing. Composite film, hydrocolloid, and hydrogel dressings are appropriate for stage II pressure ulcers. Hydrocolloid, hydrogen gel covered with foam, calcium alginate, and gauze dressings are appropriate for stage III pressure ulcers. Hydrogel covered with foam, calcium alginate, and gauze dressings are appropriate for stage IV pressure ulcers. p. 1213

Which type of ulcer can be dressed with a transparent or hydrocolloid dressing? Stage I Stage II Stage III Stage IV

Unstageable Rationale Black tissue is characteristic of an eschar. Because the eschar obscures the depth of the wound, this ulcer is unstageable. Stage I ulcers manifest as localized nonblanchable redness over intact skin. Stage II ulcers are characterized by partial-thickness dermis loss. Stage III ulcers are characterized by full-thickness skin loss to the extent that subcutaneous fat may be visible. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking, and look for key words; (2) read each answer thoroughly, and see if it completely covers the material the question asks; and (3) narrow the choices by immediately eliminating answers you know are incorrect. pp. 1189-1190

While assessing a patient who has a pressure ulcer, the nurse finds black wound tissue. In which stage is this pressure ulcer? Stage I Stage II Stage III Unstageable