ch 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 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.

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

Clean the wound from the top to the bottom and from the center to outside. Using sterile technique, clean the wound from the top to the bottom and from the center to the outside. Dry the area with a gauze sponge, not an absorbent cloth.

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.

The nurse is caring for a client with diarrhea caused by Clostridium difficile. Which is the priority nursing assessment for this client?

Monitor intake and output. A client with diarrhea caused by Clostridium difficile is at risk for dehydration. As such, the priority assessments should include intake and output, skin turgor, condition of mucous membranes, and vital signs. Assessing the coccyx area for blanching should be done with shift assessments; however, circulating fluid volume takes priority. Monitoring for nausea and assessing the client's mentation is not directly related to the effects of the infectious diarrhea.

The nurse is caring for a client who has two Jackson-Pratt drains following her bilateral mastectomy. When emptying a Jackson-Pratt drain, the nurse should prioritize what action?

Recompress the drain before replacing the cap. Recompressing the drain after replacing the cap would force air and exudate into the client, causing pain and posing an infection risk. Gloves are necessary for this procedure, but they do not need to be sterile. It is unnecessary to cleanse the area around the cap with alcohol. It is important that the tubing should not be under tension.

A nurse is preparing to remove the staples from the donor vein site on a client's leg following cardiac surgery. Which guideline should inform the nurse's decision making?

The nurse should apply adhesive wound closure strips after removing staples. After skin staples are removed, adhesive wound closure strips are applied across the wound to keep the skin edges approximated as the wound continues to heal. This task cannot be delegated to UAP. Irrigation is not necessary and alternating staples should be removed to prevent dehiscence.

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention?

applying sterile dressings with normal saline over the protruding organs and tissue The nurse will immediately apply sterile dressing moistened with normal saline over the protruding organs and tissue and call out for someone to contact the surgeon. While waiting for the surgeon, the nurse will continue to assess the area of evisceration and monitor the client's status.

The nurse is caring for a client with a stage 2 pressure injury. Which intervention will help prevent shearing force?

preventing the client from sliding in bed Shearing force occurs when tissue layers move on one another, causing vessels to stretch as they pass through the subcutaneous tissue. Pulling up from under the arms and pulling the sheets to reposition the client cause shearing force. Improving the client's hydration status could help with wound healing, but not in the prevention of shearing force.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury?

stage IV Stage IV pressure injuries are characterized as exposing muscle and bone and may have slough and a foul odor. Stage I pressure injuries are characterized by intact but reddened skin that is unblanchable. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage.

The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity?

"Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer." Wrinkling and poor skin turgor results from loss of elastic fibers and collagen changes in the dermal connective tissue. As such, clients should be taught to avoid soaps with artificial ingredients or fragrances, as these may be harsher on the skin. It is good to be clean; however, advice of taking at least two showers per day is excessive and may dry the skin. Moisturizer should be applied to the skin following bathing to prevent dryness of the skin. Drinking water is important to remain hydrated; however, the nurse should recommend drinking 1,500 to 2,000 mL of water daily. Drinking 8 ounces three times a day is 720 mL.

A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for:

dehiscence. Dehiscence is a total or partial disruption of wound edges. Clients often report feeling that the incision has given way. Manifestations of infection include redness, warmth, swelling, and fever. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

Assess the client's wound and vital signs. First, the nurse should assess the client. The nurse needs to assess the wound, assess if the therapy is working properly, assess the client's vital signs, and assess the pain. The other options might be appropriate but only after the client has been assessed.

The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action?

elevating and supporting the stump The nurse will first elevate and support the stump, then begin the process of bandaging. The bandage will be applied distally to proximally with equal tension at each turn; the nurse will monitor throughout the application to keep the bandage free from gaps between turns.

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage?

serosanguineous This describes serosanguineous wound drainage. Drainage that is pale yellow, watery, and like the fluid from a blister is called serous. Drainage that is bloody is called sanguineous. Drainage that contains white cells and microorganisms is called purulent.

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true?

A Penrose drain promotes passive drainage into a dressing. A Penrose drain is an open drainage system that promotes passive drainage of fluid into a dressing. The Jackson-Pratt drain has a small bulblike collection chamber that is kept under negative pressure. A Hemovac is a round collection chamber with a spring inside that also must be kept under negative pressure.

A nurse is removing a client's surgical sutures. Place the following steps in the correct order. Use all options.

Clean the incision using the wound cleanser and gauze. Using the forceps, grasp the knot of the first suture and gently lift the knot up off the skin. Using the scissors, cut one side of the suture below the knot, close to the skin. Grasp the knot with the forceps and pull the cut suture through the skin. Remove every other suture to be sure the wound edges are healed. Apply adhesive closure strips. Incision cleaning prevents the spread of microorganisms and contamination of the wound. Raising the suture knot prevents accidental injury to the wound or skin when cutting. Pulling the cut suture through the skin helps reduce the risk for contamination of the incision area and resulting infection. Removing every other suture allows for inspection of the wound, while leaving an adequate number of sutures in place to promote continued healing if the edges are not totally approximated. Adhesive wound closure strips provide additional support to the wound as it continues to heal.

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client?

Dehiscence of the wound Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that "something has suddenly given way." If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician. Once dehiscence occurs, the wound is managed like any open wound. Manifestations of infection include redness, warmth, swelling, and heat. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents.

The nurse is caring for an older adult admitted for thromboembolism and on bed rest. Which assessments should the nurse use to help detect the potential for pressure injury? Select all that apply.

Nutritional status Mental status Skin moisture Sensory perception The client has blood clots that could potentially travel to the lungs (thromboembolism), so the client needs to be on strict bed rest until treated for the condition and determined safe to ambulate. Stages of pressure injuries are used after there is a break in the skin's integrity, and the nurse is examining the client for potential risks for developing a pressure injury in this case. Nutritional status is important to assess to determine if skin has adequate nutrients to replace damaged or dead cells daily. In older adults, the first clue of an infection—fluid and electrolyte imbalance—is often a change in the mental status, and all these factors can influence the client not adequately moving in bed and increase pressure on the bony prominences. Skin moisture needs to be assessed because excessively dry or moist skin will break down easier than skin with a normal amount of moisture. Sensory perception is important to assess because if the client cannot feel light touch or painful stimuli, the client may not recognize lying in one position too long, which leads to increased pressure on tissues and damage to the skin.

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.

A full-thickness or third-degree burn develops a leathery covering called a(an):

eschar The full-thickness or third-degree burn appears dry and leathery. The term for this presentation is called eschar. Eschar is a thick, leathery scab or dry crust that is necrotic.