Ch 48 Skin Integrity & wound care

How many calories per kilogram per day should the nurse suggest a patient consume to promote proper wound healing?

30-35

what amount of fluid per kilogram per day should the nurse encourage the patient to drink for proper wound healing?

30-35 mL

Which solution is used to clean a wound before obtaining a culture?

A nonbacteriostatic saline solution is used to clean the wound before obtaining a culture because it won't kill the microorganisms; they must be present in order to determine the cause of infection. Povidone-iodine, hydrogen peroxide, and sodium hypochlorite solutions are cytotoxic, so culture results may be skewed

Which type of dressing will the nurse use for a patient with a clean stage 3 pressure ulcer?

Calcium Alginate --The nurse would use a calcium alginate dressing for a patient with a clean stage III pressure ulcer. No dressing is only appropriate for an intact stage I pressure ulcer. An adherent film dressing is appropriate for an unstageable pressure ulcer. A composite film dressing is appropriate for a clean stage II pressure ulcer

What are the therapeutic benefits of heat application?

Promotes the movement of waste products Improves blood flow to injured body parts Improves delivery of Leukocytes to the wound site

When an injury is a result of trauma from a dirty penetrating object, a tetanus antitoxin injection is necessary unless the patient's last shot was administered within

the past 10 years

Which tasks in applying an abdominal binder can be delegated to NAP?

-can assist in applying an abdominal binder by applying the binder itself, reporting wound drainage, and removing the binder at specified intervals. The nurse is responsible for assessing the wound and the patient's ability to move independently

which interventions should the nurse implement when proving care to a patient at risk for skin breakdown due to urinary incontinence?

-reposition the patient off at-risk areas -apply a moisture barrier ointment -cleanse perineal area with no-rinse cleaner

maintaining airtight seal for patient who is prescribed negative-pressure wound therapy

-using skin barrier around the wound -drying around the wound thoroughly -filling uneven wound surfaces with a hydrocolloid product

What amount of retinol equivalents for Vitamin A per day should the nurse recommend a patient to consume to support proper wound healing?

1600-2000

What size syringe is used for irrigating an open wound?

35mL-irrigating an open wound

While changing the wet-to-dry dressing, the nurse notes a dime-sized ulcer un the adhesive tape. What should be applied to secure the wound?

A chronic wound may require several dressings to heal completely. In such dressings, the removal of tape may cause the skin to stretch and may also induce tension, which leads to skin damage and, thus, pressure ulcers. Solid skin barriers protect the skin from increasing the tension of the adhesive tape. Montgomery ties are used for repeated dressing changes ---Elastic net and rolled gauze aid in supporting the dressings, but do not prevent pressure ulcer development. Topper dressing is a thicker dressing that prevents strike-through of wound drainage and provides a surface to tape the dressing in place; it does not prevent ulcer development

Which topical agents are used to clean highly colonized wounds?

Acetic acid, hydrogen peroxide, and sodium hypochlorite are cytotoxic agents used to clean highly colonized wounds. Topical solutions for cleansing a clean and granulating wound should be noncytotoxic agents; these do not damage or kill fibroblasts and healing tissues. Water and normal saline are examples of noncytotoxic agents

What purpose does the dry gauze dressing serve in wound healing?

Aids in hemostasis(control blood loss, establish bacterial control & seal the defect that occurs where there is an injury) provides debridement prevents microbial contamination Keep the wound moist Keep periwound dry

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?

Applying a moisture barrier ointment over the ulcer -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

What are the functions of black polyurethane foam in wound healing?

Black polyurethane foam heals the granulating wound by contraction, edema reduction, and fluid removal. White, polyvinyl alcohol (PVA) soft foam heals the wound by restricting the growth of the granulation tissue. The wound cannot be measured with black polyurethane foam. Solid skin barriers protect the periwound skin from pressure arising from the application of tapes; black polyurethane foam does not

Upon observation the nurse sees the leakage of serous fluid from a patient's ulcer dressing. Which type of topical agents should the nurse use in this situation?

Calcium Alginate Calcium alginate helps keep wounds moist and absorbs the excess drainage. Hydrogel is used when wound hydration is required, thus facilitating moist wound healing. Normal saline is a nonirritant topical agent used to clean the wound and periwound area to prevent infection from microorganisms. Debriding enzymes are used in the case of necrotic wounds

After the nurse dresses a patient's wound, which nursing intervention would help prevent the contamination of that previously cleaned wound?

Cleaning the wound from the center to the surrounding skin --The center is the least contaminated portion of the wound. Therefore, cleaning the wound from the center to the outer surrounding skin helps prevent contamination. The wound should be cleaned from an isolated drain site to the surrounding skin to prevent contamination, but not from surrounding skin to an isolated drain site. The dressing containing the drainage should be folded with the drainage inside, and the gloves should be removed inside out, and not in a usual way to prevent contamination. An irrigating solution should be allowed to flow from the center of the wound to the surrounding skin to prevent contamination, but not from the surrounding skin to the center of the wound

The primary health care provider instructs the nurse to irrigate an infected wound that has a high concentration of bacteria. Which type of irrigating fluids will the nurse most likely use?

Dakins solution, Hydrogen peroxide & Povidone-iodine solution Dakin's solution contains sodium hydrochloride, which is a cytotoxic fluid that helps kill bacteria in the wound. Hydrogen peroxide solution and povidone-iodine solution are also used for colonized wounds. Plain water is used for the irrigation of granulating wound and draining wound. Normal saline can be used for irrigation of granulating wound

How can the nurse prevent maceration of tissue surrounding a wound?

Drying the wound edges with gauze -Excessive moisture can cause maceration of tissue surrounding a wound, so the nurse can prevent this by drying the edges of the wound with gauze. An appropriate dressing helps maintain a protective barrier and creates a healing environment for the wound. Periodic inspection of the wound is part of evaluating the patient's healing and the need for any modification in the plan of care, but it does not prevent maceration. The wound should be observed for the presence of retained irrigant solution, because this can be a medium for the growth of the bacteria, causing infection, but not maceration

Which nursing action regarding bandages is beneficial for enhancing venous returns?

Elevating the dependent extremities before applying the bandages for 20 minutes -Sitting or standing does not alter venous return. Leaving the toes of the patient visible can help circulatory assessment at the follow-up visit, but it does not enhance venous return

Which is required for wound irrigation?

Gauze dressing supplies Required for applying elastic bandages-clips, safety pins, bandages

Which statement is true regarding hydrogel dressings?

Hydrogel dressings are used for partial thickness and full thickness wounds, and enhance autolytic debridement. Some hydrogels require a secondary dressing; these dressings hydrate wounds and are used for painful wounds, as they do not adhere to the wound bed. Hydrogel dressings are used to relieve pain in the wounds. Hydrogel dressings are sheet dressings or gauze dressings impregnated with glycerin-based amorphous gel, but not saline solution

abnormal characteristics for primary wound abnormal characteristics for secondary wound

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

Which nursing intervention is appropriate when wound drainage increases?

Increase irrigation frequency wound cultures- obtained to ID the growth of microorganisms if wound does not appear to be healing changing the dressing-should be done as needed, but it will not decrease drainage warm cleaning solutions-used to increase comfort to the patient and reduce vascular constriction in the tissues, but they will not affect drainage quantities

While caring for a patient who has a chronic wound, the nurse observes exudates in the periwound area. Which nursing intervention is appropriate in this scenario?

Increase the frequency of dressing change Use of petroleum-based skin protectant Use of dressing material that has more absorbing capacity -A sterile cotton-tipped applicator helps determine the depth of the pressure ulcer; it cannot be used to prevent moisture-associated skin damage. Dakin's solution is used as a topical agent for cleaning a wound; it cannot reduce the risk of pressure ulcer formation

Which pressure ulcer site is found immediately distal to the buttock?

Ischium -The sole pressure ulcer site is found on the bottom of the foot. The sacrum pressure ulcer site is on the tailbone, or just above the gluteal area. The scapula pressure ulcer site is found on the shoulder blade

Which type of support surface should the nurse plan to use to treat and prevent pulmonary, venous stasis, and urinary complications associated with immobility?

Lateral rotation Low-air-loss and nonpowered and support surfaces are indicated for prevention or treatment of skin breakdown. Air-fluidized beds may also be used to prevent or treat skin breakdown and to protect newly flapped or grafted surgical sites.

A nurse finds that a patient who has urinary incontinence scores 11 on the Braden scale. Which nursing action is most appropriate to prevent this patient from developing pressure ulcers?

Managing moisture. The use of absorbable clothes or diapers can also be suggested. Managing shear to prevent the development of pressure ulcers is advisable for the patient who experiences friction with the surface of a chair or bed linens. Patients who have a poor nutritional intake are at an increased risk for the development of pressure ulcers, and should be provided with nutritional information. Foam wedges are required for patients who are bedridden due to surgery; these patients are at increased risk for developing pressure ulcers, because they are unable to shift position easily

Which patient is at risk for systemic infection if heat is applied as a form of therapy?

Patient with an abscessed tooth is at risk for rupture and systemic injury if heat is applied during therapy. The pediatric patient, spinal cord injury patient, and patient with arteriosclerosis are at risk for burns, not systemic infection, with application of heat

Which nursing action is appropriate when providing care to a patient who has intact skin but is at high risk for impaired skin integrity of the heels?

Place a pillow under the calves Avoiding prolonged elevation of the head of the bed is appropriate for a high-risk patient who already has a pressure ulcer. Ordering a standard hospital foam mattress is appropriate for a high-risk patient who is not at risk for impaired skin integrity. Considering an alternating pressure support surface is appropriate for a patient who is already diagnosed with an ulcer

Evaluation of a patient after application of an elastic bandage

Remove the dressings at night, reapply in morning Assess skin of patient under bandage 2x during 8 hour period Observe the skin for Cyanosis Observe the mobility of the extremity Ask the patient about numbness and tinging in the bandaged areas

How are the irrigation procedures for cleaning a wound with a wide opening and a deep wound with a narrow opening similar?

Same gauge size of the angiocatheter --A 19-gauge angiocatheter is used for cleaning both a wound with a wide opening and a deep wound with a narrow opening. Cleaning a deep wound with a narrow opening can take longer to empty the irrigant from the opening. Pressure applied to flush a deep wound with a narrow opening is slow and continuous, and pressure applied to flush a wound with a wide opening is not as slow. While cleaning a wound with a wide opening, the syringe tip is positioned 1 in above the upper end of the wound. While cleaning a deep wound with a narrow opening, the catheter tip is inserted into the wound

what are the therapeutic benefits of using bandages over dressings?

Secures splints prevents edema in the lower legs secures dressings -does not reduce pressure of facilitate mobility

Wound drainage color/consistency

Serous- clear sanguineous-bright and red serosanguineous- pink purulent- thick & yellow

Which advantages should the nurse include in a teaching session on the benefits of using moist applications for treating a wound?

Softens wound exudate Conforms will to most body areas Penetrates deeply into tissue layers dry--Decreased risk for burns and retaining temperature longer because evaporation does not occur

Pressure ulcer healing

Stage IV pressure ulcers are expected to heal through granulation and reepithelialization. Wound care for a stage I pressure ulcer is aimed at slow healing without epidermal loss over 7 to 14 days. Stage II pressure ulcers are expected to heal through reepithelialization. Wound care for an unstageable pressure ulcer includes debridement done to soften the eschar

which adjuvant treatment is only considered for patients diagnosed with an unstageable pressure ulceration?

Surgical consultation for debridement

The RN is overseeing a student nurse who is caring for a patient who has impaired circulation distal to an elastic bandage. Which of the practical nurse's actions need correcting?

Taking a wound culture Taking a wound culture is necessary if infection is suspected, but it doesn't relieve impaired circulation. Releasing the bandage, palpating the extremity, and reapplying the bandage in the same area with less pressure are appropriate interventions when circulation is impaired

Skin layers

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

sutures

The finer the sutures, the more minimal the tissue injury. Deep sutures are composed of an absorbable, not nonabsorbable, material that disappears over time. All sutures are foreign bodies, and so they can all cause local inflammation. Retention sutures are placed more deeply than skin sutures

What is characteristic of abnormal healing in a secondary-intention wound?

The presence of necrotic or slough tissue at the base of the wound indicates abnormal healing in a secondary-intention wound. An increase in inflammation in the first 3 to 5 days after injury, an absence of epithelialization of the wound edges by day 4, and the presence of drainage for more than 3 days after wound closure are characteristic of abnormal healing of a primary-intention wound, not a secondary-intention wound

Wound irrigation

The syringe should never occlude the wound opening Fluid should flow directly into the wound The syringe flushes the wound with constant low-pressure flow Syringe tip should be held over drainage site, not in it The pressure applied during irrigation is safe and wont damage the healing wound tissue

Which nursing interventions minimize the risk for pressure ulcer development

Three major areas of nursing interventions for prevention of pressure ulcers are: (1) skin care and management of incontinence, such as applying barrier creams for patients who are incontinent; (2) mechanical loading and support devices, which include proper positioning and the use of therapeutic surfaces, such as repositioning the patient every 2 hours and using a draw sheet during repositioning; and (3) education, such as information related to preventing skin breakdown. Conducting a nutritional assessment is important; however, this is a part of assessment and is not necessary every 8 hours

While caring for a patient in the postsurgical unit, the nurse palpates the area around the surgical wound and asks the patient if there is tenderness. What is the rationale behind this nursing action?

To assess for the risk of periwound edema. ...and pain by palpating the affected area for tenderness. An abrasion is a small superficial wound with little damage to the capillaries. Swelling, bluish discoloration, sensation, and warmth are signs of a hematoma. Evisceration is an emergency condition in which visceral organs protrude out through the wound opening. Abrasion, hematoma, and evisceration can be observed with visual inspection; palpation is not necessary.

Why is maintaining an airtight seal when providing care to a patient who is receiving negative-pressure wound therapy important?

To avoid wound desiccation -The rationale for maintaining an airtight seal when providing care to a patient who is prescribed negative-pressure wound therapy is to avoid wound desiccation. An airtight seal in negative-pressure wound therapy will not necessarily avoid wound infection, accelerated healing, or discomfort during dressing changes

The nurse uses an elastic net as additional dressing in a patients leg region. What is the rationale behind this nursing action?

To prevent the dressing from slipping. The nurse uses rolled gauze or elastic net while dressing wounds on the extremities to secure the dressings in place. Placing the patient in a comfortable position improves patient comfort, but this is not why using an elastic net is used. Assessing the condition of the wound would help to determine the rate of healing. Removing gloves and disposing of them in bags after dressing the wound would reduce transmission of infection to other parts of the body; applying an elastic net may not help reduce the transmission of infection

while dressing a patients wound, the nurse irrigates the wound until there is a clear flow of the solution. What is the rationale behind this nursing action?

To remove the debris from the wound.

A nurse is evaluating the circulation of a patient who has a bandage over a deep lower leg wound. What should the nurse check to assess circulation

Toes, numbness & capillary refill

Which type of dressing is used for stage 1 pressure ulcers?

Transparent film dressings/hydrocolloid are used for stage I pressure ulcers or a partial thickness wounds. Gauze sponges are the oldest and the most common dressings that are used for simple, uncomplicated wounds or wounds with minimal drainage; they are not specifically preferred for stage I pressure ulcers. Hydrogel dressings are used for partial thickness and full thickness wounds. Hydrocolloid dressings are used for shallow to moderately deep dermal ulcers

The nurse is instructing a caregiver about home care considerations for a patient who has elastic bandages on the ankles and feet.

Two sets of bandages should be available so that one can be cleaned while the other is in place The caregiver should report any changes in the skin integrity to the health care team They should not be applied as tightly as possible Bandages used for reducing swelling at the feet and ankles should be applied in the morning before getting out of the bed The bandages should be removed on a daily basis

Which statements are true regarding pulsatile high-pressure lavage?

Used for necrotic wounds The size of the wound determines the amount of irrigation to be done It can be used for a patient who is on anticoagulant therapy with caution -The lavage should not be used when muscle is exposed because it may damage soft tissue. The pressure of the lavage should be between 8 and 15 psi, not 15 and 22, during irrigation

Braden scale for pressure ulcer development

Very High Risk: Total Score 9 or less High Risk: Total Score 10-12 Moderate Risk: Total Score 13-14 Mild Risk: Total Score 15-18 No Risk: Total Score 19-23

Which Nutrient is an antioxidant that promotes wound healing? Zinc Protein Vitamin C Vitamin A

Vitamin C Vitamin C is an antioxidant that is useful in wound healing by promoting collagen synthesis, capillary wall integrity, fibroblast function, and immunity. Zinc is an essential nutrient that promotes collagen formation, protein synthesis, and cell membrane and host defenses. (15-30mg recommended) Proteins support healing with fibroplasia, angiogenesis, collagen formation, and wound remodeling while boosting immunity. Vitamin A supports healing with epithelialization, wound closure, inflammatory response, angiogenesis, and collagen formation.

Interventions-bleeding while changing the patients wound dressing

When a nurse observes bleeding during a dressing change, the nurse should apply pressure on the wound with the hands to reduce the bleeding. Due to the amount of bleeding, the condition of the patient may vary. Therefore, the nurse should obtain the patient's vital signs. The nurse should also inspect along the dressing and underneath the patient to determine the amount of bleeding. Obtaining a wound culture may not be possible when there is bleeding, and wound cultures should be obtained when the wound appears tender and inflamed. The wound site should not be covered with sterile moist dressings, unless underlying organs are protruding

equipment for irrigating a surgucal wound?

a 35-mL syringe with a 19-gauge soft angiocatheter

nursing actions intended to minimize patient pain when performing a wound care procedure?

cleaning the patients wound edges gently turning and repositioning patient carefully administering prescribed analgesics as ordered

Advantages of hydrogel dressing?

easy removal, debrides necrotic tissue, provides a moist environment

What is the function of pressure dressings when applied with an elastic bandage?

eliminates the dead space in underlying tissues to allow healing -Transparent film dressings adhere to the undamaged skin. Gauze sponges are absorbent and are used for open wounds to wick away wound exudate. Pressure dressings exert localized downward, not upward, pressure over the potential bleeding site

What are the implications for healing of a surgical wound?

heals by epithelialization clean and intact wound edges heals quickly with minimal scar formation wound contraction is present granulation tissue forms

Stage 2 dressings

hydrogel, hydrocolloid, composite film

nursing interventions appropriate for reducing the risk of infection in a sacral pressure ulcer

irrigating and cleansing the wound with saline 2x/day packing the open wound with antibiotic solution-moistened gauze

According to the Braden Scale for predicting pressure ulcer risk, which factor most puts the patient at risk for developing a pressure ulcer?

poor nutrition

advantages of dry applications for wound therapy?

reduces the risk of burns -Moist, not dry, applications soften wound exudate, conform well to most body areas, and allow heat to penetrate deeply into the tissue layers

What are the therapeutic benefits of cold application?

reduces tissue oxygen needs Reduces blood flow to injured body parts It decreases muscle tension

Skin surrounding ulcer has become macerated... appropriate nursing interventions?

reporting to the primary HCP applying liquid skin barrier on periwound area reducing the exposure of wound to topical agents

for which pressure ulcers would the nurse include education related to both granulation and reepithelialization?

stage 3 + 4

What can cause an acute wound?

trauma Surgical incision --Pressure, vascular compromise, and repetitive insults to tissue can cause chronic, not acute, wounds