Chap 32 Prep U
A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? Use clean technique to clean the wound. Clean the wound in a circular pattern, beginning on the perimeter of the wound. Clean the wound from the top to the bottom and from the center to outside. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth.
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.
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. secondary intention. tertiary intention. dehiscence.
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.
The nurse is caring for a Penrose drain for a client post-abdominal surgery. What nursing action reflects a step in the care of a Penrose drain that needs to be shortened each day? The nurse carefully cleans around the sutures with a swab and normal sterile saline solution prior to shortening the drain. The nurse empties and suctions the device, following the manufacturer's directions prior to shortening the drain. The nurse pulls the drain out a short distance using sterile scissors and a twisting motion, then cuts off the end of the drain with sterile scissors. The nurse compresses the container while the port is open, then closes the port after the device is compressed to empty the system before shortening the drain.
Sometimes the physician orders a Penrose drain that is to be shortened each day. To do so, grasp the end of the drain with sterile forceps, pull it out a short distance while using a twisting motion, then cut off the end of the drain with sterile scissors. Place a new sterile pin at the base of the drain, as close to the skin as possible. The Penrose drain does not collect drainage, therefore it does not need to be emptied or compressed. If the Penrose drain is to be shortened, it cannot be sutured into the site.
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? Glascow scale Braden scale FLACC scale Morse scale
The Braden scale is an assessment tool used to assess the client's risk for pressure injury development. The Glascow 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 Penrose drain typically exits a client's skin through a stab wound created by the surgeon. T/F
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.
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? elevate the head of the bed 90 degrees use pillows to maintain a side-lying position as needed provide incontinent care every 4 hours as needed place a foot board on the bed
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 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 I stage II stage III stage IV
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.
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? Pasta salad Fish Banana Green beans
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.
When clients are pulled up in bed rather than lifted, they are at increased risk for the development of decubitus ulcers. What is the name given to the factor responsible for this risk? friction necrosis of tissue ischemia shearing force
A shearing force results when one layer of tissue slides over another layer. Clients who are pulled rather than lifted when being moved up in bed or from bed to chair to stretcher are at risk for injury from shearing forces.
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 I Stage II Stage III Stage IV
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 small plastic ruler a sterile tongue blade lubricated with water soluble gel an otic curette
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 is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? The nurse uses wet-to-dry dressings continuously. The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown. The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. The nurse packs the wound cavity tightly with dressing material.
A wound with heavy exudate will need a more absorptive dressing and a dry wound will require rehydration with a dressing that keeps the wound moist. The nurse would not keep the surrounding tissue moist. The nurse would not pack the wound cavity tightly, rather loosely. The nurse would not use wet-to-dry dressings continuously.
The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate? Reduce the time interval between dressing changes. Assure that the packing material is completely saturated when placed in the wound. Use less packing material. Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead.
Allowing the dressing material to dry will disrupt healing tissue. Therefore, the time interval between dressing changes should be reduced to prevent the dressing from drying out. Too much moisture in the dressing may cause maceration. Shortening the time interval between dressing changes is more appropriate than increasing dressing moisture. There is no indication that too much packing material was used. A hydrocolloid dressing in not indicated.
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? a) "The condition is hard to cure." B)"You will likely experience periods of increased skin outbreaks and periods of remissions." c) "You will have this disease for life." D)"Your personal health habits will dictate how well you handle this condition."
B) 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 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 stimulating the wound bed to promote the growth of granulation tissue removing purulent drainage from the wound bed in order to accurately assess it removing excess drainage and wet tissue to prevent maceration of surrounding skin
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 postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for: infection. herniation. dehiscence . evisceration.
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.
The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate? "Dehiscence is not anything that you need to worry about." "Dehiscence is when a wound has partial or total separation of the wound layers." "Dehiscence is a total separation of the wound with protrusion of the viscera through it." "Dehiscence is the softening of tissue due to excessive moisture."
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.
Which is not considered a skin appendage? Hair Connective tissue Sebaceous gland Eccrine sweat glands
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 in the emergency department with a cut sustained 15 minutes ago while the client was preparing dinner at home. The nurse understands that the wound is in which phase of healing? maturation phase hemostasis phase inflammatory phase proliferation phase
Hemostasis is the initial phase after an injury. Hemostasis stimulates other cells to come to the wound to begin other phases of wound healing. The inflammatory phase follows hemostasis; white blood cells move into the wound to remove debris and release growth factors. The proliferation phase is the regenerative phase, in which granulation tissue is formed. The maturation phase involves collagen remodeling.
What type of dressing has the advantage of remaining in place for three to seven days, resulting in less interference with wound healing? transparent film hydrocolloid dressing hydrogel alginate
Hydrocolloids are occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment, provide minimal to moderate absorption of drainage, maintain a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing. Hydrogels maintain a moist wound environment and are best for partial or full-thickness wounds. Alginates absorb exudate and maintain a moist wound environment. They are best for wounds with heavy exudate. Transparent films allow exchange of oxygen between wound and environment. They are best for small partial-thickness wounds with minimal drainage.
The nurse would recognize which client as being particularly susceptible to impaired wound healing? an obese woman with a history of type 1 diabetes a client whose breast reconstruction surgery required numerous incisions a man with a sedentary lifestyle and a long history of cigarette smoking A client who is NPO (nothing by mouth) following bowel surgery
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.
Which education points would the nurse use to explain the development of pressure injuries to clients and how to prevent them? Select all that apply. "Pressure injuries usually occur over bony prominences where body weight is distributed over a small area without much subcutaneous tissue." "Most pressure injuries occur over the trochanter and calcaneus." "Generally, a pressure injury will not appear within the first 2 days in a person who has not moved for an extended period of time." "The major predisposing factor for a pressure injury is internal pressure over an area, resulting in occluded blood capillaries and poor circulation to the tissues." "The skin can tolerate considerable pressure without cell death, but for short periods only." "The duration of pressure, compared to the amount of pressure, plays a larger role in pressure injury formation."
Pressure injuries usually occur over bony prominences. The skin can tolerate considerable pressure without cell death, but for short periods only. The duration of pressure, compared to the amount of pressure, plays a larger role in pressure injury formation. Pressure injuries can develop in a variety of locations where bony prominences are located. The most common are the coccyx and sacrum. A pressure injury can appear in less than 2 hours of time, depending on the factors present. Most pressure injuries develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time, or when soft tissue undergoes pressure in combination with shear and/or friction.
A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn? Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown Superficial, which may be pinkish or red with no blistering May vary from brown or black to cherry red or pearly white; bullae may be present A superficial partial-thickness burn, which can appear dry and leathery
Second-degree burns are moderate to deep partial-thickness burns that may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. First-degree burns are superficial and may be pinkish or red with no blistering. Third-degree burns are full-thickness burns and may vary from brown or black to cherry-red or pearly-white; bullae may be present; can appear dry and leathery.
The nurse is using the Braden Scale to determine a client's risk for pressure injuries. What criteria will the nurse assess? Select all that apply. sensory perception nutrition age ability friction
Sensory perception, nutrition, ability, and friction are all criteria used in the Braden Scale. Age is not a graded criterion in predicting the risk for pressure injuries.
The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces? a client sitting in a chair who slides down a client who lifts himself up on his elbows a client who lies on wrinkled sheets a client who must remain on his back for long periods of time
Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Clients who are pulled, rather than lifted, when being moved up in bed (or from bed to chair or stretcher) are at risk for injury from shearing forces. A client who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a client who sits in a chair but slides down. The client that is most likely to develop a pressure ulcer from shearing forces would be a client sitting in a chair who slides down.
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 should keep this on my ankle until it is numb." "I must wait 15 minutes between applications of cold therapy." "I will put a layer of cloth between my skin and the ice pack." "I can let this stay on my ankle an hour at a time."
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.
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 ulcer? 35-year-old client who was admitted after a motor vehicle accident and has bilateral casts 45-year-old client who has cancer, is receiving chemotherapy, and is being admitted with leukopenia 65-year-old incontinent client with a hip fracture on bed rest 70-year-old client with Alzheimer's who wanders the nursing unit and refuses to sit and eat meals
The 65-year-old client who is incontinent with a hip fracture would be at highest risk for developing a pressure ulcer. This client has several risk factors: age, incontinence, and decreased mobility related to the hip fracture. The client who had a car accident and has bilateral casts does have decreased mobility but does not have as many risk factors as the client with the hip fracture. The client with cancer has a weakened immune system. However, the client has no immobility issues noted. The client with Alzheimer's is ambulatory and has decreased nutrition. The risk for this client is not a great as that of the client with the hip fracture because of the mobility.
A nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac drain in place. Which statement indicates that the client understands? "I will check and empty the drain every 6 hours." "I will squeeze the chamber and apply the cap to maintain negative pressure." "I will apply a dressing at the end of the drain to catch any drainage." "I will alternate between positive and negative pressure every 2 hours."
The Hemovac drain chamber should be squeezed and the cap applied to maintain negative pressure. The negative pressure pulls the drainage into the collection chamber. This negative pressure must be maintained continuously unless the drain is being emptied. The drain must be checked and emptied at least every 4 hours. A Penrose drain has gauze at the end of the drain to catch drainage.
To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question? "Do you experience incontinence?" "How many meals a day do you eat?" "Do you use any lotions on your skin?" "Have you had any recent illnesses?"
The client's health history is an essential component in assessing the client's integumentary status and identification of risk factors for problems with the skin. The priority question addresses a source of moisture on the skin. Moisture makes the skin more susceptible to injury because it can create an environment in which microorganisms can multiply, and the skin is more likely to blister, suffer abrasions, and become macerated (softening or disintegration of the skin in response to moisture). Sound nutrition is important in the prevention and treatment of pressure injuries. The number of meals eaten per day does not give a clear assessment of nutritional status. The nurse should question the client about the skin care regimen, such as the use of lotions, but this would not be the priority in determining the risk for pressure injury development. Asking the client about any recent illnesses is not a priority in determining the risk for pressure injury development.
The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly? The nurse uses a safety pin to attach the pad to the bedding. The nurse covers the heating pad with a heavy blanket. The nurse places the heating pad under the client's neck. 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.
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." "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." "As soon as the infection clears, your surgeon will staple the wound closed."
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.
The nurse has started an intravenous catheter in the client's hand. What type of dressing will the nurse use to secure the IV catheter? transparent film 2 × 2 in (5 × 5 cm) gauze hydrocolloid dressing hydrogel sheet
To secure an IV catheter, the nurse uses a transparent film. The transparency film allows visualization of the IV site, is self-adhesive, and protects against contamination. The 2 × 2 in (5 × 5 cm) gauze dressing does not allow visualization of the IV site and does not protect against moisture. The hydrocolloid dressing does not allow visualization of the IV site and is best used in wounds with light to moderate drainage. Hydrogel sheets are not an appropriate dressing for an IV site. They do not allow visualization of the IV site and are best used in partial- and full-thickness wounds, burns, dry wounds, wounds with minimal exudate, necrotic wounds, and infected wounds.
The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? a surgical incision with sutured approximated edges a large wound with considerable tissue loss allowed to heal naturally a wound left open for several days to allow edema to subside a wound healing naturally that becomes infected.
Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention. Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention. If a wound that is healing by primary intention becomes infected, it will heal by secondary intention. Wounds that heal by secondary intention take longer to heal and form more scar tissue. Connective tissue healing and repair follow the same phases in healing. However, differences occur in the length of time required for each phase and in the extent of new tissue formed. Wounds healed by tertiary intention, or delayed primary closure, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed.
The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response? "This is normal tissue." "That is old clotted blood underneath the wound" "That is called undermining, a type of tissue erosion." "That is necrotic tissue, which must be removed to promote healing."
Wounds that are brown or black are necrotic and not considered normal. Slough is dead moist, stringy dead tissue on the wound surface that is yellow, tan, gray, or green. Undermining is tissue erosion from underneath intact skin at the wound edge.