PrepU_31_ Skin integrity

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."

Hemovac

A Hemovac drain is placed into a vascular cavity where blood drainage is expected after surgery. Wound pouching is used on wounds that have excessive drainage

A Penrose drain

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.

A bandage is a strip or roll of cloth wrapped around a body part

A bandage is a strip or roll of cloth wrapped around a body part to help support the area around the wound.

A hydrocolloid dressing helps .

A hydrocolloid dressing helps keep the wounds moist.

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk?

A shearing force results

A shearing force results

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

Stage I pressure ulcer

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

A stage II pressure ulcer involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II could present as a blister, abrasion, or shallow crater

Stage III pressure ulcer

A stage III ulcer 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. Ulcers at this stage may include undermining and tunneling

A nurse is caring for a client who has a 6-cm × 8-cm wound caused by a motor vehicle accident. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist with a yellow and red wound bed. Which dressing does the nurse anticipate is best to be ordered by the primary care provider?

Alginates are used in infected or noninfected wounds with moderate to heavy drainage. Alginates are used with moist wound beds with red and yellow tissue

Adequate skin perfusion requires four factors.

Arteries and veins must be patent and functioning well. b) The heart must be able to pump adequately. c) The volume of circulating blood must be sufficient. d) Local capillary pressure must be higher than external pressure

(see full question) A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 cm x 6.4 cm. Which action should the nurse use during wound care?

Cleanse with a new gauze for each stroke.

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

Corticosteroids

The nurse is taking care of a client on the second post-operative day who asks about wound dehiscence. Which response by the nurse is most accurate?

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

Dehiscence

Dehiscence is wound separation, not wound healing

To determine a client's risk for pressure ulcer development, it is most important for the nurse to ask the client which question?

Do you experience incontinence?"

Which best describes the third phase of the wound healing process: proliferative?

Epidermal cells, which appear pink, reproduce and migrate across the surface of the wound in a process called epithelialization

The nurse is assessing a client's surgical wound after abdominal surgery and sees that the viscera is protruding through the abdominal wound opening. Which term best describes this complication

Evisceration is the protrusion of viscera through an abdominal wound opening. Evisceration can follow dehiscence if the opening extends deeply enough to allow the abdominal fascia to separate and internal organs to protrude

Gauze dressing is ideal for

Gauze dressing is ideal for covering fresh wounds that are likely to bleed, or wounds that exude drainage

Which is not considered a skin appendage?

Hair, the sebaceous gland, and eccrine sweat glands are skin appendages that are formed with the enfolding of the epidermis into the dermis.

The nurse is discussing care of a client's wound that has nonviable tissue in the base with the wound care nurse. The wound care nurse recommends that the nurse utilizes a dressing that would promote autolytic debridement of the wound. Which of the following dressings should the nurse select?

Hydrocolloid

Jackosn-Pratt

Jackson-Pratt drains are typically used with breast and abdominal surgery drainage A Penrose drain provides a sinus tract for drainage

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which of the following actions should the nurse perform in obtaining a wound culture?

Keep the swab and inside of the culture tube sterile

Decubitus ulcer

Many factors predispose an individual to have pressure ulcers; factors can be physical (local infections, malnutrition), functional (impaired mobility, incontinence), and psychosocial (poor adherence to treatment, impaired cognition). (less)

Which best describes the last phase of the wound healing process

Maturation is the final stage of full-thickness wound healing, in which the number of fibroblasts decreases, collagen synthesis is stabilized, and collagen fibril become increasingly organized

A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in this situation?

Moisten sterile gauze with sterile saline to loosen crusts before removing sutures

Negative-pressure wound therapy (NPWT)

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

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

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 is smoking and sedentary lifestyle.

Penrose drain

Penrose drains are commonly used after a surgical procedure or for drainage of an abscess.

A nurse is teaching a nursing student about surgical drains and their purposes. Which of the following would the nursing student understand is the purpose for a t-tube drain?

Provides drainage for bile A t tube is used to brain bile such as after a cholecystectomy.

(see full question) A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action?

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

Stage II ulcer

Stage II involves a partial tissue loss such as a blister. A stage II could present as a blister, abrasion, or shallow crate

Stage IV

Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscles

Stage IV pressure ulcer

Stage IV ulcers 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. (less)

Which activity should the nurse implement to decrease shearing force on the client with a stage II pressure ulcer?

Support the client from sliding in bed.

Suspected deep tissue injury

Suspected deep tissue injury A maroon blood-filled blister is staged as a suspected deep tissue injury. It is often preceded by a boggy or painful area. A stage II wound is a partial thickness loss of dermis that often presents as an open blister.

A nurse is caring for a client at a wound care clinic. The client has a 5-cm × 6-cm abdominal wound dehiscence. Which type of wound repair would the nurse expect with this wound?

The client with a wound dehiscence will undergo wound repair by secondary intention. In these wounds, the wound edges are not well approximated and will require more tissue replacement. Primary intention involves wound edges that are well approximated or close together. Tertiary intention involves wounds that are left open for a period of time and then closed. Desiccation is a process where cells are dehydrated. This leads to cell death and delays healing

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

The nurse should use a transparent dressing to cover the IV insertion site because such dressings allow the nurse to assess a wound without removing the dressing. In addition, they are less bulky than gauze dressings and do not require tape, since they consist of a single sheet of adhesive material

(see full question) The nurse is caring for a client who has a pressure ulcer on his back. What nursing intervention would the nurse perform?

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.

Which best describes the first phase of the wound healing process hemostasis

The onset of vasoconstriction, platelet aggregation, and clot formation are part of the first phase of wound healing—hemostasis

Which best describes the second phase of the wound healing process

The second phase, the inflammatory phase, is marked by vasodilation and phagocytosis as the body works to clean the wound.

(see full question) A female patient who is being treated for self- inflicted wounds tells the nurse that she is anorexic. What criteria would alert the health care worker to her nutritional risk?

Total lymphocyte count of 1,500/mm3

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

Transparent film dressings are semipermeable, waterproof, and adhesive, allowing for visualization of the access site to aid assessment, as well as protecting the site from microorganisms. Gauze dressings do not allow the nurse to visualize the site without partially or completely removing the dressing

Which would be appropriate actions for the nurse to take when cleaning and dressing a pressure ulcer? Select all that apply

Use whirlpool treatments, if ordered, until the ulcer is considered clean. • Keep the ulcer tissue moist and the surrounding skin dry. • Use a dressing that absorbs exudate but maintains a moist healing environment

Depth of a wound

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

Wounds healing by delayed primary intention or tertiary intention

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.

Wounds healing by primary intention

Wounds healing by primary intention form a clean, straight line with little loss of tissue. .

Wounds healing by secondary intention

Wounds healing by secondary intention are large wounds with considerable tissue loss. The edges are not approximated. Healing occurs by formation of granulation tissue.

In the older adult client, wrinkling is related to:

Wrinkling and poor skin turgor results from loss of elastic fibers and collagen changes in the dermal connective tissue.

The nurse considers the impact of shearing forces in the development of pressure ulcers in clients. Which client would be most likely to develop a pressure ulcer from shearing forces?

a client sitting in a chair who slides down

The following laboratory criteria indicate that a patient is nutritionally at risk for development of a pressure ulcer:

albumin level <3.2 mg/dL (normal, 3.5-5 mg/dL), prealbumin <19 mg/dL (normal 16-40 mg/dL), body weight decrease of 5% to 10%. Additional laboratory tests to consider in patients at risk for or presenting with pressure ulcers include: total lymphocyte count <1,800/mm3 (normal, 1,000- 4,000/mm3), hemoglobin A1C >8% (normal <6%), glucose >120 mg/dL (normal 70-120 mg/dL). Although one of the options is body weight decrease of 5%, it is not the best answer.

(see full question) A nurse is assessing a pressure ulcer on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound?

stage III ulcer

A nurse assessing client wounds would document which examples of wounds as healing normally without complications?

• The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. • a wound that does not feel hot upon palpation • a wound that forms exudate due to the inflammatory response