Chapter 31: Skin Integrity and Wound Care

The client with vaginal itching and burning has been scheduled for an examination and Pap procedure. Which teaching regarding douching will the nurse provide to the client to prepare for the appointment?

"Do not douche 24-48 hours before the procedure."

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 will put a layer of cloth between my skin and the ice pack."

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?

"You will likely experience periods of increased skin outbreaks and periods of remissions."

In which situations has the nurse used a dressing properly? (Select all that apply.)

A nurse places OpSite over a central venous access device insertion site. A nurse uses appropriate aseptic techniques when changing a dressing. A nurse places Sof-Wick around a drain insertion site.

A nurse is evaluating a client's laboratory data. Which of the following laboratory findings should the nurse recognize as increasing a client's risk for pressure ulcer development?

Albumin 2.8 mg/dL

Which is not considered a skin appendage?

Connective tissue

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

Corticosteroids

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 ulcer?

Use pillows to maintain a side-lying position as needed.

A nurse is caring for a client who has a wound on the right thigh from an axe. The nurse is using the RYB wound classification system and has classified the wound as "Yellow". Based on this classification which of the following nursing actions should the nurse perform?

Wound irrigation

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

Wound

break or disruption in the normal integrity of the skin and tissues

Sinus tract

cavity or channel underneath the wound that has potential for infection

Serous drainage

composed primarily of the clear, serous portion of the blood and from serous membranes.

Sanguineous drainage

consist of large numbers of red blood cells and looks like blood

Necrosis

death of tissue

Ischemia

deficiency of blood in a particular area

Desiccation

dehydration

Epithelialization

epithelial migration to the wound bed

Dermis

second layer of skin, consist of a framework of elastic connective tissue

Bandages

strips of cloth, gauze, or elasticized material used to wrap a body part

Biofilm

thick grouping of microorganisms

Eschar

thick, leathery scab or dry crust that is necrotic (dead tissue) and must be removed before the stage can be determined accurately

Epidermis:

top layer, uttermost portion

Subcutaneous tissue

underlying layer that anchors the skin layers to the underlying tissues of the body

The nurse is caring for a client for whom maggot therapy has been ordered for a nonhealing leg wound. The client states, "You're not putting those nasty bugs on me!" What is the appropriate nursing response? Select all that apply.

"Medical maggots are sterilized before they are introduced to the wound." "I understand your concern; let's talk further about your thoughts about this treatment." "The choice regarding whether to have or decline this treatment is yours."

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

The nurse is performing an admission assessment on a client being admitted to a long-term care facility. The nurse notes the client has a history of psoriasis. Which locations on the body is the nurse most likely to find manifestations consistent with the condition? Select all that apply.

Elbows Knees Soles of the feet

A physician orders a wound irrigation to apply an antiseptic to a client's wound. The nurse will follow which guideline for performing this procedure?

If the wound is closed, clean technique may be used instead of sterile technique.

What is true about the dermis? Select all that apply.

It is responsible for producing the proteins collagen and elastin. It is the thickest skin layer.

A client with a history of pressure ulcers is discussing nutrition with the nurse. The client correctly indicates plans to include which vitamin in the diet to promote wound healing? Select all that apply.

Vitamin B3 (niacin) Vitamin B6 (pyridoxine)

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use?

figure-of-eight turn

A woman fell from a truck and required abdominal surgery to repair lacerations of the abdomen and bowel. The client now has constant drainage from a wound that will not heal on the surface of the abdomen. The client has a(an):

fistula.

Scar

formed by new collagen that continues to be deposited, which compresses the blood vessels in the healing wound, so, an avascular collagen tissue that does not sweat, grow hair, or tan in sunlight, eventually becomes a flat, thin line.

Granulation tissue

forms the foundation for scar tissue development

Purulent drainage

made up of WBC, liquefied dead tissue debris, and both dead and live bacteria.

Serosanguineous drainage

mixture of serum and red blood cells (light pink to blood)

Friction

occurs when two surfaces rub against each other.

Exudate

plasma and blood that leak out forming liquid

Negative pressure wound

promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid, while providing a moist wound healing environment.

Dressing

protective covering placed over a wound

Debridement

removal of devitalized tissue and foreign material

Shear

results when one layer of tissue slides over another layer