Skin integrity

The acute care nurse is caring for a patient whose large surgical wound is healing by secondary intention. The patient asks, "Why is my wound still open? Will it ever heal?" Which of the following responses by the nurse is most appropriate?

"Your wound will heal slowly as granulation tissue forms and fills the wound." There is no indication of infection. Large wounds with extensive tissue loss may not be able to be closed by primary intention

A nurse is caring for clients on a medical surgical unit. Based on known risk factors, the nurse understands which of the following clients has the highest risk for developing a pressure ulcer?

65-year-old incontinent client with a hip fracture on bed rest 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 with bilateral casts does have decreased mobility but does not have as many risk factors as the hip fracture client. The cancer patient has a decreased immune system. However, the patient has no immobility issues noted. The Alzheimer's client is ambulatory and has decreased nutrition. The risk for this client is not a great as the client with the hip fracture because of the mobility.

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?? The client's health history is an essential component for 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 ulcers. The number of meals eaten per day does not give a clear assessment of nutritional status. You want to question the client about skin care regimens, such as the use of lotions, but this would not be the priority in determining the risk for pressure ulcer development. Asking the client about any recent illnesses is not a priority in determining the risk for pressure ulcer development

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

A Penrose drain promotes drainage passively into a dressing. A Penrose drain is an open drainage system that promotes drainage of fluid passively into a dressing. Additional drains include the Jackson-Pratt drain that has a small bulb like collection chamber that is kept under negative pressure. A Hemovac is a round collection chamber with a spring inside that must be kept under negative pressure also

The nurse is performing pressure ulcer assessment for patients in a hospital setting. Which patient would the nurse consider to be at greatest risk for developing a pressure ulcer?

A critical care patient Various factors are assessed to predicate a client's risk for pressure ulcer development. Client mobility, nutritional status, sensory perception, and activity are assessed. The client would also be assessed for possible moisture/incontinence issues as well as possible friction and sheer issues. Considering these factors, the individual that would be at greatest risk of developing a pressure ulcer would be a critical care client.

You are preparing to measure the depth of a patient's tunneled wound. Which of the following implements should you use to measure the depth accurately?

A sterile, flexible applicator moistened with saline A sterile, flexible applicator is the safest implement to use. The other implements are too large, inflexible, or not sterile

A client's risk for the development of a pressure ulcer is most likely due to which lab result?

Albumin 2.5 mg/dL An albumin level of less than 3.2 mg/dL indicates the client is nutritionally at risk for the development of a pressure ulcer. Hemoglobin A1C levels greater than 8% place the client at risk for the development of pressure ulcers due to prolonged high glucose levels. Glucose levels greater than 120 mg/dL are a risk factor for the development of pressure ulcers. Sodium of 135 mEq/L is normal and would not place the client at risk for the development of a pressure ulcer.

A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has ordered fly larvae to debride the wound. Which of the following types of debridement does the nurse understand has been ordered?

Biosurgical debridement Biosurgical debridement uses fly larvae to clear the wound of necrotic tissue. This is accomplished through an enzyme the larvae releases. Autolytic debridement involves using the client?s own body to break down the necrotic tissue. Enzymatic debridement involves the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed. Mechanical debridement involves physically removing the necrotic tissue, such as surgical debridement.

A nurse is cleaning the wound of a gunshot victim. Which of the following is a recommended guideline for this procedure?

Clean the wound from the top to the bottom and 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 in the same manner and apply ointment and dressing.

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 cm by 6.4 cm. Which of the following actions should the nurse use during wound care?

Cleanse with a new gauze for each stroke. When cleansing a wound the nurse should use a new gauze or swab on each downward stroke using the cleansing agent. The wound should be cleaned from the inner to the outer portions of the wound. This keeps the wound from being contaminated with bacteria from outside the wound. The wound should be cleansed at least one inch beyond the end of the new dressing. Also, the wound should be cleansed in full or half circles beginning in the center and working toward the outside.

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 caring for client that had abdominal surgery 12 hours ago notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse?

Document the findings. The nurse should document the findings and continue to monitor the dressing. As it is a small amount of drainage, there is no need to contact the physician or the wound care nurse. The nurse should not change the dressing, as the dressing is still the surgical dressing and most often the surgeon will change the first surgical dressing within 24 to 48 hours.

What type of dressing has the advantages of remaining in place for 3 to 7 days, resulting in less interference with wound healing?

Hydrocolloid dressings Hydrocolloids are occlusive or semiocclusive 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 3 to 7 days, 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 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 The swab and the inside of the culture tube should be kept sterile. The wound should be cleansed prior to obtaining the culture. The culture swab should not touch the skin surround the wound site. In addition, if multiple sites have to be cultured then separate culture swabs should be used.

A nurse is removing sutures from the surgical wound of a patient 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 If sutures are crusted with dried blood or secretions, making them difficult to remove, the nurse should moisten sterile gauze with sterile saline and gently loosen crusts before removing sutures. (less)

A nurse is caring for a client with laceration wounds on the knee. The nurse notes that the client is in remodeling phase of wound repair. Which of the following statements describes this phase of wound recovery?

Period during which the wound undergoes changes and maturation The remodeling phase can be described as the period during which the wound undergoes changes and maturation. The remodeling phase follows the proliferative phase and may last for 6 months to 2 years. The inflammatory phase is the physiological defense immediately after tissue injury. The proliferation phase is the period during which new cells fill and seal the wound. Resolution is the process by which damaged cells recover and re-establish normal function. This forms part of the proliferation phase.

The dressing change on a deep upper-arm wound is painful for the patient. When preparing a care plan for the patient, the nurse will incorporate which nursing measure?

Plan to administer a prescribed analgesic 30 to 45 minutes prior to the dressing change. The nurse should plan to administer a prescribed analgesic 30 to 45 minutes prior to changing the dressing. Analgesic administration immediately prior to a dressing change will not allow the analgesic to reach its maximum pain control impact. When patients are fatigued, the sensation of pain may be greater. Also, plan to change the dressing midway between meals so that the patient's appetite and mealtimes are not disturbed.

A medicalsurgical nurse is assisting a wound care nurse with the debridement of a patient's coccyx wound. What is the primary goal of these nurses' 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.

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 of the following stages should the nurse assign to this client's wound?

STAGE III Stage III wounds have full-thickness tissue loss. Subcutaneous tissue may be visible but no bone, tendons, 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 muscles.

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

Support the client from sliding in bed Shear force occurs when tissue layers move on each other, causing vessels to stretch as they pass through the subcutaneous tissue.

FISH 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.

The nurse is helping a confused client with a large leg wound order dinner. Which is the most appropriate food for the nurse select to promote wound healing?

The nurse is caring for a patient 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 patient in a chair. Positioning devices such as pillows, foam wedges, or pressure-reducing boots can prove helpful to keep body weight off bony prominences. For example, a standard pillow placed under the calves raises the heels off the bed and alleviates pressure. The nurse should never use ring cushions, or "donuts," because they increase venous pressure. The nurse should minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible.

The nurse caring for a postoperative patient is cleaning the patient's wound. Which nursing action reflects the proper procedure for wound care?

The nurse works outward from the wound in lines parallel to it. A postoperative wound has well approximated edges. With a postoperative wound, the nurse should work from the incision outward, in lines parallel to the incision. This method would be considered from clean to dirty. The nurse would not use friction when cleaning the wound. The nurse would not use povidone-iodine to fight infection in the wound. The nurse would not swab the wound from the bottom to the top.

A nurse caring for a patient who has a surgical wound following a cesarean section notes dehiscence of the wound and contacts the surgeon. Which of the following is a finding related to this condition?

There is an accidental separation of the wound. With dehiscence, there is an accidental separation of wound edges, especially in a surgical wound. In approximated wound edges, the edges of a wound are lightly pulled together. Edema is an accumulation of fluid in the interstitial tissue, and redness or inflammation of an area as a result of dilation is erythema

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?

Transparent 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 because they consist of a single sheet of adhesive material. Gauze dressing is ideal for covering fresh wounds that are likely to bleed or wounds that exude drainage. Hydrocolloid dressing helps keep the wounds moist. A bandage is a strip or roll of cloth wrapped around a body part to help support the area around the wound.

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

Transparent film 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.

What is the most accurate definition of a wound?

a disruption in normal skin and tissue integrity A wound is a break or disruption in the normal integrity of the skin and tissues. The disruption may range from a small cut on the finger to a third-degree burn covering almost all of the body.

A student nurse studying anatomy and physiology learns that the largest organ of the body is the:

skin The skin, or integument, is the largest organ of the body and has multiple functions. The integumentary system is made up of the skin, the subcutaneous layer directly under the skin, and the appendages of the skin, including glands in the skin, hair, and nails. The integumentary system also includes the blood vessels, nerves, and sensory organs of the skin. The skin is essential for maintaining life.

A nursing instructor is teaching a student nurse about the layers of the skin. Which of the following layers should the student nurse understand is a potential source of energy in an undernourished client?

subcutaneous tissue The subcutaneous tissue is the skin layer that is responsible for storing fat for energy. The epidermis is the outer layer that protects the body with a waterproof layer of cells. The dermis contains the nerves, hair follicles, blood vessels, and glands. The muscle layer moves the skeleton

In which situations has the nurse used a dressing properly? SELECT ALL

• 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. The nurse would place an OpSite over a central venous access device insertion site. An OpSite helps to secure the device and is appropriate for a site with little drainage. The nurse would use appropriate aseptic techniques when changing a dressing. The nurse would place a Sof-Wick around a drain insertion site. The Sof-Wick absorbs drainage and protects the wound from contamination or injury. The nurse would not place a transparent dressing over an ABD pad. The nurse would use tape on the ABD pad. Drainage could be marked on the tape to determine any changes in drainage. The purpose of a Telfa is to not adhere to the wound, and allows drainage to pass through to a secondary dressing. (l

A nurse is using the RYB wound classification system to document patient wounds. Which wounds would the nurse document as a Y (yellow) wound? (Select all that apply.)

• A wound that is characterized by oozing from the tissue covering the wound • A wound with drainage that is a beige color • A wound that requires wound cleaning and irrigation The nurse would document a wound that is characterized by oozing form the tissue covering the wound as a Y (yellow) wound. The nurse would document a wound that has beige colored drainage and a wound that requires wound cleaning and irrigation as Y (yellow) wounds. A wound that reflects the color of normal granulation tissue would be a R (red) wound. A wound that is covered with thick eschar would be documented as a B (black) wound. A wound that is treated by using sharp, mechanical, or chemical debridement would be documented as a B (black) wound.

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

A patient sitting in a chair who slides down 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.

patient'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. 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 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. 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.

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child?

An infant's skin and mucous membranes are easily injured and at risk for infection An infant's skin and mucous membranes are easily injured and at risk for infection. In children younger than 2 years, the skin is thinner and weaker than in adults. The structure of the skin changes as a person ages. A child's skin becomes more resistant to injury and infection as the child grows

When giving a back rub to an older patient at home, the nurse notices a stage II pressure ulcer. What nursing interventions would the nurse perform next?

Clean the wound with normal saline. Normal saline solution (0.9% sodium chloride) is usually the agent of choice, particularly when cleaning pressure ulcer wounds. The pressure ulcer would not need to be covered with a sterile dressing, or wet-to-dry dressing. The nurse would not use a nonadherent dressing

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

Corticosteroids Patients who are taking corticosteroids or require postoperative radiation therapy are at high risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing.

A nurse is measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline and inserting it gently into the wound at a 90-degree angle. The nurse then marks the point where the applicator is even with the skin, removes the applicator and measures with a ruler. What wound measurement is determined by this method?

Depth 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.

A nurse is caring for a client on a medical surgical unit. The client has a wound on the ankle that is covered in eschar and slough. The primary care provider has ordered debridement in the surgical department for the following morning. Which of the following types of debridement does the nurse understand has been ordered on this client?

Mechanical debridement Mechanical debridement involves physically removing the necrotic tissue, such as surgical debridement. Biosurgical debridement utilizes fly larvae to clear the wound of necrotic tissue. This is accomplished through an enzyme the larvae release. Autolytic debridement involves using the client?s own body to break down the necrotic tissue. Enzymatic debridement involves the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed

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

Secondary intention The patient 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 at a wound care clinic. The client has a 5-cm × 6-cm abdominal wound dehiscence. Which of the following types of wound repair would the nurse expect with this wound?

Secondary intention The patient 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.

nurse is documenting a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observe

Serosanguineous Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink in color. Serous drainage is a clear drainage consisting of the serous portion of the blood. Sanguineous drainage consists of red blood cells and looks like blood. Purulent drainage has various colors such as green or yellow; this drainage indicates infection.

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

Stage II 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. 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 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. 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.

A Penrose drain typically exits a patient's skin through a stab wound created by the surgeon.

TRUE Antimicrobial dressings are appropriate for chronic wounds at risk for infection.

A nurse is caring for a client who has an avulsion of her left thumb. Which of the following descriptions should the nurse understand as being the definition of avulsion?

Tearing of a structure from its normal position An avulsion involves tearing of a structure from its normal position on the body. Tearing of the skin and tissue with some type of instrument with the tissue not aligned is a laceration. Cutting with a sharp instrument with wound edged in close approximation and correct alignment is an incision. A puncture of the skin is simply a puncture

A nurse is admitting a client to a long term care facility. Which of the following should the nurse plan to use to assess the client for risk of pressure ulcer development?

The Braden scale is an assessment tool used to assess the client?s risk for pressure ulcer development. The Glascow scale is used to assess a client?s neurological 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.

The nurse is applying a heating pad to a patient experiencing neck pain. Which nursing action is performed correctly?

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.

During a skin assessment, the nurse recognizes the first indication that a pressure ulcer may be developing when she notices the skin is which color?

White The first indication that a pressure ulcer may be developing is blanching (becoming pale and white) of the skin over the area under pressure. Insufficient blood circulation makes the skin appear paler than in areas where circulation is adequate. When the pressure is relieved, the area will appear red and feel warm. Yellow skin is indicative of jaundice. Stage I pressure ulcer is a defined area of persistent redness in lightly pigmented skin and persistent red, blue, or purple hue in darker pigmented skin.

A med-surg nurse is assessing wounds of patients. Which wound complications are accurately described below? (Select all that apply.)

• Dehiscence, which is present when there is a partial or total disruption of wound layers • Evisceration, which occurs when the viscera protrudes through the incisional area • Postoperative fistula formation, most often the result of delayed healing, commonly manifested by drainage from an opening in the skin or surgical site Dehiscence is a partial or total disruption of wound layers. Evisceration occurs when the viscera protrudes through the incisional area. Postoperative fistula formation commonly manifests by drainage from an opening in the skin or surgical site. Symptoms of wound infection occur before 1 to 2 weeks after the injury or surgery. Delayed wound healing in clients who are thin and at greater risk for complications is not due to thinner layer of tissue cells, but possibly from malnutrition, or other complications. An increase in the flow of serosanguineous fluid between postoperative days 4 and 5 would be a sign of an impending dehiscence, not evisceration.

A med-surg nurse is assessing wounds of patients. Which wound complications are accurately described below? (Select all that apply.

• Dehiscence, which is present when there is a partial or total disruption of wound layers • Evisceration, which occurs when the viscera protrudes through the incisional area • Postoperative fistula formation, most often the result of delayed healing, commonly manifested by drainage from an opening in the skin or surgical site Explanation: Dehiscence is a partial or total disruption of wound layers. Evisceration occurs when the viscera protrudes through the incisional area. Postoperative fistula formation commonly manifests by drainage from an opening in the skin or surgical site. Symptoms of wound infection occur before 1 to 2 weeks after the injury or surgery. Delayed wound healing in clients who are thin and at greater risk for complications is not due to thinner layer of tissue cells, but possibly from malnutrition, or other complications. An increase in the flow of serosanguineous fluid between postoperative days 4 and 5 would be a sign of an impending dehiscence, not evisceration.

A nurse is caring for a client who has recently undergone hernial surgery. The nurse knows that which of the following are possible causes of complications with regard to surgical wounds? Select all that apply.

• Insufficient protein and vitamin C intake • Weak tissue and muscular support due to obesity • Distension of the abdomen from accumulated intestinal gas The nurse should remember that insufficient protein and vitamin C intake, weak tissue, muscular support due to obesity, and distension of the abdomen from accumulated intestinal gas are the likely causes of surgical complications. Premature removal of sutures or staples; unusual strain on the incision from severe coughing, sneezing, vomiting, dry heaves, or hiccupping; or compromised tissue integrity from previous surgical procedures in the same area are some of the other causes of surgical complication. Compromised blood circulation and serous fluid accumulation that prevents skin tissue approximation are the factors that interfere with wound healing.