Skin Integrity and Wound Care

Wound Assessment

-inspection (sight and smell) -palpation for appearance, drainage, odor, pain -assessment determines the status of the wound -appearance, location of nearest anatomical landmark, such as bony prominences -document size by measuring in mm or cm, length, width, and depth

Purposes of Wound Dressings

-provide physical, psychological, and aesthetic comfort -remove necrotic tissue -prevent, eliminate, or control infection -absorb drainage -maintain a moist wound environment -protect wound from further injury -protect skin surrounding wound

Presence of Infection

-wound swollen -wound deep red in color -wound hot on palpation -drainage increases/ purulent -foul odor -wound edges may be separated/ dehiscence

Question: A nurse is performing negative pressure wound therapy on a client with a wound in his left ischial tuberosity area. Which of the following is the correct order of steps the nurse should perform during this dressing change? 1. Apply a vacuum device to wound 2. Place the drape to cover the wound and an additional 3-5 cm 3. Cut the foam to the shape and measurement of the wound 4. Use sterile gloves 5. Cut a 2-cm hole in the drape 6. Ensure that negative pressure has been achieved

Correct Order Is: 4. 3. 2. 5. 1. 6.

A stable eschar on the heel of the foot can serve as "the body's natural (biological) cover" and should not be removed. True or False

True

The first indication that a pressure ulcer may be developing is blanching (becoming pale and white) of the skin over the area under pressure. True or False

True

Serosanguineous Drainage

a mixture of serum and red blood cells/ light pink to blood tinged

Definition of Eschar

a thick, leathery scab or dried crust that is necrotic and must be removed before a stage can be determined accurately.

A client's risk for the development of a pressure ulcer is most likely due to which lab result? a) Albumin 2.5 mg/dL b) Sodium 135 mEq/L c) Glucose 110 mg/dL d) Hemoglobin A1C 7%

a) Albumin 2.5mg/dL

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? a) Secondary intention b) Tertiary intention c) Desiccation d) Primary intention

a) Secondary intention

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. a) Weak tissue and muscular support due to obesity b) Distension of the abdomen from accumulated intestinal gas c) Insufficient protein and vitamin C intake d) Compromised blood circulation e) Serous fluid accumulation prevents skin tissue approximation

a. b. c.

A nurse is caring for a client on a medical surgical unit who has had an evisceration of an abdominal wound after a coughing episode. Which of the following actions by the nurse are appropriate in this situation? Select all that apply. a) Place client in low Fowler's position b) Pack the wound with iodoform gauze c) Use sterile techniques d) Cover wound with a gauze moistened with normal saline e) Reinsert protruding structures and apply a pressure dressing

a. c. d.

A med-surg nurse is assessing wounds of patients. Which wound complications are accurately described below? (Select all that apply.) a) Postoperative fistula formation, most often the result of delayed healing, commonly manifested by drainage from an opening in the skin or surgical site b) Delayed wound healing in patients who are thin and at greater risk for complications owing to a thinner layer of tissue cells c) Dehiscence, which is present when there is a partial or total disruption of wound layers d) A wound with an increase in the flow of serosanguineous fluid between postoperative days 4 and 5, which is a sign of an impending evisceration e) Evisceration, which occurs when the viscera protrudes through the incisional area f) Symptoms of wound infection, which are usually apparent within 1 to 2 weeks after the injury or surgery

a. c. e.

Gauze, iodoform gauze, NuGuaze

allow healing from base of wound; infected wounds, after removal of hemorrhoids

A client has developed blisters around the tape that secures the dressing. The nurse should a) Use Montgomery straps b) Apply the dressing with a binder c) Apply skin barrier to protect skin d) Apply tape to the side of the blisters

b) Apply dressing with a binder

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 of the following modifications is most appropriate? a) Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead. b) Reduce the time interval between dressing changes. c) Assure that the packing material is completely saturated when placed in the wound. d) Use less packing material.

b) Reduce the time interval between dressing changes.

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? a) Muscle layer b) Subcutaneous tissue c) Dermis d) Epidermis

b) Subcutaneous tissue

A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage? a) Maintains a moist environment b) Supports the area around the wound c) Keeps the wound clean d) Reduces swelling and inflammation

b) Supports the area around the wound

Which interventions might a nurse be expected to perform when providing competent care for a patient with a draining wound? (Select all that apply.) a) Apply an absorbent dressing material as the first layer of the dressing. b) Apply a protective ointment or paste, if appropriate, to cleansed skin surrounding the draining wound. c) Apply a nonabsorbent material over the first layer of absorbent material. d) Apply another layer of protective ointment or paste on top of the previous layer when changing dressings. e) Change the dressing midway between meals. f) Administer a prescribed analgesic 30 to 45 minutes before changing the dressing, if necessary.

b. e. f.

Pressure Ulcer Unstageable

base of ulcer is covered by slough (yellow, tan, gray, green, or brown) and or eschar (tan, brown, or black) in the wound bed

When assessing a bed bound client's right heel, the nurse notes a thick, leathery, black scab. What is the correct action by the nurse? a) Contact the surgeon for deibridement. b) Using sterile technique, debride the wound. c) Off-load pressure from the heel. d) Place a TED hose on the client's leg.

c) Off-load pressure from the heel

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? a) Arm muscle circumference 90% of standard b) Body weight decrease of 5% c) Total lymphocyte count of 1,500/mm3 d) Albumin level of 3.5 mg/dL

c) Total lymphocyte count of 1,500/mm3

Serous Drainage

clear, serous portion of the blood and from serous membranes/ clear and watery

A nurse is caring for a client who has a pressure ulcer on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-black (RYB) Wound Classification System, which of the following classifications should the nurse document? a) Unstageable b) Yellow classification (cleanse) c) Red classification (protect) d) Black classification (debride)

d) Black classification (debride)

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? a) Change the dressing. b) Notify the wound care nurse. c) Contact the physician. d) Document the findings.

d) Document the findings

Hemovac

decreases dead space by collecting drainage; after abdominal, orthopedic surgery

Jackson-Pratt

decreases dead space by collecting drainage; after breast removal, abdominal surgery

T-tube

for bile drainage; after gallbladder surgery

Pressure Ulcer Stage IV

full-thickness skin loss (tissue loss), exposed bone, tendon, and or muscle, slough and or eschar may be present on parts of wound bed, often include undermining and tunneling

Pressure Ulcer Stage III

full-thickness skin loss (tissue loss), subcutaneous fat may be visible, slough may be present

Sanguineous Drainage

large numbers of red blood cells (looks like blood), bright red drainage is indicative of fresh bleeding, dark red drainage indicates older bleeding

Purulent Drainage

made up of white blood cells, liquified dead tissue debris, and both dead and alive bacteria. Thick often having a musty or foul odor, varies in color (dark yellow or green)

Braden Scale

mental status, continence, mobility, activity, nutrition

Pressure Ulcer Stage I

nonblanchable redness of a localized area

Pressure Ulcer Stage II

partial-thickness skin loss (dermis), presents as a shallow, open ulcer

Norton Scale

physical condition, mental condition, activity, mobility, incontinence

Penrose

provides sinus tract; after incision and drainage of abscess, in abdominal surgery