Unit 5 Tissue Integrity, Heat/Cold Application & Wound Care

Proliferative phase of wound healing

-Day 3 to weeks after wound -Mediators: fibroblasts, myofibroblasts, endothelial cells, keratinocytes, macrophages -Characteristics: deposition of granulation tissue and collagen, angiogenesis, epithelial cell proliferation, dissolution of clot, and wound contraction (mediated by myofibroblasts)

stage 4 of pressure ulcers

-Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in ulcer. -Slough and/or eschar visible -Epibole (rolled edges), undermining, and/or tunneling often occur -Depth varies by anatomical location -If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury.

stage 3 of pressure ulcers

-Full-thickness, loss of skin, adipose is visible in the ulcer & granulation tissue & epibole (rolled wound edges) are present -Slough and/or eschar visible -Depth of tissue damage varies by anatomical location; areas of signification adiposity can develop deep wounds -Undermining and tunneling may occur -Fascia, muscle, tendon, ligament, cartilage, and/or bone NOT exposes -If slough or eschar obscures the extend of tissue loss, this is an Unstageable Pressure Injury

Stage 1 of pressure ulcer

-Intake skin -Non-blanchable erythema

stage 2 of pressure ulcers

-Open, partial layer skin loss -Ulcer, abrasion, blister, shallow crater

maturation phase of wound healing

-final phase begins about 3 weeks from injury -may take up to 2 years -collagen is lysed and resynthesized by macrophages, producing storng scar tissue -scar maturation, or remodeling -scar tissue slowly thins and becomes paler

Absorption

Absorbs substances, such as medications, for local and systemic effects

Vitamin D Production

Activated by ultraviolet rays from the sun to produce vitamin D

Protection

Acts as barrier to water, microorganisms, and damaging ultraviolet rays of the sub Protects against infection Protects against injury to underlying tissues and organs Prevents loss of moisture from the surface & underlying structures

Wound classification using RYB Explain B B=Black=Debride

Black in the wound may indicate presence of an eschar (necrotic tissue), which is usually black but may be brown, gray, or tan. The eschar requires debridement (removal) before it can heal. These wounds are often cared for by advanced practice nurses who are educated in the care of more complex wounds. After debridement, the wound is treated as a yellow wound and then, as healing progresses, a red wound.

effects of applying cold

Constructs peripheral blood vessels Reduced muscle spasms Promotes comfort

Psychosocial

Contributes to the external appearance and is a major contributor to self-esteem Plays important role in identification & communications

What is shearing?

Damage by tearing or bending by exerting faucet different parts in opposite directions at the same time. results when one layer of tissue slides over another

Temperature Regulation

Draws heat from the skin as perspiration occurs & evaporates Dissipate heat as blood vessels in the skin dilate Compensates for cold conditions with the constriction of blood vessels in the skin to diminish heat loss Compensates for cold through contraction of pilomotor muscles that cause the hair to stand on end, forming a layer of air on the body for insulation (gooseflesh or goose bumps)

Elimination

Excretes small amounts of water, electrolytes, and nitrogenous wastes in sweat

antibiotics in relation to tissue integrity & wound healing do what?

Prolonged use increases risk for secondary infection & superinfection

Functions of the Skin & Mucous Membranes

Protection, temperature regulation, psychosocial sensation, vitamin D production, immunologic absorption, and elimination.

Sensation

Provides the sense of touch, pain, pressure, and temperature through millions of nerve endings Allows the body to adjust to the environment through sensory impulses, in conjunction with the brain and spinal cord

Wound classification using RYB. Explain R R=Red=Protect

Red wounds are in the proliferative stage of health & reflect the color of normal granulation tissue. Wounds in this stage need protection with nursing interventions that include gentle cleansing, use of moist dressings, and changing of the dressing

Immunologic

Triggers immunologic responses when broken

T-tube drainage. What type? Purpose? Example?

Type: closed, T-shaped tube places in the common bile duct Purpose: collects bile Example: after gallbladder surgery

Jackson-Pratt (JP) drainage. What type? Purpose? Example?

Type: closed, bulb suction device Purpose: drains blood & fluid Example: after breast surgery or mastectomy, abdominal surgery

Chest tube drainage. What type? Purpose? Example?

Type: closed, mediastinal placement (different from a chest tube used in the pleural space) Purpose: drains blood Example: after cardiac surgery

Hemovac drainage. What type? Purpose? Example?

Type: closed, portable negative pressure suction device Purpose: drains blood & fluid Example: after abdominal orthopedic surgery

Blake drain. What type? Purpose? Example?

Type: closed, silicon tube with four chambers--similarly to a JP externally Purpose: drains blood & fluid Example: used in cardiac surgery in place of a chest tube or JP drain

Penrose drain. What type? Purpose? Example?

Type: open drainage system consisting of a soft rubber tube that provides a sinus tract Purpose: drains blood & fluid Example: After incision & drainage of abscess, in abdominal surgery

Gauze, iodoform gauze, NuGauze drain. What type? Purpose? Example?

Type: open, gauze dressings packed loosely so the wound is allowed to drain Purpose: allow healing from base of wound Example: infected wounds, after removal of hemorrhoids

Wound classification using RYB. Explain Y Y=Yellow=Cleanse

Yellow in the wound may indicate the presence of exudate (drainage) or slough and requires wound cleaning. These wounds are characterized by oozing from the tissue covering the wound, often accompanied by purulent drainage. Drainage can be whitish yellow, creamy yellow, yellowish green, or beige. To cleanse use would cleansers and irrigate the wound.

abscess

a collection of infected fluid that has not drained

Serosanguineous drainage

a mixture of serum and RBCs. Light pink to blood tinged

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? a. Desiccation b. Maceration c. Necrosis d. Evisceration

a. Desiccation Explanation: Desiccation is localized wound dehydration. Maceration is localized wound overhydration or excessive moisture. Necrosis is death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area.

The nurse is performing an assessment of a client's full thickness pressure injury to the coccyx. The nurse observes that the wound bed is black and will consequently document what finding? a. Eschar b. Granulation tissue c. Gangrene d. Erythema

a. Eschar Explanation: A dark brown or black wound bed is characterized as eschar. Erythema denotes redness and granulation tissue has rich, red coloration. A dark wound bed does not necessarily indicate the tissue decomposition associated with gangrene.

Two nurses, an RN and a wound care nurse, are discussing care of a client's wound that has nonviable tissue in the base. The wound care nurse recommends that the RN utilize a dressing that would promote autolytic debridement of the wound. Which dressing should the nurse select? a. Hydrocolloid b. Wet to dry c. Negative wound pressure therapy d. Telfa

a. Hydrocolloid Explanation: The nurse should select the hydrocolloid dressing to promote autolytic debridement of the wound. Wet to dry dressings promote mechanical debridement. Telfa pads are nonstick and do not promote debridement. Negative wound pressure therapy is not utilized to promote debridement.

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action? a. Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. b. Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. c. Carefully pick the crusts off the sutures with the forceps before removing them. d. Do not attempt to remove the sutures because the wound needs more time to heal.

a. Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. Explanation: 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 the sutures; soap is not used for this purpose. Picking at the sutures could cause pain and bleeding. Crusting does not necessarily indicate inadequate wound healing.

When measuring the size, depth, and wound tunneling of a client's stage 4 pressure injury, what action should the nurse perform first? a. Perform hand hygiene. b. Insert a swab into the wound at 90 degrees. c. Measure the width of the wound with a disposable ruler. d. Assess the condition of the visible wound bed.

a. Perform hand hygiene. Explanation: Hand hygiene should precede any wound assessment or wound treatment. Performing hand hygiene prior to the wound assessment reduces the risk for infection. Inserting a swab into the wound at 90 degrees, measuring the width of the wound with a disposable ruler, and assessing the condition of the visible wound bed are all appropriate wound assessments.

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. Supports the area around the wound b. Maintains a moist environment c. Keeps the wound clean d. Reduces swelling and inflammation

a. Supports the area around the wound Explanation: Bandages and binders are used to secure dressings, apply pressure, and support the wound. A roller bandage is a continuous strip of material wrapped on itself to form a cylinder or roll and is applied using a circular turn, spiral turn, or figure-of-eight turn. It is effective for use around joints, such as the knee, elbow, ankle, and wrist.

A student nurse is preparing to perform a dressing change for a pressure injury on a client's sacrum area. The chart states that the pressure injury is staged as "unstageable." Which wound description should the student nurse expect to assess? a. The wound is 3 × 5 cm, with yellow tissue covering the entire wound. b. The wound is 3 × 5 cm, with 50 percent gray tissue and 50 percent red tissue, with subcutaneous tissue visible. c. The wound is 3 × 5 cm, with 60 percent tan tissue and 40 percent granulation tissue, with a tendon showing. d. The wound is a 3 × 5-cm blood-filled blister.

a. The wound is 3 × 5 cm, with yellow tissue covering the entire wound. Explanation: The wound with yellow tissue covering the entire wound is unstageable. The depth of the wound cannot be determined, because it is covered entirely with slough. A stage III wound will have subcutaneous tissue visible. A stage IV wound will have tendon, muscle, or bone exposed. A suspected deep tissue injury presents as a maroon or purple lesion or blood-filled blister.

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. a sterile, flexible applicator moistened with saline b. a small plastic ruler c. a sterile tongue blade lubricated with water soluble gel d. an otic curette

a. a sterile, flexible applicator moistened with saline Explanation: 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 assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? a. a surgical incision with sutured approximated edges b. a large wound with considerable tissue loss allowed to heal naturally c. a wound left open for several days to allow edema to subside d. a wound healing naturally that becomes infected.

a. a surgical incision with sutured approximated edges Explanation: 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.

A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing? a. contusion b. incision c. avulsion d. puncture

a. contusion Explanation: A contusion is an injury to soft tissue, so this is what the nurse expects to see on the basis of the teacher's description of the incident. A puncture involves an opening in the skin caused by a narrow, sharp, pointed object such as a nail. An incision involves a clean separation of skin and tissue with smooth, even edges. An abrasion involves stripping of the surface layers of skin. In an avulsion injury, large areas of skin and underlying tissues have been stripped away.

A nurse is assessing a client with a stage 4 pressure injury. What assessment of the injury would be expected? a. full-thickness skin loss b. skin pallor c. blister formation d. eschar formation

a. full-thickness skin loss Explanation: A stage 4 pressure injury is characterized by the extensive destruction associated with full-thickness skin loss. At stage 2, the skin breaks open, wears away, or forms an ulcer or blister, which is usually tender and painful. Slough or eschar may be present on some parts of the wound bed in stage 4 but not always. Skin pallor occurs in stage 1.

A nurse is evaluating a client who was admitted with partial-thickness (second-degree) burns. Which describes this type of burn? a. moist with blisters, which may be pink, red, pale ivory, or light yellow-brown b. pinkish or red with no blistering c. from brown or black to cherry red or pearly white; bullae may be present d. dry and leathery

a. moist with blisters, which may be pink, red, pale ivory, or light yellow-brown Explanation: Partial-thickness (second-degree) burns are moderate to deep burns that may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. Superficial (first-degree) burns may be pinkish or red with no blistering. Full-thickness (third-degree) burns vary from brown or black to cherry-red or pearly-white; bullae may be present; can appear dry and leathery.

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: a. primary intention. b. secondary intention. c. tertiary intention. d. dehiscence.

a. primary intention. Explanation: 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.

Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment? a. proliferation phase b. hemostasis c. inflammatory phase d. maturation phase

a. proliferation phase Explanation: The proliferation phase is characterized by the formation of granulation tissue (highly vascular red tissue that bleeds easily). During the proliferation phase, new tissue is built to fill the wound space. Hemostasis involves the constriction of blood vessels and the beginning of blood clotting immediately after the initial injury. The inflammatory phase lasts about 4 to 6 days; white blood cells and macrophages move to the wound. The maturation phase is the final phase of wound healing and involves remodeling of collagen that was haphazardly deposited in the wound; in addition, a scar forms.

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? a. removing dead or infected tissue to promote wound healing b. stimulating the wound bed to promote the growth of granulation tissue c. removing purulent drainage from the wound bed in order to accurately assess it d. removing excess drainage and wet tissue to prevent maceration of surrounding skin

a. removing dead or infected tissue to promote wound healing Explanation: 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 measuring the wound of a stab victim by moistening a sterile, flexible applicator with saline, then 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? a. size b. depth c. tunneling d. direction

a. size Explanation: 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. Size is measured with a ruler on the outside of the wound. Tunneling is measured by a finger probe or sterile probe instrument. Direction is a visual inspection.

While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open injury with a red-pink wound bed and partial-thickness loss of dermis. What is the correct name of this wound? a. stage 2 pressure injury b. stage 1 pressure injury c. stage 3 pressure injury d. stage 4 pressure injury

a. stage 2 pressure injury Explanation: Stage 1 is defined as intact skin with a localized area of nonblanchable redness, usually over a bony prominence. Stage 2 is defined as partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed. Stage 3 is defined as full-thickness loss without exposed bone, tendon, or muscle. Stage 4 is defined as full-thickness tissue loss with exposed bone, tendon, and muscle.

Fistula

abnormal passage from an internal organ or vessel to the outside of the body, or from one internal organ or vessel to another. Fistula formation usually is the result of infection that developed into an abscess

The nurse is caring for a client who has reported to the emergency department with a steam burn to the right forearm. The burn is pink and has small blisters. What staging will the nurse most likely identify? a. First degree or superficial b. Second degree or partial thickness c. Third degree or full thickness d. Fourth degree or fat layer

b. Second degree or partial thickness Explanation: Partial-thickness burns may be superficial or moderate to deep. A superficial partial-thickness burn (first degree; epidermal) is pinkish or red with no blistering; a mild sunburn is a good example. Moderate to deep partial-thickness burns (second degree; dermal or deep dermal) may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. Exposure to steam can cause this type of burn. A full-thickness burn (third degree) may vary from brown or black to cherry red or pearly white. Thrombosed vessels and blisters or bullae may be present. The full-thickness burn appears dry and leathery.

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? a. Stage I b. Stage II c. Stage III d. Stage IV

b. Stage II Explanation: 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.

A client limps into the emergency department and states, "I stepped on a nail and did not have shoes on. Now I can barely walk." What types of concern does the nurse anticipate the client will have? a. Scarring, sutures, and wound care b. Tetanus, infection, wound care, and pain control c. Prevention of recurring infection, ability to work, and wound care d. Tetanus, being able to walk, and scarring

b. Tetanus, infection, wound care, and pain control Explanation: Chances are the client knows that stepping on a nail could lead to a serious complication or illness, even if the client cannot remember or does not know about tetanus or infections. How to care for the wound is usually something clients will want to know before being discharged. The client in this scenario is reporting pain, so pain control will be one of the concerns. It is unlikely that the client will be worried about scarring on the bottom of the foot or sutures due to it being a puncture. The client is still walking, although in pain and with a limp, it would be unlikely the client would be concerned about being able to walk. More than likely, the client has already figured out the injury may not have occurred or would not be as bad had he or she been wearing shoes, so the nurse would not anticipate the need for preventative education.

Contusion

blunt instrument, overlying skin remains intact, with injury to underlying soft tissue; possible resultant bruising and/or hematoma

Puncture

blunt of sharp instrument puncturing that skin; intentional (such as venipuncture) or accidental; consider penetrating object when considering infection probability

The health care provider has ordered a cold ice bag to be applied to the wrist of a client with a sprain. The nurse will ensure that the cold application is at what temperature before application? a. 26.6°-33.8° C (80°-93° F) b. 18.3°-26.6° C (65°-80° F) c. 10°-18.3° C (50°-65° F) d. Below 10° C (below 50° F)

c. 10°-18.3° C (50°-65° F) Explanation: Cold applications should be between 10° and 18.3° C (50°-65° F). An application of 26.6° to 33.8° C (80°-93° F) is tepid; 18.3°- 26.6° C (65°-80° F) is cool; below 10° C (below 50° F) is very cold.

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? a. Use clean technique to clean the wound. b. Clean the wound in a circular pattern, beginning on the perimeter of the wound. c. Clean the wound from the top to the bottom and from the center to outside. d. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth.

c. Clean the wound from the top to the bottom and from the center to outside. Explanation: 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.

The nurse is caring for a client who had abdominal surgery 12 hours ago and notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse? a. Contact the health care provider. b. Change the dressing. c. Document the findings. d. Notify the wound care nurse.

c. Document the findings. Explanation: The nurse should document the findings and continue to monitor the dressing. Because it is a small amount of drainage, there is no need to contact the health care provider or the wound care nurse. The nurse should not change the surgical dressing. Most often, the surgeon will change the first dressing in 24 to 48 hours. For this reason, the wound care nurse does not need to be notified.

The health care provider prescribes negative-pressure wound therapy for a client with a pressure injury. Before initiating the treatment, it is important for the nurse to implement which nursing assessment? a. assessing for the use of antihypertensives b. assessing the client for claustrophobia c. assessing the wound for active bleeding d. assessing the client's mental status

c. assessing the wound for active bleeding Explanation: 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 use in the presence of active bleeding. The nurse needs to assess for the use of anticoagulants, not antihypertensives, because these can cause bleeding. Mental status and the presence of claustrophobia are not significant when negative-pressure wound therapy is to be initiated.

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a pale pink drainage on the dressing. Which drainage type should the nurse document? a. serous b. sanguineous c. serosanguineous d. purulent

c. serosanguineous Explanation: Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink or pink-yellow. 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 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? a. stage I b. stage II c. stage III d. stage IV

c. stage III Explanation: 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.

A nurse is caring for a client with a nonhealing stage IV pressure injury. The nurse observes an area in the wound that is hollow between the outer surface and the wound bed. What is the correct term for this condition? a. eschar b. slough c. undermining d. dehiscence

c. undermining Explanation: Undermining is the term for a hollow area between the outer wound and the wound bed. It resembles a cave. Eschar is a leathery covering that is dead tissue; it is usually removed by debridement. Tunneling is a cavity or channel formed from a wound. Dehiscence is the opening of a previously closed surgical wound.

Serous drainage

composed primarily of the clear, serous portion of the blood and from serous membranes. Serous drainage is clear & watery

Pressure ulcer

compromised circulation secondary to pressure or pressure combined with friction; classified by stages 1-4, unstageable, and deep tissue injury

sanguineous drainage

consists of large numbers of RBCs and looks like blood. Bright red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding.

Incision

cutting or sharp instrument; wound edges well approximated & aligned; surrounding tissue undamaged; bleeds freely & least likely to become infected

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? a. "This is normal tissue." b. "That is old clotted blood underneath the wound" c. "That is called undermining, a type of tissue erosion." d. "That is necrotic tissue, which must be removed to promote healing."

d. "That is necrotic tissue, which must be removed to promote healing." Explanation: 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.

The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next? a. Determine the extent of wound undermining. b. Measure length, width, and depth of the wound. c. Massage the healthy tissue surrounding the wound. d. Document the color, odor, amount, and type of wound drainage.

d. Document the color, odor, amount, and type of wound drainage. Explanation: After completing a dressing change and retuning the client to a comfortable position, it is important to document color, odor, amount, and the type of wound drainage. Early documentation helps to assure the most accurate information can be recorded. Determining the extent of wound undermining and measuring length, width, and depth of the wound should be performed during the dressing change, while the wound is still exposed. The healthy tissue surrounding the wound should never be massaged because it could cause further breakdown of healthy tissue.

A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain? a. If there is contamination of dirt and debris b. The event leading up to the trauma c. Staging the wound for assessment d. The status of the client's tetanus immunization

d. The status of the client's tetanus immunization Explanation: Staging the wound is only done with pressure injuries. The presence of dirt or debris is something that will need to be addressed, but not the most important assessment. Understanding how the client stepped on the nail will need to be noted and is a possible educational opportunity for prevention, but it is not the most important assessment concern. Tetanus is caused by the Clostridium bacteria that can enter the body through a deep injury like stepping on a nail. The tetanus vaccine booster should be given every 10 years and is the best defense against developing the tetanus illness. Tetanus is a concern because it is a painful medical emergency that could lead to death. So, finding out the status of the client's tetanus immunization is the most important assessment information the nurse can collect from the client.

A nurse working in long-term care is assessing residents at risk for the development of a decubitus ulcer. Which one would be most at risk? a. an 83-year-old who is mobile b. a 92-year-old who uses a walker c. a 75-year-old who uses a cane d. an 86-year-old who is bedfast

d. an 86-year-old who is bedfast Explanation: Most pressure ulcers occur in older adults as a result of a combination of factors, including aging skin, chronic illness, immobility, malnutrition, fecal and urinary incontinence, and altered level of consciousness. The bedfast resident would be most at risk in this situation.

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 type of debridement does the nurse understand has been ordered on this client? a. autolytic debridement b. biosurgical debridement c. enzymatic debridement d. mechanical debridement

d. mechanical debridement Explanation: Mechanical debridement involves physical removal of 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 assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage? a. clear, watery blood b. large numbers of red blood cells c. mixture of serum and red blood cells d. white blood cells, debris, bacteria

d. white blood cells, debris, bacteria Explanation: Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serous drainage is composed primarily of the clear, serous portion of the blood and from serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged.

ischemia

deficiency of blood in a particular area

Desiccation

dehydration

Patients who are taking corticosteroids or require post op radiation therapy are at high risk of what?

delayed healing and wound complications. Steroids slow wound healing.

what are the effects of applying heat?

dilates peripheral blood vessels increases tissue metabolism reduces body viscosity & increases capillary permeability reduces muscle tension helps relieve pain

Penetrating

foreign object entering the skin or mucous membrane & lodging in underlying tissue; fragments possibly scattering throughout tissues

Abrasion

friction, rubbing or scraping epidermal layers of skin; top layer of skin scraped away; dirt & germs often embedded and can become infected

Thermal

high to low temperatures; cellular necrosis as a possible result

Venous ulcers

injury and poor venous return, resulting from underlying conditions, such as incompetent valves or obstruction; frequently have significant drainage; compression essential (after arterial flow verified)

Diabetic ulcers

injury and underlying diabetic neuropathy, peripheral arterial disease, diabetic foot structure; located below ankle

Arterial ulcers

injury and underlying ischemia, resulting from a lack of blood flow to lower extremities secondary to conditions such as atherosclerosis or thrombosis; many have black eschar; increasing blood flow essential for treatment

Purulent drainage

made up of WBC's, liquefied dead tissue debris, and both dead & live bacteria. Often thick, often has musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism.

NERDS Explain N

nonhealing wound

when do you not use cold?

on open wounds or patients with impaired peripheral circulation or adverse reactions to cold Must assess pulses and skin color

Where can friction burns occur when the patient is pulled or slid over sheets while being moved up in bed or transferred onto a stretcher?

on their back

Negative pressure wound therapy (NPWT)

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

Debridement

removal of devitalized tissue and foreign material

patients who are pulled rather than lifted when being moved up in bed or from bed to chair or stretching are at risk for injury from what?

shearing force

Where dose friction occur most commonly on the body when patients lift & help themselves up on bed using their arms and feet?

skin over the elbows & heels

Macceration

softening of tissue by soaking overhydration

Assessment of 3 or more signs/symptoms from NERDS indicates what?

superficial critical colonization

Avulsion

tearing a structure from normal anatomic position; possible damage to blood vessels, nerves, and other structures

Laceration

tearing of skin & tissue with blunt or irregular instrument; tissue no aligned, often with loose flaps of skin & tissue; frequently contaminated with dirt or other material ground into the wound and likely to become infected

Inflammatory phase of wound healing

the initial phase of wound healing in which bleeding is reduced as blood vessels in the affected area constrict

Evisceration

the most serious complication of dehiscence. It occurs primarily with abdominal incisions. The abdominal wound completely separates, with protrusion of viscera (internal organs) through the incisional area.

Dehiscence

the partial or total separation of wound layers as a result of excessive stress on wounds that aren't healed

Necrosis

tissue death

When do you not apply heat?

to open wounds immediately after tram, during hemorrhage, over non-inflammatory edema, to acutely inflamed areas, a localized malignant tumor, the test or abdomen of a pregnant women; or over metallic implants

Hemostasis

to stop or control bleeding

Chemical

toxic agents such as drugs, acids, alcohols, metals, & substances released from cellular necrosis

Irradiation

ultraviolet light or radiation exposure; can cause wet or dry desquamation