Wound Management
Which injury is a severe avulsion? A. Road rash B. Degloving C. Compartment syndrome D. Abscess
A degloving injury is a severe avulsion in which the skin is peeled away from the hand, foot, or a greater portion of an extremity. This injury results in devascularization of the skin and underlying tissue damage. Road rash is the most severe of all abrasions. Compartment syndrome results when extensive extremity contusions or a puncture wound into the fascia causes compression of the nerves and blood vessels in an enclosed space. An abscess is a localized collection of pus beneath the skin.
Which statement accurately characterizes wound care? A. A tetanus-prone wound can result from a crushing mechanism. B. Uncomplicated minor wounds require prophylactic antibiotics. C. Tetanus toxoid provides passive immunization against tetanus. D. The most effective intervention to reduce the risk of infection is antibiotic administration.
A tetanus-prone wound can result from a crushing mechanism. Tetanus-prone wounds also include those that are more than 6 hours old, are stellate or avulsed, are caused by missiles, show obvious signs of infection, have devitalized tissue, or contain contaminants, such as dirt, feces, soil, or saliva. Uncomplicated minor wounds do not require prophylactic antibiotics. Meticulous wound care, debridement, proper wound closure, and dressings are the most important infection-control techniques for minor wounds. Tetanus toxoid provides active immunization, whereas tetanus immune globulin (TIG) provides passive immunization. The most effective intervention to reduce the risk of infection is thorough wound cleansing. The use of antibiotics for all acute wounds is controversial.
Which assessment should the nurse include in a thorough neurovascular examination of a hand injury? A. Obtaining a detailed health history. B. Determining the severity of the pain. C. Examining for a foreign body. D. Evaluating flexor and extensor tendon function.
A thorough neurovascular examination includes testing sensation, strength, and flexor and extensor tendon function. Determining the severity of the pain is not part of a neurovascular examination, but wound assessment is most effective after adequate pain control is achieved. Examining for a foreign body and obtaining a detailed health history are not part of a thorough neurovascular examination, but can provide information that helps determine the plan of care.
Which statement accurately characterizes wounds? A. Wounds are typically a triage priority. B. Wounds are tissue disruptions caused by the transfer of external mechanical forces. C. These soft tissue injuries are the second leading cause of lawsuits. D. All wounds are classified as minor injuries.
A wound is the disruption of the normal anatomic integrity and function of any tissue caused by the transfer of external mechanical forces. Unless the wound threatens the patient's airway, breathing, or circulation, it is not typically a triage priority. Despite the lower urgency associated with most wounds, these soft tissue injuries remain the fourth leading cause of lawsuits. Besides wounds that are minor injuries, such as abrasions, contusions, lacerations, bites, and puncture wounds, more serious and disfiguring wounds include degloving injuries and amputations.
Which of these is a patient-related factor that may affect wound healing? A. Morbid obesity B. Bacterial contamination C. Location of injury D. Injury more than 8 hours old
Internal or patient-related factors involve a poor host environment and include morbid obesity, age, circulatory problems, diabetes mellitus and neuropathy, malnutrition, preexisting infection, and immunosuppression. The other answer options represent external or injury-related factors that affect wound healing.
Which agent added to the anesthetic decreases pain during injection or infiltration? A. Benzoin B. Epinephrine 1% C. Cocaine D. Sodium bicarbonate 8.4%
Adding sodium bicarbonate 8.4%, warming the anesthetic to room temperature, and slowly infiltrating the wound can decrease the discomfort of local anesthesia. Epinephrine is commonly added to lidocaine to prolong the duration of local anesthesia, provide hemostasis, slow anesthetic absorption, and increase the level of anesthetic blockade. Epinephrine does not decrease the discomfort of infiltration. Cocaine is a component of the topical anesthetic TAC (tetracaine, adrenaline, and cocaine) and is not used during anesthetic injection or infiltration. Tincture of benzoin applied to both sides of the wound improves the adhesion of tape closures (Steri-Strips).
Four patients come to the emergency department with identical leg wounds sustained in a 2-foot fall when a deck collapsed. Which patient is most likely to have impaired wound healing? A. A 45-year-old obese man who has type 2 diabetes mellitus and steroid-dependent asthma. B. A 23-year-old man who has no significant medical history and whose last tetanus immunization was more than 10 years ago. C. A 54-year-old woman who currently takes warfarin (Coumadin) for chronic atrial fibrillation. D. A 17-year-old adolescent girl who has sickle cell disease.
An obese man, age 45, who has type 2 diabetes mellitus and steroid-dependent asthma is most likely to have impaired wound healing. Obesity, diabetes mellitus, and corticosteroid use are all factors that delay wound healing. Two or more internal or external risk factors increase the risk of wound infection exponentially. The man, age 23, has no risk factors for delayed wound healing, but should receive tetanus prophylaxis during his emergency department visit. The woman, age 54, initially may have a delayed ability to clot. However, once the clot has formed, her increased risk for delayed wound healing is negated. The adolescent girl has one risk factor that affects wound healing because of anemia from sickle cell disease. However, the obese man, age 45, has multiple risk factors, placing him at greater risk.
For a patient with an avulsion, which type of wound closure is most appropriate? A. Primary intention B. Secondary intention C. Delayed closure D. Tertiary intention
Avulsions are characterized by full-thickness tissue loss that prevents wound edge approximation. In secondary intention, healing occurs when extensive tissue loss has happened and prevents the wound edges from being approximated. The wound is left open to heal by granulation and often leaves an obvious scar. The other answer options are incorrect. In primary intention, healing occurs when wound edges can be approximated and underlying structures are aligned, eliminating dead space. In tertiary intention (also called delayed closure), the wound is left open initially and closed 5 to 10 days later. Skin grafting may be used.
Which injury is characterized by full-thickness tissue loss and commonly affects the fingertips or tip of the nose? A. Laceration B. Abrasion C. Contusion D. Avulsion
Avulsions are characterized by full-thickness tissue loss that prevents wound edge approximation. This injury most commonly occurs in the fingertips or tip of the nose. Abrasions occur when friction removes the epidermal layer of the skin and can also remove part of the dermis, exposing deeper skin layers. A contusion results from blunt trauma that causes blood accumulation under the skin, but no break in the skin. Lacerations are open wounds that result from shearing force through the skin layers.
When caring for a patient with a wood splinter embedded in the foot, which intervention is appropriate? A. Determine the patient's tetanus immunization status.** B. Soak the foot in warm, soapy water. C. Obtain a radiograph to locate the foreign body. D. Apply a pressure dressing to provide hemostasis.
Because all puncture wounds pose a high risk of tetanus, you should determine the patient's tetanus immunization status. If the patient's immunizations are not current, administer tetanus immunization, as ordered. A puncture wound caused by vegetative matter, such as wood, should not be soaked because the wood will absorb the liquid and disintegrate. This type of foreign body should be removed before soaking. A radiograph can detect radiopaque material only. To find wood or other nonradiopaque material, computed tomography, ultrasonography, fluoroscopy, or local wound exploration is required. Puncture wounds bleed minimally and seal off quickly, placing the patient at a high risk of infection, not blood loss.
Which anesthetic has the longest duration of effect? A. Lidocaine without epinephrine B. Bupivacaine C. Lidocaine with epinephrine D. Tetracaine, adrenaline, and cocaine (TAC)
Bupivacaine (Marcaine, Sensorcaine) has a duration of 4 to 8 hours. Lidocaine without epinephrine has a duration of 1 to 2 hours, and lidocaine with epinephrine has a slightly longer effect because epinephrine prolongs the duration of local anesthesia. Effects of the topical agent TAC last 30 to 60 minutes.
A patient presents to the emergency department after falling from her bicycle and landing in gravel. She has multiple abrasions on both arms and legs. After thorough cleansing, the wounds require dressing before the patient is discharged. For this patient, which wound dressing strategy promotes optimal wound healing? A. Cover all the wounds with transparent film dressings. B. Cover the wounds with topical antibiotic ointment and nonadhesive dressings. C. Leave the wounds open to the air so that they can heal more rapidly. D. Dry the areas and then cover all the wounds with gauze dressings.
Cover the wounds with topical antibiotic ointment, and nonadhesive dressings. These dressings provide a moist wound environment to promote and protect epithelialization of the wound and provide antibacterial activity against infecting organisms. If the patient had dry wounds, you would cover all the wounds with transparent film dressings. Leaving the wounds open to the air is not appropriate because keeping the wound moist promotes optimal wound healing. Gauze dressings are useful in absorbing exudates, supporting debridement, and holding dressings in place. However, to protect wound epithelialization, a nonadhesive dressing or thin layer of antibiotic ointment should be applied before the gauze dressing.
Which common anesthetic should be used to suture a laceration to the ear? A. Lidocaine without epinephrine** B. Lidocaine with epinephrine C. Lidocaine, epinephrine, and tetracaine (LET) D. Tetracaine, adrenaline, and cocaine (TAC)
Do not use lidocaine with epinephrine in areas supplied by end arteries, including the nose, ears, digits, and penis. Epinephrine prolongs the duration of local anesthesia, provides hemostasis, slows anesthetic absorption, and increases the level of anesthetic blockade. Lidocaine without epinephrine or bupivacaine can be used if the physician thinks it is the correct drug and duration of action for the area. Topical agents that contain epinephrine, such as TAC or LET, should not be used on extensive wounds, areas supplied by end arteries, or mucous membranes.
Which wound dressing supports debridement if kept moist after application? A. Transparent film dressing B. Nonadhesive dressing C. Gauze dressing D. Polyurethane foam
Gauze dressings provide absorption of exudates, support debridement if applied and kept moist, and can be used to maintain a moist wound surface and to fill sinus tracts as in an abscess. The other dressings do not support debridement. Nonadhesive dressings have minimal absorbency and may be impregnated with saline, petrolatum, or antimicrobial agents. Transparent film dressings have a semipermeable membrane; permit gaseous exchange between the wound bed and the environment; are minimally absorbent, creating a fluid environment in the presence of exudates; do not allow bacteria to penetrate the membrane; and are used for dry, noninfected wounds or wounds with minimal drainage. Polyurethane foams are used for partial- or full-thickness wounds with minimal to heavy drainage. Hydrocolloid, absorption, and hydrogel dressings also support debridement.
A 72-year-old patient is admitted with a hip fracture after a fall at home. This patient at risk for developing which complication? A. Tattooing B. Tetanus C. Pressure ulcer D. Abscess
Geriatric and paralyzed patients are at highest risk for pressure ulcers. Pressure ulcers typically affect skin over bony or cartilaginous areas, such as the sacrum, elbows, knees, and ankles. The patient does not have an injury that is tetanus prone or at risk of developing an abscess. Tattooing is permanent scarring caused by foreign bodies that have been left in the skin and stain the epidermis.
In which wound is part of the epidermis removed by friction? A. Abrasion B. Avulsion C. Contusion D. Laceration
In an abrasion, friction removes the epidermal layer of the skin and can also remove part of the dermis, exposing deeper skin layers and increasing the risk of infection. In an avulsion, full-thickness tissue loss prevents wound edge approximation. In a contusion, blunt trauma causes blood accumulation under the skin, but no break in the skin's integrity. In a laceration, an open wound results from shearing force through dermal layers. Lacerations may be superficial, involving the epidermis and dermis, or severe, involving the subcutaneous tissue and muscle.
Which type of wound healing occurs when wound edges can be approximated and underlying structures are aligned, eliminating dead space? A. Secondary intention B. Primary intention C. Delayed closure D. Tertiary intention
In primary intention, healing occurs when wound edges can be approximated and underlying structures are aligned, eliminating dead space. This type of wound healing is most commonly used in the emergency department. In secondary intention, healing occurs when extensive tissue loss has happened and prevents the wound edges from being approximated. The wound is left open to heal by granulation, which leaves an obvious scar. In tertiary intention (also called delayed closure), the wound is left open initially and closed 5 to 10 days later. Skin grafting may be used.
The emergency nurse should classify and document skin blistering or open sore formation as which stage of a pressure ulcer? A. Stage I B. Stage II C. Stage III D. Stage IV
In stage II, the skin blisters or forms an open sore, and the area around the sore may be red and irritated. In stage I, a reddened area on the skin does not blanch when pressed. In stage III, skin breakdown looks like a crater with damage to the tissue below the skin. In stage IV, the pressure ulcer is so deep that damage affects the muscle, bone, and sometimes the tendons and joints.
For a patient who was treated for an avulsion, which discharge instruction is appropriate? A. Return in 2 days for removal of the packing and for a wound check. B. Use a sunscreen or wear protective clothing for at least 6 months to prevent permanent tissue discoloration. C. Keep the area splinted until advised otherwise by your primary physician. D. Keep the wound covered with a bulky dressing to protect the exposed tissue.**
Keep the wound covered with a bulky dressing to protect the exposed tissue. Also arrange for a consultation with a plastic surgeon, if requested. Instruct a patient with an abrasion to use sunscreen or wear protective clothing for at least 6 months. For a patient with a human bite on the hand, aggressively clean the wound and splint the hand to rest the joint and improve healing. Then instruct the patient to keep it immobilized to decrease the flow of lymphatic fluid and microflora. For a patient with an abscess that has been drained, packed, and covered with a loose dressing, explain the need for follow-up to closely monitor the patient and wound healing.
A permanent "tattoo" may be a complication of which injury? A. Contusion B. Avulsion C. Abrasion D. Laceration
Meticulous cleaning is essential with an abrasion because foreign bodies left in the skin can stain the epidermal layer, causing permanent scars or a "tattoo." Although the injuries in the other answer options do not cause "tattoos," they require proper cleaning and removal of any foreign bodies.
Which injury has the lowest risk of infection? A. High-velocity injury B. Injury caused by blunt trauma C. Crush injury D. Injury that lacerated the epidermis
Of these injuries, an injury that lacerates the epidermis is the most superficial and causes the least amount of injury or trauma to underlying structures. The other injuries are more complex, and the risk of wound infection is much higher.
Which wound is defined as a lesion caused by factors, such as unrelieved pressure, friction, and shearing forces? A. Abrasion B. Avulsion C. Pressure ulcer D. Abscess
Pressure ulcers (decubitus ulcers or bedsores) are lesions caused by many factors, such as unrelieved pressure, friction, humidity, shearing force, and incontinence. Avulsions are characterized by full-thickness tissue loss that prevents wound edge approximation. Abrasions result from friction that removes the epidermal layer of the skin and can also remove part of the dermis, exposing deeper skin layers. Abscesses are localized collections of pus beneath the skin.
Which statement correctly describes rabies? A. It causes respiratory depression. B. It should be considered when an animal attack is unprovoked. C. It is an endotoxin. D. It travels from the central nervous system out to the peripheral nerves.
Rabies should be considered when an animal attack is unprovoked. Rabies is rare in the United States, but should be considered when an animal attack is unprovoked, involves an unimmunized domestic animal, or involves an unknown or wild animal. Tetanus, not rabies, causes respiratory depression. The rabies virus is a neurotoxin. Once inoculation occurs, the rabies virus travels by peripheral nerves to the central nervous system.
Which statement accurately characterizes the use of staples for wound closure? A. Staples do not provide the same quality of closure as sutures.** B. Wound closure with staples minimizes scar formation. C. No liquid or ointment should be applied to a wound closed with staples. D. Staples can be used in areas of the scalp with permanent hair loss.
Staples do not provide the same quality of closure as sutures. Staples are typically used if linear lacerations require closure on the scalp, trunk, or extremities. They are a fast, economical method to close a wound, but do not provide the same quality of closure as sutures. Scarring is more pronounced, so expect to use staples in areas where a scar is not bothersome. The use of sutures—not staples—minimizes scar formation. No liquid or ointment should be applied to a wound closed with surgical glue—not staples. Staples should not be used in areas of the scalp with permanent hair loss because of poor aesthetic results.
For a patient with a tetanus-prone wound who has not received at least two previous tetanus immunizations, which treatment is indicated? A. Tetanus immune globulin (TIG) B. Tetanus vaccine C. Tetanus immune globulin (TIG) and tetanus vaccine D. Tetanus immune globulin (TIG) followed by tetanus vaccine 1 week later
TIG and tetanus vaccine is indicated. According to the Centers for Disease Control and Prevention, both should be administered to a patient with a tetanus-prone wound who has not received at least two previous tetanus immunizations.
Which statement correctly describes tetanus? A. Its incubation period is 4 to 8 weeks. B. It results from a bacillus found in the saliva of nonimmunized animals. C. It can be destroyed using sterilization. D. It is a systemic infection caused by Clostridium tetani.
Tetanus is a systemic infection caused by Clostridium tetani. The bacillus is a gram-positive, spore-forming, anaerobe. C. tetani spores are present in soil, mulch, and anywhere animal or human excrement is found. Rabies is a virus found in the saliva of infected mammals. Once activated, Clostridium tetani is virtually indestructible, even by sterilization. The incubation period for tetanus is 2 days to 2 weeks. For rabies, it is 4 to 8 weeks.
Which patient has the highest risk of complications? A. A 52-year-old diabetic patient with a nail gun injury. B. A 72-year-old woman with a clean laceration from a paring knife. C. A teenager with embedded glass in the thigh. D. A 45-year-old man with anemia and a laceration from a sterile scalpel.
The 52-year old patient with diabetes mellitus and has a nail gun injury is at highest risk of complications. This patient has a patient-related risk factor (diabetes mellitus, which impairs phagocytosis) and an injury-related risk factor (nail gun injury, which involves a contaminated high-velocity mechanism and is commonly associated with severe injury). Having two or more risk factors increases the risk of wound infection exponentially. The other patients each have one risk. The woman, age 72, has age as a patient-related risk factor. The teenager has embedded glass (foreign matter) as an injury-related risk factor. The man, age 45, has anemia as a patient-related risk factor.
Which skin layer is the key layer for wound healing? A. Stratum corneum B. Epidermis C. Dermis D. Deep fascia
The dermis, which is much thicker than the epidermis, is primarily composed of connective tissue and is the key layer for wound healing. Removal of debris and devitalized tissue from the dermis results in optimal healing and minimal scar formation. The epidermis is the outermost layer and protects against chemicals and microorganisms. The outermost layer of the epidermis is the stratum corneum, which gives skin its cosmetic appearance. The deep fascia is part of the subcutaneous layer and covers and protects underlying muscles.
When evaluating a patient who presents with a laceration, which assessment is the priority? A. Determine the time elapsed since the injury occurred. B. Assess for associated injuries. C. Evaluate the patient's tetanus immunization status. D. Identify care measures taken by the patient before arrival.
The emergency nurse should assess the patient for associated injuries, such as fractures, dislocations, or neurovascular compromise associated with the wound. The nurse also should consider tendon or ligament injuries, the presence of a foreign body, and peripheral nerve damage. After addressing any life- or limb-threatening problems, the nurse obtains a detailed history, which would include the other answer options.
Which intervention is appropriate for a patient with a large "road rash" on the leg from a motorcycle crash? A. Procedural sedation B. Wound infiltration C. Topical anesthetic application D. Local nerve block administration
The most severe of all abrasions is a "road rash." This may result in almost 100% tissue loss and, in extreme cases, requires care at a burn center. Because of the extent of this injury, procedural sedation is most beneficial to patient care. Wound infiltration is not an option due to the extent of tissue loss. Because the injured area is large, a topical anesthetic probably would not be effective. Local nerve block or digital block is not appropriate for this patient.
Which intervention is appropriate for a patient with a large "road rash" on the leg from a motorcycle crash? A. Procedural sedation B. Wound infiltration C. Topical anesthetic application D. Local nerve block administration
The most severe of all abrasions is a "road rash." This may result in almost 100% tissue loss and, in extreme cases, requires care at a burn center. Because of the extent of this injury, procedural sedation is most beneficial to patient care. Wound infiltration is not an option due to the extent of tissue loss. Because the injured area is large, a topical anesthetic probably would not be effective. Local nerve block or digital block is not appropriate for this patient.
When caring for a wound, which intervention is associated with the lowest infection rate? A. Shaving the hair follicles around the wound. B. Scrubbing the wound vigorously for 10 minutes. C. Cleansing the wound with hydrogen peroxide solution. D. Irrigating the wound with high pressure.
The preferred method of wound cleansing is high-pressure irrigation because it is excellent at removing debris and decreasing the risk of infection. Scrubbing the wound vigorously destroys surrounding tissue and increases the risk of infection. Even with a soft brush (direct contact), it can destroy tissue. Cleansing with hydrogen peroxide solution causes oxygen absorption in the wound and cell destruction. It provides no protection against anaerobes. Shaving the hair around a laceration is not recommended because it destroys the hair follicles and increases the risk of infection. Clipping the hair is preferred instead.
A patient's wound was closed with surgical glue (DERMABOND). Which statement indicates that the patient understands the discharge instructions? A. "I'll return to the emergency department if the glue does not slough off in 3 days." B. "I'll apply petroleum jelly to the area four times a day." C. "I'll apply bacitracin ointment to the area four times a day." D. "I'll return to the emergency department if I notice any discharge from the area."
The statement "I'll return to the emergency department if I notice any discharge from the area," reflects the patient's correct understanding of the discharge instructions about signs of infection and the need for further care. Petroleum jelly or acetone removes surgical glue and should be applied only on areas where surgical glue was not intended. The patient should avoid applying ointment or liquid to the closed wound because it can weaken the glue, leading to dehiscence. The glue should slough off naturally in 5 to 10 days, not in 3 days.
The nurse knows a topical anesthetic has achieved its desired effect when which finding is present? A. The skin margins approximate. B. The wound edges redden. C. The wound edges blanch. D. The skin margins are distorted.
The vasoconstrictive effect of epinephrine causes a white ring around the wound, indicating that the area is anesthetized. This usually takes at least 20 minutes. Topical anesthetics can cause skin reddening initially (before the anesthetic effect occurs), but they do not approximate skin margins. Anesthetic infiltration, not topical application, can distort the wound edges.
A male patient has a jagged, deep, 6-cm laceration in the middle of his forehead after being struck by a broken bottle. Bleeding from the wound is controlled. As ordered, you have applied a topical anesthetic to the wound. For this patient, which wound closure technique should you anticipate? A. Surgical glue B. Tape C. Staples D. Sutures
The wound is jagged and deep, which suggests that it requires absorbable sutures for underlying tissues and additional sutures to close the surface of the wound. Tape closure is indicated for superficial linear wounds. Skin staples are associated with more pronounced scarring than other wound closure techniques, so they are an unlikely choice for closing a forehead laceration. Surgical glue is a viable wound closure method when the skin edges are easily approximated. In a jagged wound, the wound edges are difficult to approximate.
Macrophages first move to the injury site during which phase of wound healing? A. Inflammatory phase B. Proliferative phase C. Remodeling phase D. Maturation phase
Wound healing occurs in overlapping phases. In the inflammatory phase, macrophages move to the site and phagocytize bacteria and debris. This phase lasts 3 to 5 days. In the proliferative phase, inflammatory processes make the wound more painful and edematous. This phase occurs 12 to 72 hours after injury and ends about 3 weeks after injury. The remodeling (maturation) phase is the final phase of wound healing, which usually begins about 2 to 3 weeks after the injury and may last up to 2 years.
