Alterations in Skin Integrity-Sherpath
A patient is recovering from surgery. After the sixth day of recovery, which action made by the nurse indicates proper assessment of how the patient's incision is healing?
Palpating the area of induration next to the incision line.
Which statements are true about superficial- or partial-thickness wounds?
-These wounds tend to heal quickly. -Superficial wounds affect only the epidermis. -Partial-thickness wounds affect the epidermis and the dermis, but do not extend through the dermis to the subcutaneous layer.
The student nurse is discussing skin integrity with a patient who has a closed wound. Which statement made by the student nurse indicates teaching has been effective?
"A closed wound indicates that underlying tissue damage may still exist."
A student nurse understands that some patients are more prone to developing pressure ulcers than others. Which statement made by the student nurse indicates teaching has been effective?
-"Patients with a low BMI are at risk for pressure ulcers." -"Patients with zinc deficiencies are at risk for pressure ulcers."
How are wounds classified?
-Cause. -Depth. -Presence or absence of infection.
Which factors are related to pressure ulcers?
-Duration. -Intensity. -Moisture. -Immobility.
Which external forces can result in pressure ulcers?
-Friction. -Pressure. -Shear force.
Which factors affect skin integrity?
-Medications. -Vascular diseases. -Nutritional deficits.
A patient who was recently diagnosed with diabetes mellitus asks the student nurse why diabetes mellitus affects skin integrity and healing. Which response by the student nurse indicates effective learning?
"Diabetes mellitus causes changes to the micro-vascular and macro-vascular systems."
The student nurse is learning how to classify burn wounds. Which statement made by the student nurse reflects a misunderstanding?
"I can classify burn wounds according to the depth and width of the lesion."
A nurse is teaching a group of patients about skin integrity. When asked by a patient about whether or not smoking affects wound healing, what is the best response from the nurse?
"Smoking decreases blood and oxygen circulation."
The nurse is caring for a patient with a contaminated wound that was initially left open for a while after surgery. What is the most appropriate explanation of tertiary intention that the nurse makes to the patient?
"The wound will be closed later when the infection risk is reduced."
The registered nurse is teaching the student nurse about delayed wound healing. Which statement made by the student nurse indicates a need for further teaching?
"Wounds should be kept wet and moist to prevent skin tissue from tightening."
The nurse understands that which patient is at highest risk of getting a pressure ulcer?
75-year-old patient with diabetes who is hospitalized for a hip fracture.
A nurse is working in the emergency department and a child was brought in with a burn on his arm. Which action made by the nurse demonstrates appropriate wound classification?
Classifying the wound according to the degree of burn.
What is a fistula?
Abnormal connection between two internal organs or between protruding internal organ and the outside of the body.
The nurse understands that which patient is most at risk for developing a pressure ulcer?
Patient with unrelieved pressure exceeding 12-32 mmHg.
The student nurse understands that a patient with enterocutaneous fistula has what type of opening?
Between the skin and the intestines.
Which wound is classified as a closed wound?
Bruise.
A patient with diabetes is being seen in the emergency department for blood sugar issues. What is the most appropriate nursing action in this scenario?
Checking the patient's feet.
How does sensory loss relate to the formation of a pressure ulcer?
Patients may be unable to feel pain or discomfort.
What two primary complications of wound healing can occur when tissues of surgical incisions are under physical stress?
Dehiscence and evisceration.
What is the first phase of wound healing?
Inflammatory.
Match the pressure ulcer stage with the characteristic.
Intact, non-blistered skin-Stage I. Partial-thickness wound, involving the epidermis and dermis-Stage II. Full-thickness wound, extending into the subcutaneous tissue-Stage III. Full-thickness wound with necrotic tissue (eschar)-Unstageable.
The nurse is classifying a wound in her chart. The nurse understands that which documentation would be a standard classification that other health care workers would be able to comprehend?
Open knife wound with contamination.
The nurse is caring for a patient with a recent, minor injury. As the nurse assesses the site of the injury, she notes that the new tissue has a granular, bumpy texture. The patient reports that the injured site still "bleeds easily." The nurse understands the phase of wound healing by documenting which stage in the patient's chart?
Proliferative.
Which change is associated with aging of the skin?
Reduced insulation and cushioning, which increases the risk for skin trauma and temperature extremes.
Match the burn classification with the characteristic.
Results in pain and redness-Superficial. Results in extreme pain and blistering-Superficial and Deep Partial-Thickness. Results in white or brown areas, charring, and loss of sensation-Full-Thickness and Deep Full-Thickness.
A patient has a post-operative follow-up appointment with the nurse. During the appointment, the nurse removes the patient's dressing and observes that the wound appears infected. Which action by the nurse demonstrates proper knowledge of wound healing and skin integrity?
Reviewing the patient's medications.
A nurse is caring for a patient with paralysis who has a full-thickness wound that extends into the subcutaneous tissue, but not into the fascia, muscle, or bone. The nurse demonstrates knowledge of wound classification by documenting the pressure ulcer as which stage?
Stage III.
The nurse is caring for a patient whose intestines are coming out of his surgical incision. Which action made by the nurse demonstrates proper knowledge of wound healing complications?
Telling the health care provider that the patient is experiencing evisceration.
