Chapter 31: Skin Integrity and Wound Care
A skin infection caused by beta-hemolytic streptococci common in children is:
impetigo. Impetigo, which usually is caused by beta-hemolytic streptococci, is the most common bacterial skin infection.
The nurse is teaching a client about healing of a minor surgical wound by first-intention. What teaching will the nurse include?
"Very little scar tissue will form." Very little scar tissue is expected to form in a minor surgical wound. Second-intention healing involves a complex reparative process where margins of the wound are not in direct contact. Third-intention healing takes place when wound edges are intentionally left widely separated and are later brought together for closure.
A child is brought to the clinic by his mother. The mother states he has been at Boy Scout camp. The child has a rash on his face, arms, and legs. The child states it itches severely. The child has probably come in contact with:
poison ivy.
The health care provider prescribes negative-pressure wound therapy for a client with a pressure ulcer. Before initiating the treatment, it is important for the nurse to implement which nursing assessment?
Assess the wound for active bleeding. 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 the 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 initiating negative-pressure wound therapy.
A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 cm x 6.4 cm. Which action 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 1 inch (2.5 cm) 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.
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?
Off-load pressure from the heel. The correct action by the nurse is to off-load pressure from the heel. This can be accomplished by placing a pillow under the client's leg so that the heel is touching neither the bed or the pillow. The hard leathery, black scar is an eschar that forms a protective covering over the heel and should not be debrided. Utilizing TED hose on the client will not impact the status of the heel wound.
A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing describes this?
Secondary intention
The nurse is caring for a woman with a labile carbuncle. Which intervention will most likely be included in the plan of care?
Soak in a warm bath for drainage.
While walking in the woods, an 8-year-old boy trips and a stick cuts his right leg. The camp nurse inspects the wound and determines a portion of the dermis is intact, so she cleanses and bandages the wound. What wound classification will the nurse document on the child's health record?
Unintentional, partial-thickness wound The child sustained an unintentional, partial-thickness wound. An unintentional wound is an accidental wound. A partial-thickness wound is characterized by all or a portion of the dermis remaining intact. A full-thickness wound is characterized by severing of the entire dermis, sweat glands, and hair follicles.
The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective? "I should keep this on my ankle until it is numb." "I must wait 15 minutes between applications of cold therapy." "I will put a layer of cloth between my skin and the ice pack." "I can let this stay on my ankle an hour at a time."
"I will put a layer of cloth between my skin and the ice pack." Teaching has been affective when the client understands that a layer of cloth is needed between the ice pack and skin to preserve skin integrity. The ice pack should be removed if skin becomes mottled or numb, as this indicates that the cold therapy is too cold. The ice pack can be in place for no more than 20-30 minutes at a time, and a minimum of 30 minutes should go by before reapplying.
A client has undergone an open surgical procedure. Which teaching provided by the nurse accurately reflects what the client should expect during the remodeling period?
"The wound will contract and scarring will shrink." Constriction of blood vessels and appearance of polymorphonuclear leukocytes takes place during the inflammation period. Granulation tissue forms during the proliferation period. The surgical wound contracts and scarring shrinks during the remodeling period.
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. In children younger than 2 years, the skin is thicker and stronger than in adults. A child's skin becomes less resistant to injury and infection as the child grows. An individual's skin changes little over the life span.
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.
Which is not considered a skin appendage?
Connective tissue Hair, the sebaceous gland, and eccrine sweat glands are skin appendages that are formed with the enfolding of the epidermis into the dermis. The dermis is composed of connective tissue.
The nurse is caring for a client who needs blood drawn for analysis. When gathering supplies, which dressing will the nurse select to cover the site where the needle was inserted to gather blood?
Gauze Gauze dressings absorb blood or drainage. Transparent dressings like OpSite are used to protect intravenous insertion sites. Hydrocolloid dressings like Duoderm and Tegasorb are used to used keep a wound moist.
Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors?
Local capillary pressure must be lower than external pressure. Local capillary pressure must be higher than external pressure for adequate skin perfusion.
A nursing student is assessing a patient who is being treated for cancer with metastases. The student's assessment of the patient's integumentary system reveals that the patient has a yellowish tinge to some skin surfaces and to the sclerae of her eyes. What is the student's most appropriate follow-up?
Review the patient's most recent liver function tests. Jaundice is a result of the accumulation of bilirubin, which is among the components of liver function testing. Jaundice does not result from impaired oxygenation or dehydration, and it does not necessitate wound care.
The nurse is applying a heating pad to a client 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.
An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site?
a transparent film
A full-thickness burn develops a leathery covering called a(an): eschar. static. abrasion. erythema.
eschar.
The client with vaginal itching and burning has been scheduled for an examination and Pap procedure. Which teaching regarding douching will the nurse provide to the client to prepare for the appointment?
"Do not douche 24-48 hours before the procedure." Clients should be informed to refrain from douching 24-48 hours prior to a Pap test, as this can wash away diagnostic cells. The healthcare provider is unlikely to recommend routine douching; this procedure is usually used to assist with treatment of an infection. The Pap procedure involves obtaining cell samples; it does not include application of a douche.
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.
The dressing change on a deep upper-arm wound is painful for the client. When preparing a care plan for the client, 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 clients are fatigued, the sensation of pain may be greater. Also, plan to change the dressing midway between meals so that the client's appetite and mealtimes are not disturbed.
A nursing student is assessing a patient who is being treated for cancer with metastases. The student's assessment of the patient's integumentary system reveals that the patient has a yellowish tinge to some skin surfaces and to the sclerae of her eyes. What is the student's most appropriate follow-up? Assess the patient's SpO2 and hemoglobin levels. Assess the patient's skin turgor and fluid balance. Review the patient's most recent liver function tests. Refer the patient to the wound care clinical nurse specialist.
Review the patient's most recent liver function tests. Jaundice is a result of the accumulation of bilirubin, which is among the components of liver function testing. Jaundice does not result from impaired oxygenation or dehydration, and it does not necessitate wound care.
A nursing student is preparing to perform her first dressing change on a patient who has a surgical incision. What risk nursing diagnosis should the student prioritize when planning this intervention? Risk for Infection Risk for Acute Pain Risk for Delayed Surgical Recovery Risk for Injury
Risk for Infection Many of the actions involved in changing a dressing are specifically aimed at reducing the risk of wound infection. Pain and injury must be avoided, of course, but strict maintenance of asepsis is a high priority when changing a surgical wound. Delayed surgical recovery is a less likely consequence of changing a dressing.
A nurse has begun removing a patient's surgical staples as ordered and observes that the wound edges are pulling apart where each staple has been removed. What is the nurse's most appropriate action?
Stop removing staples and inform the primary care provider. The nurse should abort the attempt to remove the staples if dehiscence is evident; this is not an expected finding. A Steri-Strip cannot be applied over a staple that will be imminently removed.
A client's hand was severely wounded upon coming in contact with a running lawn mower blade. The nurse notes that large amounts of flesh are missing, and the bones of two fingers are visible. How will the nurse document this assessment finding?
avulsion An avulsion involves stripping away of large parts of tissue leaving cartilage and bone exposed. Therefore, the nurse will document this assessment finding as an avulsion. A puncture involves an opening of skin caused by a narrow, sharp, pointed object. A laceration involves separation of skin and tissue with torn, irregular edges. A contusion is an injury to soft tissue. Therefore, the nurse would not document the finding as a puncture, laceration, or contusion.
What is the best nursing diagnosis to describe a minor laceration to finger sustained when a client was cutting fruit in the kitchen with a knife?
impaired skin integrity related to open wound Impaired skin integrity best describes the minor laceration. Pain, knowledge deficit, and risk for infection are all sustained as a result of the laceration.
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: primary intention. secondary intention. tertiary intention. dehiscence.
primary intention. 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.
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?
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 new mother is asking the nurse about care of her baby's skin. The nurse should instruct the mother:
to apply sunscreen when exposed to ultraviolet rays. Sunscreen is necessary to protect against damage caused by ultraviolet rays.
A nurse is evaluating a client who was admitted with second-degree burns. Which describes a second-degree burn?
usually moist with blisters, they may be pink, red, pale ivory, or light yellow-brown Second-degree burns are moderate to deep partial-thickness burns that may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. First-degree burns are superficial and may be pinkish or red with no blistering. Third-degree burns are full-thickness burns and may vary from brown or black to cherry-red or pearly-white; bullae may be present; can appear dry and leathery.
A client who had a Cesarean section to deliver twins is learning to care for her incision. Which teaching will the nurse include?
"It is important to keep your sutured incision clean." After a Cesarean section, a client will be sutured and have staples put in place for a number of days. It is important to keep the sutured incision clean. Steri-Strips are not strong enough to hold this type of wound together. A binder is not sufficient to hold this type of incision together.
The nurse is teaching a client who is preparing for a left mastectomy due to breast cancer. Which teaching about a Jackson-Pratt drain will the nurse include?
"It provides a way to remove drainage and blood from the surgical wound." The bulb-like drain allows for removal of blood and drainage from the surgical site. It does not provide a route for medication administration, decrease the chance for infection, nor does it stay attached permanently.
The nurse is teaching a client about wound care at home following a Cesarean section to deliver her baby. Which client statement requires further nursing teaching?
"Steri-Strips will hold my wound together until it heals." After a Cesarean section, a client will be sutured and have staples put in place for a number of days. The healthcare provider or nurse will remove staples. Steri-Strips are not strong enough to hold this type of wound together.
The nurse is applying a saline-moistened dressing to a client's wound. The client asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which response is most appropriate?
"Wounds heal better when a moist wound bed is maintained." A moist wound surface enhances the cellular migration necessary for tissue repair and healing.
The nurse is providing education to a client recently diagnosed with psoriasis. The client questions the nurse about the potential for curing the condition. What response by the nurse is most appropriate?
"You will likely experience periods of increased skin outbreaks and periods of remissions." Psoriasis is a chronic condition. It may be managed with lifestyle changes and medications. There is no permanent cure. Periods of remission are followed by exacerbations, which can be triggered by stress, infection, or environmental factors.
A client recovering from abdominal surgery sneezes, and then screams, "My insides are hanging out!" What is the initial nursing intervention?
Apply sterile dressings with normal saline over the protruding organs and tissue. The nurse will immediately apply sterile dressing moistened with normal saline over the protruding organs and tissue, and call out for someone to contact the surgeon. While waiting for the surgeon, the nurse will continue to assess the area of evisceration and monitor the client's status.
A nursing student is performing a skin assessment of an older adult patient. After pinching the skin below the patient's clavicle, the student counts 6 seconds before the skin returns to a flat position. What additional assessment should the student perform? Assess the integrity of the patient's mucous membranes. Assess the patient for signs and symptoms of dehydration. Assess the texture of the skin adjacent to the test site. Assess the patient's nutritional status.
Assess the patient for signs and symptoms of dehydration. Reduced skin turgor can be caused by malnutrition, but it is more commonly associated with deficient fluid volume. The patient's mucous membranes may appear dry, but their integrity is unlikely to be compromised. Changes in skin texture are rarely associated with alterations in skin turgor.
A nurse is cleaning the wound of a gunshot victim. Which 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.
Which is not considered a skin appendage? Hair Connective tissue Sebaceous gland Eccrine sweat glands
Connective tissue Hair, the sebaceous gland, and eccrine sweat glands are skin appendages that are formed with the enfolding of the epidermis into the dermis. The dermis is composed of connective tissue.
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.
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?
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.
The nurse is performing an admission assessment on a client being admitted to a long-term care facility. The nurse notes the client has a history of psoriasis. Which locations on the body is the nurse most likely to find manifestations consistent with the condition? Select all that apply.
Elbows Knees Soles of the feet The elbows, knees, scalp, and soles of the feet are common sites for psoriasis.
The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action?
Elevate and support the stump. The nurse will first elevate and support the stump, then begin the process of bandaging. The bandage will be applied distally to proximally with equal tension at each turn; the nurse will monitor throughout the application to keep the bandage free from gaps between turns.
The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough, a bad odor, and extends into the muscle. How will the nurse categorize this pressure injury?
Stage IV Stage IV pressure injuries are characterized as exposing muscle and bone, and may have slough and a foul odor. Stage I pressure injuries are characterized by intact, but reddened, skin that is unblanchable. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage.
A patient has told the nurse that her daughter is a frequent user of tanning beds and that she is concerned about her daughter's consequent risk of skin cancer. What health promotion guideline should the nurse provide to this patient?
Tanning beds should never be used, especially by younger people. Tanning beds present a significant risk of skin cancer and should be avoided by all individuals. The risks are especially pronounced among younger people. Due to the high ultraviolet exposure, sunscreens would not even provide adequate protection (and would eliminate the individual's motivation for using a tanning bed).
A patient has presented for care because of mole on his chest that he did not previously have. What other characteristic of the mole is suggestive of melanoma? The diameter of the mole is approximately 5 mm. The borders of the patient's mole are irregularly shaped. The mole is on a skin surface that is normally covered by clothing. The mole is a dark brown colour.
The borders of the patient's mole are irregularly shaped. Uneven borders constitute the "B" of the ABCDE of melanoma. Irregular coloration is a warning sign, but dark brown coloration is not necessarily problematic. Size exceeding 6 mm is problematic. The fact that the mole is on a body part that is normally covered is not necessarily indicative of cancer.
Which nursing interventions reflect the accurate use of heat or cold during wound care? Select all that apply. The nurse makes more frequent checks of the skin of an older adult using a heating pad. The nurse places a heating pad on a sprained wrist that is in the acute stage. The nurse instructs the client to lean or lie directly on the heating device. The nurse fills an ice bag with small pieces of ice to about two-thirds full. The nurse covers a cold pack with a cotton sleeve to keep it in place on an arm. The nurse applies moist cold to a client's eye for 40 minutes every 2 hours.
The nurse makes more frequent checks of the skin of an older adult using a heating pad. The nurse fills an ice bag with small pieces of ice to about two-thirds full. The nurse covers a cold pack with a cotton sleeve to keep it in place on an arm. The nurse would make more frequent checks of the skin of an older adult using a heating pad. The nurse would fill an ice bag with small pieces of ice to about two-thirds full. The nurse would cover a cold pack with a cotton sleeve to keep it in place on an arm. The nurse would place cold therapy, not a heating pad, on a sprained wrist in the acute stage. The nurse would instruct the client not to lie or lean directly on the heating device. The nurse would apply moist cold to a client's eye for 30 minutes, not 40 minutes, every 2 hours.
The nurse caring for a postoperative client is cleaning the client'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 client with a history of pressure ulcers is discussing nutrition with the nurse. The client correctly indicates plans to include which vitamin in the diet to promote wound healing? Select all that apply. Vitamin D Vitamin B3 (niacin) Vitamin B6 (pyridoxine) Vitamin B7 (biotin) Vitamin B9 (folic acid)
Vitamin B3 (niacin) Vitamin B6 (pyridoxine) Adequate intake of vitamins A, B6, C, K, niacin, and riboflavin is important to prevent abnormal skin changes.
A client is recovering from abdominal surgery sneezes, and then screams, "I think I popped a couple of my sutures." What is the initial nursing intervention?
Wet sterile dressings with normal saline and apply over tissue. The nurse will immediately apply sterile dressing moistened with normal saline over the tissue, and call out for someone to contact the surgeon. While waiting for the surgeon, the nurse will continue to assess the area of dehiscence and monitor the client's status. The other actions are not the initial actions the nurse would take.
A child has been brought to the emergency department after being bitten by a spider. The site is elevated above the surface of the child's skin and is irregularly shaped and filled with fluid. The nurse should document what type of primary skin lesion?
Wheal Wheals are elevated, irregular-shaped area of fluid under the skin. A papule is a circumscribed, solid, elevation of the skin, less than 1 cm. A cyst does not normally result from an insect bite. A keloid is a type of secondary skin lesion that is associated with scarring.
A nursing student is providing a complete bed bath to a 60-year-old diabetic client. The student is conducting an assessment during the bath. The student observes a red, raised rash under the client's breasts. This manifestation is most consistent with:
a rash related to a yeast infection. Diaphoresis or inadequate drying after hygiene, especially in skin folds, can increase moisture and encourage the growth of yeast. In addition, the client's history of diabetes will increase the risk for the development of a yeast infection. The rash resulting from an allergic reaction would not likely be limited to the region beneath the breast. Immobility will not directly result in a rash.
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 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.
The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention?
a surgical incision with sutured approximated edges 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.
The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use?
figure-of-eight turn A figure-of-eight turn is used for joints like elbows and knees. Other answers are incorrect.
The nurse has collected blood from a client for laboratory analysis. Which dressing supply will the nurse select to cover the site from which the blood was drawn?
gauze Gauze dressings absorb blood or drainage. Montgomery straps are strips of tape with eyelets which are used to secure a gauze dressing that needs frequent changing; they are not necessary for this type of wound. Transparent dressings like OpSite are used to protect intravenous insertion sites. Hydrocolloid dressings like Tegasorb are used to used keep a wound moist.
When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding? avulsion abrasion incision laceration
incision An incision involves a clean separation of skin and tissue with smooth, even edges. Therefore, the nurse documents the finding as an incision. An avulsion has stripped away of large areas of skin and underlying tissues. An abrasion involves stripped surface layers of skin. A laceration involves separation of skin and tissue with torn, irregular edges. Therefore, the nurse does not document the finding as an avulsion, abrasion, or laceration.
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. The burn is most likely:
second degree 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.