Chapter 31 Skin Integrity and Wound Care

The nurse is preparing to measure the depth of a client's tunneled wound. Which of the following implements should the nurse use to measure the depth accurately?

A sterile, flexible applicator moistened with saline. The applicator is the safest implement to use, the others are too large, inflexible, or not sterile.

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. Transparent film dressings are semipermeable, waterproof, and adhesive, allowing for visualization of the access site to aid assessment, as well as protecting the site from microorganisms.

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.

The nurse would recognize which of the following clients as being particularly susceptible to impaired wound healing?

An obese woman with a history of type1 diabetes. Obese people tend to be more vulnerable to skin irritation and injury. More significant however, is the role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process.

A nurse prepares to give a sitz bath to a client after perianal surgery. Which of the following would be most important for the nurse to do?

Assess for rapid pulse and facial palor. When giving a sitz bath, the nurse should assess the client for a rapid pulse, pale facial color, or complaints of nausea. Because heat is being applied to a large area, vasodilation can occur, causing the client to feel light-headed and faint.

A nurse is cleaning the wound of a gunshot victim. Which of the following 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 of the following actions should the nurse perform when cleansing a wound prior to the application of a new dressing? Select all that apply.

Clean the wound from top to bottom. Use a sterile applicator to apply any ointment that is ordered. Use a new gauze for each wipe of the wound. Avoid touching the wound bed, whether with gloves or forceps.

What are the effects of applying cold?

Constructs peripheral blood vessels, Reduces muscle spasms, and promotes comfort.

Which type of wound is caused by a blunt instrument that causes injury to underlying soft tissue with the overlying skin remaining intact?

Contusion

Which of the following actions should the nurse perform when applying negative pressure wound therapy?

Cut foam to the shape of the wound and place it in the wound.

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.

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 client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound?

Desiccation. A localized wound dehydration.

What are the effects of applying heat?

Dilates peripheral blood vessels, increases tissue metabolism, reduces blood viscosity and increases capillary permeability, reduces muscle tension, helps relieve pain

Which of the following types of wound drainage should alert the nurse to the possibility of infection?

Foul-smelling drainage that is grayish in color. Purulent drainage is frequently foul-smelling and may vary in color; such drainage is associated with infection.

While the nurse is preparing the client with a leg wound for heat therapy, the client asks the nurse how long the warm compress will need to stay on since he wants to get up and walk. What would be the nurse's best response?

Heat produces maximum vasodilation in 20 to 30 minutes. If heat is continued beyond that time, tissue congestion and vasoconstriction can occur and this can be detrimental to healing.

A home care nurse is visiting a client as a part of a regular visit. The client's daughter age 4 years falls while playing and sustains an abrasion on her knee. The nurse suggests that the client apply a cold compress to the child's knee based on the understanding that cold achieves which effect?

Help in controlling swelling. It causes vasoconstriction which decreases blood flow to the area. This controls bleeding and fluid coming into the tissue.

What are the phases of wound healing?

Hemostasis, inflammatory, proliferation, maturation

What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing?

Hydrocolloid dressings. They are occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment, provide minimal to moderate absorption of drainage, maintain a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing.

What are the types of wounds?

Intentional or unintentional, open or closed, acute or chronic, partial thickness full thickness or complex.

A physician orders the application of a warm, sterile compress to reduce edema in a client's wound. Which of the following is a recommended step in this procedure?

Keep the dressing in place for the prescribed amount of time or up to 30 minutes.

A nurse is removing sutures from the surgical wound of a client after an appendectomy and notices that the sutures are encrusted with blood and difficult to pull out. What would be the appropriate intervention in the situation?

Moisten sterile gauze with sterile saline to loosen crusts before removing sutures.

What are the type of drainage systems?

Open systems: penrose Closed: Jackson-pratt drain, hemovac drain.

A client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation?

Penrose drain. Penrose drains are commonly used after a surgical procedure or for drainage of an abscess. Jackson-pratt drains are typically used with breast and abdominal surgery. A hemovac drain is placed into a vascular cavity where blood drainage is expected after surgery. Wound pouching is used on wounds that have excessive drainage.

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate?

Reduce the time interval between dressing changes.

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.

What are the types of bandages?

Roller bandages, circular turn, spiral turn, figure-of-eight turn, recurrent-stump bandage

What are the stages of pressure ulcers?

Stage I: nonblanchable erythema of intact skin, Stage II: partial-thickness skin loss, Stage III: full-thickness skin loss; not involving underlying fascia, Stage IV: full-thickness skin loss with extensive destruction, Unstageable: base of ulcer covered by slough and/or eschar in wound bed.

What are the types of dressings?

Telfa, Gauze dressings, Transparent dressings.

A nurse caring for a client who has a surgical wound following a cesarean section notes dehiscence of the wound and contacts the surgeon. What is a finding related to this condition?

There is an accidental separation of the wound. Especially in surgical wounds

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site?

Transparent. A transparent dressing allows the nurse to assess the wound without moving the dressing. They are less bulky than gauze dressings and do not require tape.

True/false A stage II pressure ulcer requires debridement through wet-to-dry dressings, surgical intervention, or proteolytic enzymes.

True.

What observation should the nurse note about a client's open wound if the wound is healing by the third-intention?

Wound edges are widely separated and brought together with closure material.

You are 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?" What response by the nurse 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 acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "why is my wound still open? Will it ever heal?" Which response by the nurse is the most appropriate?

Your wound will heal slowly as granulation tissue forms and fills the wound.