Chapter 31: Skin Integrity and Wound Care

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."

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.

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?

incision An incision involves a clean separation of skin and tissue with smooth, even edges. Therefore, the nurse documents the finding as an incision. Other Definitions: 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.

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."

The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next?

Document the color, odor, amount, and type of wound drainage.

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.

An obese client on the unit has demonstrated difficulty healing a large pressure ulcer. The nurse correctly recognizes that this is most likely because of which factor?

Adipose tissue is poorly vascularized. Wound healing may be decreased in obese clients. Because adipose tissue is relatively avascular, it provides only a weak defense against microbial invasion and impairs delivery of nutrients to the wound.

What is true about the dermis? Select all that apply.

The major cell of the dermis produces collagen and elastin and is the thickest skin layer. The dermis underlies the epidermis, which is the skin's outermost layer. The major cell of the epidermis produces keratin, while the basal cells of the epidermis produce melanin.

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 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 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.

A client has a fissure on her finger due to chafing. The client asks "How long will it be painful?" The nurse explains that the inflammation phase will last:

3 days.

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 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 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 will put a layer of cloth between my skin and the ice pack."

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."

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 most appropriate?

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

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.

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.

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.

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.

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors.

Local capillary pressure must be higher than external pressure. The heart must be able to pump adequately. The volume of circulating blood must be sufficient. Arteries and veins must be patent and functioning well.

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 this situation?

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

The nurse is preparing to change a dressing in which blood and drainage is expected. In addition to gauze, which dressing supply will the nurse gather to take in the client's room?

Montgomery straps Montgomery straps are used with gauze dressings to absorb blood or drainage. Transparent dressings like Tegaderm and OpSite are used to protect intravenous insertion sites. Hydrocolloid dressings like DuoDerm are used to used keep a wound moist.

The nurse considers the impact of shearing forces in the development of pressure ulcers in clients. Which client would be most likely to develop a pressure ulcer from shearing forces?

a client sitting in a chair who slides down Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Clients who are pulled, rather than lifted, when being moved up in bed (or from bed to chair or stretcher) are at risk for injury from shearing forces. A client who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a client who sits in a chair but slides down. The client that is most likely to develop a pressure ulcer from shearing forces would be a client sitting in a chair who slides down.

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 would recognize which client as being particularly susceptible to impaired wound healing?

an obese woman with a history of type 1 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 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?

contusion A contusion is an injury to soft tissue, so this is what the nurse expects to see based on the incident. Other definitions A puncture involves an opening of 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 stripped surface layers of skin. An avulsion has stripped away of large areas of skin and underlying tissues.

A postoperative client describes the following during a transfer, "I feel like something just popped." The nurse immediately assesses for:

dehiscence. Dehiscence is a total or partial disruption in wound edges. Clients often report feeling the incision has given way. 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.

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."

Which teaching will the nurse provide to a caregiver about wound healing for an 85-year-old client? Select all that apply.

"It may take twice as long as normal for the wound to heal." "Consider having a home health aide to decrease the client's stress level." "Older adults with lots of sun exposure may experience delayed healing." The nurse will teach that wound healing is delayed in older adult clients, especially those with long-term sun exposure. Normal aging changes include decreased (not increased) appetite. A home health aide can assist with caregiving to reduce stress from the client. Depression after surgery can affect wound healing, and this is not a normal finding.

The nurse is taking care of a client on the second post-operative day who asks about wound dehiscence. Which response by the nurse is most accurate?

"Dehiscence is when a wound has partial or total separation of the wound layers." 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.

A skin infection caused by beta-hemolytic streptococci common in children is:

impetigo.

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk?

shearing force

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.

A nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client?

Subcutaneous tissue

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 medical-surgical nurse is assessing wounds of clients. Which wound complications are accurately described below? Select all that apply.

Dehiscence, which is present when there is a partial or total disruption of wound layers Evisceration, which occurs when the viscera protrudes through the incisional area Postoperative fistula formation, most often the result of delayed healing, commonly manifested by drainage from an opening in the skin or surgical site Dehiscence is a partial or total disruption of wound layers. Evisceration occurs when the viscera protrudes through the incisional area. Postoperative fistula formation commonly manifests by drainage from an opening in the skin or surgical site. Symptoms of wound infection occur before 1 to 2 weeks after the injury or surgery. Delayed wound healing in clients who are thin and at greater risk for complications is not due to thinner layer of tissue cells, but possibly from malnutrition, or other complications. An increase in the flow of serosanguineous fluid between postoperative days 4 and 5 would be a sign of an impending dehiscence, not evisceration.

A nursing instructor is teaching a student nurse about the layers of the skin. Which layer should the student nurse understand is a potential source of energy in an undernourished client?

Subcutaneous tissue The subcutaneous tissue is the skin layer that is responsible for storing fat for energy. The epidermis is the outer layer that protects the body with a waterproof layer of cells. The dermis contains the nerves, hair follicles, blood vessels, and glands. The muscle layer moves the skeleton.

In which situations has the nurse used a dressing properly? (Select all that apply.)

The nurse would place an OpSite over a central venous access device insertion site. An OpSite helps to secure the device and is appropriate for a site with little drainage. The nurse would use appropriate aseptic techniques when changing a dressing. The nurse would place a Sof-Wick around a drain insertion site. The Sof-Wick absorbs drainage and protects the wound from contamination or injury. The nurse would not place a transparent dressing over an ABD pad. The nurse would use tape on the ABD pad. Drainage could be marked on the tape to determine any changes in drainage. The purpose of a Telfa is to not adhere to the wound, and allows drainage to pass through to a secondary dressing.

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

There is an unintentional separation of the wound. With dehiscence, there is an unintentional separation of wound edges, especially in a surgical wound. In approximated wound edges, the edges of a wound are lightly pulled together. Edema is an accumulation of fluid in the interstitial tissue. Redness or inflammation of an area as a result of dilation is erythema.

The nurse is helping a confused client with a large leg wound order dinner. Which is the most appropriate food for the nurse to select to promote wound healing?

To promote wound healing, the nurse should ensure that the client's diet is high in protein, vitamin A, and vitamin C. The fish is high in protein and is therefore the most appropriate choice to promote wound healing.

To determine a client's risk for pressure ulcer development, it is most important for the nurse to ask the client which question?

"Do you experience incontinence?" he client's health history is an essential component for assessing the client's integumentary status and identification of risk factors for problems with the skin. The priority question addresses a source of moisture on the skin. Moisture makes the skin more susceptible to injury because it can create an environment in which microorganisms can multiply and the skin is more likely to blister, suffer abrasions, and become macerated (softening or disintegration of the skin in response to moisture).

A nurse is caring for clients on a medical surgical unit. Based on known risk factors, the nurse understands which client has the highest risk for developing a pressure ulcer?

65-year-old incontinent client with a hip fracture on bed rest The 65-year-old client who is incontinent with a hip fracture would be at highest risk for developing a pressure ulcer. This client has several risk factors: age, incontinence, and decreased mobility related to the hip fracture.

A nurse is evaluating a client's laboratory data. Which of the following laboratory findings should the nurse recognize as increasing a client's risk for pressure ulcer development?

Albumin 2.8 mg/dL An albumin level of less than 3.2 mg/dL increases the risk of the client developing a pressure ulcer. This indicates that the client is nutritionally deficient.

A nurse is evaluating a client's laboratory data. Which of the following laboratory findings should the nurse recognize as increasing a client's risk for pressure ulcer development?

Albumin 2.8 mg/dL An albumin level of less than 3.2 mg/dL increases the risk of the client developing a pressure ulcer. This indicates that the client is nutritionally deficient. The hemoglobin A1C level of 5% is a normal value. The BUN level is within normal limits. The white blood cell count is also a normal value.

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.

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.

A nurse assesses an area of pale white skin over a client's coccyx. After turning the client on her side, the skin becomes red and feels warm. What should the nurse do about these assessments?

Recognize that this is ischemia, followed by reactive hyperemia. Blanching (skin becomes white) of skin over an area under pressure results from ischemia. When pressure is relieved, reactive hyperemia follows and the skin is red and feels warm. Reactive hyperemia is not a stage I pressure ulcer.

Which activity should the nurse implement to decrease shearing force on the client with a stage II pressure ulcer?

Support the client from sliding in bed. Shearing force occurs when tissue layers move on each other, causing vessels to stretch as they pass through the subcutaneous tissue.

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure ulcer?

Use pillows to maintain a side-lying position as needed. Using pillows to maintain a side-lying position allows the nursing staff to change position to alleviate and alternate pressure on client's bony prominences. The client's position should be changed a minimum of every 2 hours. In addition, incontinent care should be performed a minimum of every 2 hours and as needed to decrease moisture and irritation to the skin. A foot board prevents footdrop in clients but does not decrease the risk for pressure ulcers.

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.

True

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.