Chapter 32

puncture

(n.) a small hole made by a sharp object; (v.) to make such a hole, pierce

inflammatory phase

*follows hemostasis 4-6 days *white blood cells *macrophages *debris ingested and growth factors *fibroblasts

factors affecting wound healing

-age -circulation and oxygenation -nutritional status -wound condition -health status -immunosuppression -medication use

Principles of Wound Healing

-intact skin is the first line of defense against microorganisms -surgical asepsis is used in caring for a wound -body responds systemically to trauma of any of its parts -adaquate blood supply is essential for normal body response to injury -normal healing is promoted when wound is free of foreign material -extent of damage and persons state of health affects wound healing -response to wound is more effective if proper nutrition is maintained

Causes of Skin Alterations

1) Very thin & very obese people are more susceptible to skin injury. 2) Fluid loss during illness causes dehydration. 3) Excessive perspiration during illness predisposes skin to breakdown. 4) Jaundice causes yellowish, itchy skin 5) diseases of the skin, like eczema & psoriasis, may cause lesions that req. special care.

_____________________ typically exits a client's skin through a stab wound created by the surgeon.

A Penrose drain

serous fluid

A clear, watery fluid secreted by the cells of a serous membrane.

applying sterile dressings with normal saline over the protruding organs and tissue

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention?

Assess the client's wound and vital signs.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first?

decubitus ulcer

A client suffering from infectious diarrhea, dehydration, and right-sided paralysis is confined to bed. What is the client most prone to?

Stage II

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury?

avulsion

A forcible pulling away of a part or structure

eschar

A full-thickness or third-degree burn develops a leathery covering called a(an):

removing dead or infected tissue to promote 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?

to apply sunscreen when exposed to ultraviolet rays.

A new mother is asking the nurse about care of her baby's skin. The nurse should instruct the mother:

Apply a bath blanket over the aquathermia pad. Assess skin and pain level at baseline and ongoing. Check the water level in the aquathermia unit periodically.

A nurse applies an aquathermia pad to the back of a client with arthritis. What administration considerations should the nurse use? Select all that apply.

use pillows to maintain a side-lying position as needed

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 injury?

Tearing of a structure from its normal position

A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion?

cleanse with a new gauze for each stroke

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 × 6.4 cm. Which action should the nurse use during wound care?

Clean the wound from the top to the bottom and from the center to outside.

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure?

serosanguineous

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage type should the nurse document?

Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn?

The nurse should apply adhesive wound closure strips after removing staples.

A nurse is preparing to remove the staples from the donor vein site on a client's leg following cardiac surgery. Which guideline should inform the nurse's decision making?

secondary intention

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 is this?

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

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action?

An infant's skin and mucous membranes are easily injured and at risk for infection.

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child?

Dehiscence of the wound

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?

Biofilm

A surface-coating colony of one or more species of prokaryotes that engage in metabolic cooperation, or sluff

factors affecting pressure ulcer development

Aging skin Chronic illnesses Immobility Malnutrition Fecal and urinary incontinence Altered level of consciousness Spinal cord and brain injuries Neuromuscular disorders

a transparent film

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?

Proliferation Phase

Begins within 2 to 3 days of injury and may last up to 2 to 3 weeks New tissue is built to fill the wound space through the action of fibroblasts. Capillaries grow across the wound. A thin layer of epithelial cells forms across the wound. Granulation tissue forms a foundation for scar tissue development.

Dehiscence

Bursting open of a wound, especially a surgical abdominal wound

Cleaning a pressure ulcer

Clean with each dressing change. Use careful, gentle motions to minimize trauma. Use 0.9% normal saline solution to irrigate and clean the ulcer. Report any drainage or necrotic tissue.

Psychosocial

Describing the relation of the individual's emotional needs to the social environment

maturation phase

Final stage of healing begins about 3 weeks to 6 months after injury. Collagen is remodeled. New collagen tissue is deposited. Scar becomes a flat, thin, white line.

Stage IV pressure ulcer

Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material)

Stage III pressure ulcer

Full-thickness tissue loss with no bone, tendon, or muscle visible

Phases of wound healing

Hemostasis Inflammatory Proliferation Maturation

Types of wounds

Intentional or unintentional - surgical vs traumatic Open or closed - skin break vs bruise Acute or chronic Partial thickness, full thickness, complex

gas gangrene

Necrosis in a wound infected by an anaerobic gas forming bacillus, the most common etiologic agent being Clostridium perfringens.

Record the quantity of drainage once per shift and document on the intake and output record.

Negative pressure wound therapy (NPWT) has been ordered for a client who is being treated for a chronic wound. What should be included in this client's nursing care plan?

Stage I Pressure ulcer

Nonblanchable redness of a localized, area of intact skin

PUSH tool

Not a risk assessment Use for pressure ulcers to help track healing Total score - next time patient comes in, going to give a new total score and plot the score Trying to give a visual representation of the wounds healing

serosanguineous

Pale, red, watery: mixture of clear and red fluid

unstageable

Pressure ulcer where wound cannot be visualized; ulcer is full-thickness tissue loss in which base of the ulcer is covered by slough, typically has eschar

Braden Scale

Pressure ulcers lower the number, higher the risk 4-23 less than 17 = risk for pressure ulcers

Functions of the skin

Protection, Thermoregulation, Cutaneous Sensation, Vitamin D synthesis, Immunologic, Absorption, Elimination

Staging of Pressure Ulcers: Stage 1

Stage I: Prolonged redness with unbroken skin.

Staging of Pressure Ulcers: Stage II

Stage II: Partial-thickness skin loss that appears as shallow, open ulcer with pink wound bed and w/o slough.

Staging of Pressure Ulcers: Stage III

Stage III: Full thickness skin loss with damage to the subcutaneous tissue with no bone, tendon or muscle exposed.

Staging of Pressure Ulcers: Stage IV

Stage IV: Full thickness tissue loss with exposed bone, muscle or tendon. Eschar or slough may be present in some parts of wound bed. Unstageable: If entire wound bed covered by slough or eschar.

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

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?

partial thickness wound

The dermis and epidermis of the skin are broken

Evisceration

The displacement of organs outside of the body.

"Necrotic tissue is devitalized tissue that must be removed to promote healing."

The nurse and client are looking at a client's heel pressure injury. The client asks, "Why is there a small part of this wound that is dry and brown?" What is the nurse's appropriate response?

a client sitting in a chair who slides down

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

oblique

The nurse is caring for a bedridden client who is at risk for the development of pressure injuries. In which position can the nurse place the client to relieve pressure on the trochanter area?

Document the findings.

The nurse is caring for a client who had abdominal surgery 12 hours ago and notes a small amount of sanguineous drainage on the abdominal surgical dressing. What is the appropriate action by the nurse?

The nurse uses positioning devices and techniques to maintain posture and distribute weight evenly for the client in a chair.

The nurse is caring for a client who has a pressure injury on the back. What nursing intervention would the nurse perform?

Keep the swab and the inside of the culture tube sterile.

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 action should the nurse perform in obtaining a wound culture?

second degree or partial thickness

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:

"I will put a washcloth between my knee and the ice pack."

The nurse is caring for a client with a knee sprain. Which client statement regarding use of an ice pack indicates that nursing teaching has been effective?

Stage IV

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury?

fish

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

Discontinue the therapy and assess the client.

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time?

elevating and supporting the stump

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?

Don a mask, gown, and eye protection. Carefully remove the soiled dressing. Don sterile gloves. Fill the irrigation syringe with warmed irrigation solution. Gently direct a stream of solution into the wound. Dry the surrounding skin with gauze dressings.

The nurse is preparing to irrigate a client's wound. Arrange the following steps in the correct order.

a sterile, flexible applicator moistened with saline

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?

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

The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate?

"Very little scar tissue will form." "This is a simple reparative process." "Your wound edges are right next to each other."

The nurse is teaching a client about healing of a large wound by primary intention. What teaching will the nurse include? Select all that apply.

"Very little scar tissue will form."

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include?

"Reinforced adhesive skin closures will hold my wound together until it heals."

The nurse is teaching a client about wound care at home following a cesarean birth of her baby. Which client statement requires further nursing teaching?

"It provides a way to remove drainage and blood from the surgical wound."

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?

an obese woman with a history of type 1 diabetes

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

puncture

The occupational nurse is caring for a construction worker employee who stepped on a nail. The nail penetrated the sole of the boot and injured the worker's foot. What type of injury does the nurse anticipate?

"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator."

The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surigical wound during a dressing change. What instructions should the RN provide the LPN regarding this action?

Desiccation

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

Children younger then 2 have _______ skin then adults.

Thinner and weaker

Factors affecting the skin

Unbroken and healthy skin and mucous membranes defend against harmful agents. Resistance to injury is affected by age, amount of underlying tissues, and illness. Adequately nourished and hydrated body cells are resistant to injury. Adequate circulation is necessary to maintain cell life.

corticosteroids

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound?

incision

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?

preventing the client from sliding in bed

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury?

Connective tissue

Which is not considered a skin appendage?

Tertiary intention healing

Wound is left open for 3-5 days to allow edema or infection to resolve

sanguineous

bloody drainage

contusion

bruise

purulent

containing pus

hemostasis phase

immediately after injury blood vessels constrict blood clotting begins exudate is formed causing swelling and pain platelets stimulate other cells to migrate

psychological effects of wounds

pain, anxiety, fear, loss of function, change in body image

Stage II pressure ulcer

partial thickness skin loss

eschar

scab

Measurement of pressure ulcer

size, depth, presence of undermining, tunneling, or sinus tract

Macerated wound

skin white and boggy around dressing when it is not dried properly

Function of Vitamin D

stimulates GI absorption of calcium & phosphorous; stimulates kidney reabsorption of calcium & phosphorous; required for healthy bone development

slough

tan, yellow, or green scab-like material

complex wound

the dermis and underlying subcutaneous fat tissue are damaged or destroyed

full thickness wound

the entire dermis and sweat glands and hair follicles are severed

Primary intention healing

tissue surfaces are approximated (closed) and there is minimal or no tissue loss, formation of minimal granulation tissue and scarring

Secondary intention healing

wound in which the tissue surfaces are not approximated and there is extensive tissue loss; formation of excessive granulation tissue and scarring