NU 272: Tissue Integrity

A nurse knows to assess a patient with a burn injury for gastrointestinal complications. Which of the following is a sign that indicates the presence of a paralytic ileus? Hyperactive bowel sounds Decreased peristalsis Fecal occult blood Hematemesis

Decreased peristalsis Decreased peristalsis and hypoactive bowel sounds are manifestations of a paralytic ileus.

The nurse is assessing a client for acute inflammation of a wound. For which symptom of infection does the nurse assess? Pallor Edema Hypothermia Tissue necrosis

Edema Cardinal signs of inflammation include rubor (redness), tumor (swelling or edema), calor (heat), dolor (pain) and functio laesa (loss of function). Tissue necrosis occurs with chronic inflammation.

The nurse recognize what as an early sign of sepsis in a client with a burn injury? Normal body temperature Decreased heart rate Elevated serum glucose Widened pulse pressure

Elevated serum glucose In clients with burn injuries early sepsis can be hard to detect. Clients with burn injuries exhibit tachycardia, tacypnea, and elevated body temperature, all typical indications of sepsis. In the client with burn injury, indications of sepsis include elevated serum glucose values, increased heart rate, and narrowing mean arterial pressure. Both the typical elevated temperature and a temperature of less than 96.8 F (36 C) can indicate sepsi in a client with a burn injury.

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? Anemia Gastric ulcers Hyperthyroidism Cardiac arrest

Gastric ulcers The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to develop gastric (Curling's) ulcers. Anemia develops because of the heat destroying the erythrocytes. Release of histamine does not cause hyperthyroidism or cardiac arrest.

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: Hyperkalemia. Hypernatremia. Hypocalcemia. Hypoglycemia.

Hyperkalemia. Circulating blood volume decreases dramatically during burn shock due to severe capillary leak with variation of serum sodium levels in response to fluid resuscitation. Usually, hyponatremia (sodium depletion) is present. Immediately after burn injury, hyperkalemia (excessive potassium) results from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement.

A child tips a pot of boiling water onto his bare legs. The mother should: Avoid touching the burned skin and take the child to the nearest emergency department. Cover the child's legs with ice cubes secured with a towel. Immerse the child's legs in cool water. Liberally apply butter or shortening to the burned areas.

Immerse the child's legs in cool water. The application of cool water is the best first-aid measure. Soaking the burned area intermittently in cool water or applying cool towels gives immediate and striking relief from pain and limits local tissue edema and damage.

During the late stages of healing, which intervention helps a burn wound to heal with minimal scarring? Removing eschar from the skin Applying continuous-compression wraps Wearing clothing to protect the burn from the sun Maintaining wound care irrigation

Applying continuous-compression wraps Applying continuous-compression wraps helps skin healing and prevents hypertrophied tissue from forming. Removing eschar from the skin, wearing clothing to protect the burn from the sun, and maintaining wound care irrigation are appropriate for the client with a burn wound, but these interventions don't necessarily help minimize scarring.

A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the: Epidermal layer only. Epidermis and a portion of deeper dermis. Entire dermis and subcutaneous tissue. Dermis and connective tissue.

Epidermis and a portion of deeper dermis. A deep partial-thickness burn includes the epidermis, upper dermis, and a portion of the deeper dermis. A burn limited to the epidermal layer is classified as a superficial partial-thickness burn. The last two choices refer to a full-thickness burn.

The nurse is caring for a client who has a heavily exudating wound that needs autolytic debridement. Which wound dressing/product is most appropriate to use on the wound? an alginate dressing transparent film a hydrogel dressing an antimicrobial dressing

an alginate dressing Alginate dressings contain alginic acid from brown seaweed. Covered in calcium-sodium salts, they absorb exudate, maintain a moist wound environment, and facilitate autolytic debridement. A secondary dressing is required to secure them. Transparent film allows frequent assessment of the site but provides a barrier. A hydrogel dressing comprises an 80%-99% water base and is used with partial- and full-thickness wounds. An antimicrobial dressing has an antibiotic that reduces bacterial growth.

To meet early nutritional demands for protein, a 198-lb (90-kg) burned patient will need to ingest a minimum of how much protein every 24 hours? 90 g/day 110 g/day 180 g/day 270 g/day

180 g/day Recommendations from recent literature advocate protein requirements of 1.5 to 2 g/kg/day (Saffle, Graves, & Cochran, 2012). Prevent negative nitrogen balance in order to maximize healing

The nurse is developing a plan of care for a client with a stage 3 heel ulcer. Which intervention should the nurse include? Apply a hydrocolloidal dressing. Place the extremity in a dependent position. Cleanse the area with hydrogen peroxide, and wrap with clean gauze. Restrict protein intake, and encourage fluids.

Apply a hydrocolloidal dressing. Full-thickness skin loss occurs in a stage 3 pressure injury. WIth this type of injury, subcutaneous fat may be visible, but bone, tendon, and muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. Treatment of this type of injury includes the use of a hydrocolloidal dressing because it forms an occlusive barrier over the area while maintaining a moist environment; this prevents infection, friction, and shear. The extremity should be elevated to reduce pain and improve blood flow. The area should not be cleansed with hydrogen peroxide as this will harm granulation tissue and prevent healing. The injury should be wrapped with sterile gauze to prevent infection. Protein intake should be encouraged to promote wound healing. Fluids should be encouraged to maintain adequate hydration for skin integrity.

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern? BUN: 28 mg/dL K+: 5.0 mEq/L Na+: 145 mEq/L Ca: 9 mg/dL

BUN: 28 mg/dL The elevated BUN would cause the nurse the most concern (normal BUN is 7-20 mg/dL). The nurse should report decreased urine output or increased BUN and creatinine values to the physician. These laboratory values indicate possible renal failure. Renal failure from burn patients is caused by fluid loss which leads to decreased cardiac output (and blood flow to kidneys). In addition, myoglobinuria, associated with electrical burns, is common with muscle damage and may also cause kidney failure if not treated. The other values are within normal limits.

The nurse caring for a postoperative client documents that the surgical incision is healing by: Primary intention Secondary intention Tertiary intention Systemic intention

Primary intention Explanation: The nurse would document the surgical wound as healing by primary intention as there is no tissue loss. Wounds healing from secondary intention are larger and have a greater loss of tissue and contamination. Wounds do not heal by tertiary intention or systemic intention.

Which of the following is true regarding a split-thickness skin graft? Split thickness grafts are less successful than other types of grafts. Their cosmetic appearance are more desirable. Hair is able to grow back from their surface. The epidermis and a thin layer of dermis are harvested from the client's skin.

The epidermis and a thin layer of dermis are harvested from the client's skin. In a split-thickness skin graft, the epidermis and a thin layer of the dermis are harvested from the client's skin. Their cosmetic appearance is less desirable. Hair does not grow back from their surface. Split thickness grafts are more successful that other types of grafts.

When caring for a client with a 3-cm stage I pressure ulcer on the coccyx, which action may the nurse institute independently? Using a povidone-iodine wash on the ulceration three times per day Using normal saline solution to clean the ulcer and applying a protective dressing as necessary Applying an antibiotic cream to the area three times per day Massaging the area with an astringent every 2 hours

Using normal saline solution to clean the ulcer and applying a protective dressing as necessary The nurse may wash the area with normal saline solution and apply a protective dressing. These interventions will protect the area and are within the nurse's scope of practice. A nurse must obtain a physician's order to use a povidone-iodine wash or an antibiotic cream. Massaging with an astringent can further damage the skin.

The nurse documenting an acute open wound should include which characteristic(s)? Select all that apply. Wound size Periwound skin Wound bed Pattern of eruption

Wound size Periwound skin Wound bed When documenting an acute open wound, the nurse should consider the wound's size, the condition of the periwound skin (skin surrounding the wound), a description of the wound bed, and the wound edges and margins. The pattern of eruption relates to the patterns of lesions on a client's skin and does not apply to an acute open wound.

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: first degree or superficial second degree or partial thickness third degree or full thickness fourth degree or fat layer

second degree or partial thickness 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.

A nurse is assessing a pressure injury on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound, 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound? stage I stage II stage III stage IV

stage III Stage III wounds have full-thickness tissue loss. Subcutaneous tissue may be visible, but no bone, tendon, or muscle should be seen. Stage I involves intact skin with nonblanchable redness. Stage II involves a partial tissue loss, such as a blister. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle.

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? Size Depth Tunneling Direction

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. Size is measured with a ruler on the outside of the wound. Tunneling is measured by a finger probe or sterile probe instrument. Direction is a visual inspection.

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? Complaints of intense thirst Moderate to severe pain Urine output of 70 ml the first hour Hoarseness of the voice

Hoarseness of the voice Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss, leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate.

Following a serious thermal burn, which complication will the nurse take action to prevent first? Tissue hypoxia Infection Renal failure Hypovolemia

Hypovolemia After a burn, fluid from the body moves toward the burned area, which leads to intravascular fluid deficit. Steps must be taken to prevent irreversible hypovolemic shock in the initial stages of treatment. The inflammatory processes that affect the tissues cause additional injury, which contributes to tissue hypoxia. Myoglobin and hemoglobin that were destroyed during the burn can result in acute renal failure. Destruction of the skin barrier results in colonization of bacteria and can lead to life-threatening infection in days following the burn.

Which type of debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar? Mechanical Surgical Natural Chemical

Mechanical Mechanical debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar. Topical enzymatic debridement agents are available to promote debridement of the burn wounds. With natural debridement, the dead tissue separates from the underlying viable tissue spontaneously. Surgical debridement is an operative procedure involving either primary excision (surgical removal of tissue) of the full thickness of the skin down to the fascia (tangential excision) or shaving of the burned skin layers gradually down to freely bleeding, viable tissue.

While examining a client's leg, a nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressing should the nurse apply? Dry sterile dressing Sterile petroleum gauze Moist sterile saline gauze Povidone-iodine-soaked gauze

Moist sterile saline gauze Moist sterile saline dressings support wound healing and are cost-effective. Dry sterile dressings adhere to the wound and debride the tissue when removed. Petroleum supports healing but is expensive. Povidone-iodine is used as an antiseptic cleaning agent but because it can irritate epithelial cells, it shouldn't be left on an open wound.

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem? Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg Urine output of 20 ml/hour White pulmonary secretions Rectal temperature of 100.6° F (38° C)

Urine output of 20 ml/hour A urine output of less than 30 ml/hour in a client with burns indicates a deficient fluid volume. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions are normal. The client's rectal temperature isn't significantly elevated, and the slight increase in temperature probably results from the deficient fluid volume. You were thinking about PaO2 which should be 95-100 mm Hg

On postoperative day 2, a client requires care for a surgical wound using second-intention healing. What type of dressing change should the nurse anticipate doing? Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing Covering the well-approximated wound edges with a dry dressing Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive Cleaning the wound with soap and water, then leaving it open to the air

Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing Postoperative surgical wounds that are allowed to heal using second-intention healing are usually packed with a sterile saline-soaked dressing and covered with a dry dressing. The edges of a wound healing by second intention are not approximated. The wound may be cleaned using sterile saline, but the nurse would not apply a cyanoacrylate tissue adhesive. The wound should not be left open to the air, as it could expose the wound to microorganisms and dry out the wound bed, impairing healing.