PrepU Fundamentals: Skin Integrity and Wound Healing

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." Rationale: 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 nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac drain in place. Which statement indicates that the client understands?

"I will squeeze the chamber and apply the cap to maintain negative pressure." Rationale: The Hemovac drain chamber should be squeezed and the cap applied to maintain negative pressure. The negative pressure pulls the drainage into the collection chamber. This negative pressure must be maintained continuously unless it is being emptied. The drain must be checked and emptied at least every 4 hours. A Penrose drain uses gauze at the end of the drain to catch drainage.

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" Rationale: 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.

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." Rationale: A moist wound surface enhances the cellular migration necessary for tissue repair and healing.

Which is not considered a skin appendage?

Connective tissue Rationale: 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 nurse is assessing a client with a stage IV pressure ulcer. What assessment of the ulcer would be expected?

Full-thickness skin loss Rationale: A stage IV pressure ulcer is characterized by the extensive destruction associated with full-thickness skin loss.

A client is brought to a health care facility for treatment of a bleeding cut. The client was injured by a sharp knife. How can the nurse describe the client's wound?

A clean separation of skin and tissue with smooth, even edges Rationale: The nurse can describe a wound caused by a sharp knife as an incision wound with clean separation of skin and tissue with smooth, even edges. Ulceration is a shallow crater in which skin or mucous membrane is missing. An abrasion is a wound in which the surface layers of the skin have been scraped away. A laceration is the separation of skin and tissue in which the edges are torn and irregular.

What is the most accurate definition of a wound?

A disruption in normal skin and tissue integrity Rationale: A wound is a break or disruption in the normal integrity of the skin and tissues. The disruption may range from a small cut on the finger to a full-thickness or third-degree burn covering almost all of the body.

A nurse uses an open drain to drain the blood and drainage from a client's wound. The nurse knows that an open drain functions in which way?

Drainage occurs passively by gravity and capillary action Rationale: Drainage in an open drain occurs passively by gravity and capillary action, which is the movement of a liquid at the point of contact with a solid (in this case, the gauze dressing). Open drains are flat, flexible tubes that provide a pathway for drainage toward the dressing. Closed drains are more efficient than open drains because they pull fluid by creating a vacuum or negative pressure. This is done by opening the vent on the receptacle, squeezing the drainage collection chamber, and then capping the vent.

A nurse is caring for a client with draining wounds. The nurse needs to apply a dressing that has a highly absorbent nature. Which type of dressing should the nurse use for this client?

Gauze Rationale: Gauze dressing is ideal for covering fresh wounds because of its highly absorbent nature. Gauze is applied to fresh wounds that are likely to bleed or wounds that exude drainage. The nurse uses a hydrocolloid dressing when caring for a client with superficial burn wounds; hydrocolloid dressings are self-adhesive, opaque, air- and water-occlusive wound coverings that keep wounds moist. Transparent dressing allows the nurse to assess a wound without removing the dressing; transparent dressings are especially used for peripheral and IV insertion sites. A bandage is a strip or roll of cloth wrapped around a body part to help support the area around the wound.

When treating a client for a sprained ankle, the nurse wraps the client's ankle in a bandage. What is the purpose of wrapping the client's ankle in a bandage?

Limits movement in the wound area Rationale: The nurse wraps a bandage over the client's sprained ankle in order to limit movement in the wound area to promote healing. Bandages are also used to hold dressings in place, especially when tape cannot be used or the dressing is extremely large. Bandages also support the area around a wound or injury to reduce pain. A dressing is used to hold medication in place, maintain a moist environment, and protect the wound from further injury.

Which condition is an indication for the use of negative pressure wound therapy?

Pressure ulcers Rationale: Negative pressure wound therapy (NPWT) is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or wounds healing slowly. Examples of such wounds include pressure ulcers; arterial, venous, and diabetic ulcers; dehisced surgical wounds; infected wounds; skin graft sites; and burns. NPWT is not considered for use in the presence of active bleeding; wounds with exposed blood vessels, organs, or nerves; malignancy in wound tissue; presence of dry/necrotic tissue; or with fistulas of unknown origin (Hess, 2008; Preston, 2008; Thompson, 2008).

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 types should the nurse document?

Serosanguineous Rationale: Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink in color. Serous drainage is a clear drainage consisting of the serous portion of the blood. Sanguineous drainage consists of red blood cells and looks like blood. Purulent drainage has various colors such as green or yellow; this drainage indicates infection.

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 Rationale: A shearing force results when one layer of tissue slides over another layer. Clients who are pulled rather than lifted when being moved up in bed or from bed to chair to stretcher are at risk for injury from shearing forces.

A nurse is assessing a pressure ulcer 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 III Rationale: Stage III wounds have full-thickness tissue loss. Subcutaneous tissue may be visible but no bone, tendons, 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 muscles.

A client is admitted to the health care facility for a second cycle of chemotherapy involving vincristine. The nurse notes a small laceration on the client's leg that is healing. The nurse plans to continue to monitor the healing process based on the understanding that vincristine has which effect on wound healing?

Suppresses antibody production Rationale: Vincristine suppresses antibody production. Chemotherapy and radiation treatments retard wound repair. Chemotherapeutic agents, such as 5-fluorouracil, inhibit fibroblast replication and collagen synthesis. Radiation therapy negatively affects fibroblastic activity. Immunosuppressive agents, such as corticosteroids, suppress protein synthesis.

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. Rationale: 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.

Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections?

Thorough hand hygiene Rationale: The single most important information on which to educate clients and caregivers about home wound care is the importance of thorough hand hygiene to prevent wound infections.

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

True Rationale: A Penrose drain is an open drainage system that exits the skin through a stab wound. The purpose a Penrose drain is to provide a sinus tract for drainage.

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

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

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." Rationale: 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." Rationale: 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 assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply.

1) an older adult who is confined to bed; 2) a client with a PVD; 3) a client who is obese; 4) a client who is taking corticosteroid drugs Rationale: There are several clients that would be at risk for delayed wound healing. The older adult who is bedridden would be at risk. Older adults are at a greater risk for pressure ulcer formation because the aging skin is more susceptible to injury. Chronic and debilitating diseases, more common in this age group, may adversely affect circulation and oxygenation of dermal structures. Other problems, such as malnutrition and immobility, compound the risk of pressure ulcer development in older adults. A client with a peripheral vascular disorder would also be at risk due to issues with the peripheral circulation to the wound. An obese client would be at risk. The obese client may be malnourished or, simply because of the obesity, the client could be at risk. A client who is taking corticosteroid drugs would also be at risk. Corticosteroid drugs interfere with the immune system of the client. A client who eats a diet high in vitamins A and C would not be at risk for delayed wound healing. A 10-year old client with a surgical incision would not be at risk for delayed wound healing.

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 Rationale: 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 Rationale: 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.

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. Rationale: 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. (less)

Which statement accurately describes a developmental consideration when assessing skin integrity of clients?

An infant's skin and mucous membranes are injured easily and are subject to infection. Rationale: In children younger than 2 years, the skin is thinner and weaker than it is in adults. An infant's skin and mucous membranes are injured easily and are subject to infection. Careful handling of infants is required to prevent injury to, and infection of, the skin and mucous membranes. A child's skin becomes increasingly resistant to injury and infection. The structure of the skin changes as a person ages. The maturation of epidermal cells is prolonged, leading to thin, easily-damaged skin. Circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure.

A home health nurse has a caseload of several postoperative clients. Which one would be most likely to require a longer period of care?

An older adult Rationale: An older adult heals more slowly than do children and adults as a result of physiologic changes of aging, resulting in diminished fibroblastic activity and circulation. Older adults are also more likely to have one or more chronic illnesses, with pathologic changes that impede the healing process. The progress is based on metabolic changes, with the very young such as an infant healing faster, followed by the young adult, and then middle adult.

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. Rationale: 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 nurse is caring for a client who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time?

Assist in moving to prevent strain on the suture line Rationale: The proliferative phase of wound healing begins within 2 to 3 days of the injury. Collagen synthesis and accumulation continue, peaking in 5 to 7 days. During this time, adequate nutrition, oxygenation, and prevention of strain on the suture line are important client care considerations.

Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the physician and:

Covering the wound area with sterile towels moistened with sterile 0.9% saline Rationale: If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% saline. The client should also be placed in the low-Fowler's position, and the exposed abdominal contents should be covered as previously discussed. Notify the physician immediately because this is a medical emergency. Do not leave the client alone.

A home care nurse is visiting an older adult client. During the visit, the client's spouse sustains a minor thermal injury when cooking. The nurse intervenes, doing which of the following first?

Flush the area with copious amounts of cool water Rationale: The nurse should flush the burned area with copious amounts of cool water. If done quickly, this action halts the burning process by speeding heat dissipation. It also helps to relieve pain. Remove any of the client's clothing and jewelry in the affected area because clothing and metal can retain heat. If clothing sticks to the burned area, cut around it, rather than pull it, which may traumatize underlying burned tissues. Avoid ointments and home remedies because they can complicate burn healing.

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 Rationale: 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.

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." Rationale: There is no indication of infection. Large wounds with extensive tissue loss may not be able to be closed by primary intention.

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

An obese woman with a history of type 1 diabetes Rationale: 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. This is a greater risk factor for impaired healing than is smoking and sedentary lifestyle. Large incisions in and of themselves do not necessarily complicate the healing process. Short-term lack of food intake is not as significant as longer-term lack of nutrition.

What are the two major processes involved in the inflammatory phase of wound healing?

Blood clotting is initiated, WBCs move into the wound. Rationale: The inflammatory phase of wound healing begins at the time of injury and prepares the wound for healing. The two major physiologic activities are blood clotting (hemostasis) and the vascular and cellular phase of inflammation.

The nurse is assessing a client's surgical wound after abdominal surgery and sees that the viscera is protruding through the abdominal wound opening. Which term best describes this complication?

Evisceration Rationale: Evisceration is the protrusion of viscera through an abdominal wound opening. Evisceration can follow dehiscence if the opening extends deeply enough to allow the abdominal fascia to separate and internal organs to protrude.

A physician uses sutures during the surgery on a client at a health care facility. What are sutures?

Knotted ties that hold an incision together Rationale: Sutures are knotted ties that hold an incision together. Sutures generally are constructed from silk or synthetic materials such as nylon. Staples are wide metal clips that form a bridge to hold two wound margins together. A bandage is a strip or roll of cloth wrapped around a body part. Open drains are tubes that provide pathways for drainage toward the dressing.

A nurse is inspecting the skin of a client and notes a wound with ragged edges and torn tissue. The nurse documents this wound as:

Laceration Rationale: A laceration is a wound with ragged edges with torn tissue. An abrasion is a wound involving friction of the skin. A contusion is a closed wound with bleeding in underlying tissues. A puncture is a wound that occurs from penetration of the skin and underlying tissue.

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

Stage II Rationale: A stage II pressure ulcer involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II could present as a blister, abrasion, or shallow crater. A stage I pressure ulcer is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III ulcer presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Ulcers at this stage may include undermining and tunneling. Stage IV ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling.