Skin Integrity and Wound Care

list the 4 steps of wound healing

1) Hemotosis 2) Inflammation 3) Proliferation 4) Remodeling (HI PR)

3 pressure-related factors contribute to pressure ulcer development:

(1) pressure intensity, (2) pressure duration, (3) tissue tolerance.

56 yo hemiplegic in a long-term care falls from bed + sustains puncture wound on left deltoid muscle. The wound has some dirt on it- is bleeding profusely. What should the nurse do to stop the bleeding? Select all that apply. Elevate the client's left hand above heart level. Allow the wound to bleed to remove the dirt. Apply pressure around the wound Apply antiseptic solution and close the wound with gauze. Suture the wound if the bleeding does not stop.

Elevate the client's left hand above heart level. Allow the wound to bleed to remove the dirt. Apply pressure around the wound.

Nurse notices increased amount of red-colored fluid from drain in a post-op pt who underwent abdominal surgery 2 days ago. The nurse inspects the incision site, notices some swelling + warmth over the incision. Pt is otherwise afebrile + has stable vital signs. What are these findings indicative of? Infection Evisceration Hemorrhage Full-thickness repair

Hemorrhage

Does tylenol have an anti-inflammatory effect?

No- pt should take prescribed NSAIDs

Which of the following is an indication for a binder to be placed around a surgical client with a new abdominal wound? Collection of wound drainage Reduction of abdominal swelling Reduction of stress on the abdominal incision Stimulation of peristalsis (return of bowel function) from direct pressure

Reduction of stress on the abdominal incision

A dark-skinned hospitalized client is bedridden. While examining the client, which characteristics will determine that the client has developed a pressure ulcer? Select all that apply. The skin color remains unchanged on application of pressure. The localized area of the skin appears purple. There is blanching of the skin. The area of the skin with a pressure ulcer appears darker. As the tissue changes color, the intact skin becomes warm.

The skin color remains unchanged on application of pressure. The localized area of the skin appears purple.

risk of developing pressure ulcers based on six subscales: moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. What tool is the facility using for risk assessment of pressure ulcer development?

braden

Wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity

chronic (from Vascular compromise, chronic inflammation, or repetitive insults to tissue)

a wound involving loss of tissue such as a burn, pressure ulcer, or severe laceration heals by

secondary intention

What would you use a "peak and trough" test for

serum drug levels (peak=highest, trough is lowest) tells you how much drugs are in bloodstream

dark-skinned bedridden hospitalized pt. While examining the pt, which characteristics will determine that pt has developed a pressure ulcer? Select all that apply. The skin color remains unchanged on application of pressure. The localized area of the skin appears purple. There is blanching of the skin. The area of the skin w a pressure ulcer appears darker. As the tissue changes color, the intact skin becomes warm

skin color remains unchanged on application of pressure. localized area of the skin appears purple

Soft yellow or white tissue is characteristic of ____ (stringy substance attached to wound bed)

slough

There are two types of wounds

those with loss of tissue and those without

What characteristics differentiate a friction injury from a shear injury? Select all that apply. Type of force Location of the injury Involvement of tissue Condition of the client Presentation of the injury

Type of force Involvement of tissue Presentation of the injury

The nurse understands that exposure of skin to body fluids increases risk of skin breakdown + pressure ulcers. Which body fluids pose a HIGH RISK for skin breakdown? Select all that apply. Gastric drainage Pancreatic drainage Saliva Bile Urine

Gastric + Pancreatic drainage (bc they're caustic) (urine is considered moderate risk, not high)

The __ tool is used to assess the wound status

Bates-Jensen

Wound edges not approximated Pressure ulcers, surgical wounds that have tissue loss Wound heals by granulation tissue formation, wound contraction, and epithelialization.

Secondary

The 4 phases involved in the healing process of a full-thickness wound are

1) hemostasis, 2) inflammatory, 3) proliferative, 4) remodeling

3 components are involved in the healing process of a partial-thickness wound

1) inflammatory response, 2) epithelial proliferation (reproduction) and migration, 3) reestablishment of the epidermal layers.

A wound with an open serum-blister or having a red-pink wound bed with slough is a stage ? pressure ulcer

2

If pt has impaired skin integrity @ sacral site, which position should he sleep in?

30 degree lateral inclined- reduced pressure on bony prominences

Elevating the head of the bed to __ degrees decreases the chance of pressure ulcer development

30 degrees or less

Which of the following pts would be at increased risk of injury from heat + cold applications? Select all that apply. A 75-year-old client A 40-year-old client with peripheral vascular disease A 35-year-old client with spinal cord injury A 50-year-old comatose client A 45-year-old client with cholecystitis

A 75-year-old client A 40-year-old client with peripheral vascular disease A 35-year-old client with spinal cord injury A 50-year-old comatose client (all except cholecystitis)

Which of the following describes a hydrocolloid dressing? A seaweed derivative that is highly absorptive Premoistened gauze placed over a granulating wound A debriding enzyme that is used to remove necrotic tissue A dressing that forms a gel that interacts with the wound surface

A dressing that forms a gel that interacts with the wound surface

Pt fell while skateboarding sustained laceration on shin is brought to the emergency room. What immediate care should you perform? Select all that apply. Allow bleeding for a while. Apply direct pressure with a clean dressing. Apply an adhesive bandage after bleeding subsides. Elevate the leg with a pillow to prevent edema. Keep the wound open for examination by the health care provider.

Apply direct pressure with a clean dressing Apply an adhesive bandage after bleeding subsides Elevate the leg with a pillow to prevent edema.

When repositioning an immobile client, the nurse notices redness over a bony prominence. What is indicated when a reddened area blanches on fingertip touch? A local skin infection requiring antibiotics Sensitive skin that requires special bed linen A stage III pressure ulcer needing the appropriate dressing Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

. What should the students keep in mind when assessing dark-skinned clients? Select all that apply. Darker skin is more vulnerable to tans and sunburns. Blanching is not a conclusive sign in these clients. Differentiate skin color changes w reference to baseline skin tone. Mongolian spots may not be present in dark-skinned clients due to sun exposure. Use the Gaskin's Nursing Assessment of Skin Color (GNASC) tool for assessment of clients with dark skin.

Blanching is not a conclusive sign Differentiate skin color changes with reference to baseline skin tone. Use the Gaskin's Nursing Assessment of Skin Color

___ is used to assess stage I pressure ulcers in clients with dark skin tone.

GNASC tool

A client is admitted with a stage II pressure ulcer. What characteristics of a pressure ulcer is the nurse likely to find during a wound assessment? It has a red-pink wound bed without slough. The subcutaneous fat is visible. It may include undermining and tunneling. The wound extends to muscles and bones.

It has a red-pink wound bed without slough.

stage III pressure ulcer. Which findings are characteristic of this type of pressure ulcer? Select all that apply. It has full-thickness tissue loss. The subcutaneous fat may be visible. It may present as an open serum-filled blister. It may have a red-pink wound bed without slough. The bone, tendon, or muscle is not exposed.

It has full-thickness tissue loss. The subcutaneous fat may be visible The bone, tendon, or muscle is not exposed.

A 37 yo pt has come to the clinic after sustaining an abrasion while gardening. What characteristics of this type of wound is the nurse likely to find on assessment? Select all that apply. It is superficial. It is considered a partial thickness wound. It appears weepy. It bleeds profusely. It is associated with the risk of internal bleeding and infection

It is superficial. It is considered a partial thickness wound. It appears weepy.

Which statement is true about wet-to-dry dressings for mechanical debridement of a wound? It should be removed when partially dry. It causes slight bleeding when removed. It should be only moist, not wet, when applied. It should be left in place for at least 12 hours

It should be only moist, not wet, when applied.

Medication for your pt has the wrong name on it, who should you collaborate w to fix it? Dr, Pharmacist, Charge nurse or pt?

Pharmacist

Wound that is closed; Surgical incision, wound that is sutured or stapled Healing occurs by epithelialization; heals quickly with minimal scar formation.

Primary

What does the Braden Scale evaluate? Skin integrity @ bony prominences, including any wounds Risk factors that place pt @ risk for skin breakdown The amount of repositioning pt can tolerate The factors that place pt at risk for poor healing

Risk factors that place pt @ risk for skin breakdown

Pt is @ increased risk of impaired skin integrity due to continuous exposure to body fluids. Which body fluids put the client @ LOWEST RISK for skin breakdown? Select all that apply. Stool Saliva Urine Gastric juices Purulent exudate Serosanguineous drainage

Saliva Serosanguineous drainage

Protein deficiency can adversely affect wound healing. What parameters should be measured to determine this deficiency? Select all that apply. Serum albumin Serum transferrin Serum prealbumin Hemoglobin levels Serum creatinine levels

Serum albumin, transferrin + prealbumin

Wound left open for several days, then wound edges are approximated Wounds that are contaminated and require observation for signs of inflammation Closure of wound is delayed until risk of infection is resolved

Tertiary

The health care provider prescribes cold compressions for a client with a sprain injury in the spinal area. Which findings does the nurse assess in the client before providing the therapy? Select all that apply. The client has neuropathy. The injury site is edematous. The client reports shivering. The client has cardiovascular problems. The client has an altered level of consciousness

The client has neuropathy. The injury site is edematous. The client reports shivering.

A nurse assesses an elderly pt @ hospital after a fall. What assessment findings could place pt at risk of developing pressure ulcers? Select all that apply. The client has urinary incontinence. The client suffers from Alzheimer's. The client is immobilized due to a leg fracture. The client has impaired sensory perception. The client is confused but can express pain and discomfort.

The client has urinary incontinence. The client is immobilized due to a leg fracture. The client has impaired sensory perception

Dr. prescribes cold compressions for pt w a sprain injury in spinal area. Which findings does the nurse assess in the client before providing the therapy? Select all that apply. The client has neuropathy. The injury site is edematous. The client reports shivering. The client has cardiovascular problems. The client has an altered level of consciousness

The injury site is edematous. Neuropathy Shivering (can dangerously increase body temp)

When is an application of a warm, moist compress indicated? Select all that apply. To relieve edema For a client who is shivering To improve blood flow to an injured part To protect bony prominences from pressure ulcers To promote consolidation of purulent drainage

To relieve edema To improve blood flow to an injured part To promote consolidation of purulent drainage

An elderly client w hemiparalysis had incontinent episode. What steps do you take to ensure proper skin care when cleaning? Select all that apply Elevate the head of the bed to 45 degrees. Do not completely dry the skin. Apply moisture barrier ointment. Use a nonionic surfactant to clean the skin. Clean the skin with soap and hot water

Use a nonionic surfactant to clean the skin. apply moisture barrier ointment

A nurse is performing an admission assessment on pt who is paralyzed due to a stroke. The nurse notices a redness of the skin in the sacral area. What characteristics of the skin and surrounding tissues help the nurse to classify the wound as stage I pressure ulcer? Select all that apply. Cyanotic skin changes Warm edematous skin Cooler than the adjacent tissue Generalized blanchable erythema Localized nonblanchable erythema

Warm edematous skin Cooler than the adjacent tissue Localized nonblanchable erythema

Surgical site of a client on 4th post-op day has ongoing drainage from site. Wound edges have no epithelialization, + incision site is red/inflamed. What do these findings suggest about the wound healing? Wound healing by primary intention Wound healing by secondary intention Would healing abnormally by primary intention Wound healing abnormally by secondary intention

Would healing abnormally by primary intention

When surgical incision shows signs of drainage even 3 days after surgery, with inflammation and no epithelialization of the edges, it suggests an ___ healing

abnormal by primary intention

An ____ is a superficial wound with less bleeding. It is considered a partial thickness wound because it does not involve deep layers of the dermis

abrasion

Wound that proceeds through an orderly + timely reparative process that results in sustained restoration of anatomical + functional integrity

acute (from trauma, surgery)

eschar

necrotic tissue (brown/black)

what intention does a surgical wound heal

primary

filling of the wound with granulation tissue, contraction of the wound, and the resurfacing of the wound by epithelialization

proliferation phase

The abdominal wound is in the proliferative phase of healing. Which changes in the wound might have led the nurse to this conclusion? Select all that apply. -The wound is filled with granulation tissue. -There is localized redness, edema, warmth, and throbbing. =The wound contracts to reduce the area that requires healing. -There is vasodilation of the surrounding capillaries, and exudation of serum. -There is reepithelialization of the wound surface

filled with granulation tissue. contracts to reduce the area that requires healing. reepithelialization of the wound surface

Pt w pressure ulcer. As part of the wound treatment, the nurse applies a wet dressing + removes it after it partially dries. Which statements are true about this method of wound treatment? Select all that apply. It is a form of mechanical debridement. It is a form of enzymatic debridement It is avoided with a clean granulating wound. It is better than surgical debridement. It helps in the removal of viable as well as devitalized tissue

form of mechanical debridement. It is avoided with a clean granulating wound. helps in the removal of viable as well as devitalized tissue

red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing.

granulation tissue

___ levels indicate the oxygen carrying capacity of the blood.

hemoglobin

increased amount of red drainage from the surgical drain is indicative of ___

hemorrhage or internal bleeding from the underlying tissues

injured blood vessels constrict, and platelets gather to stop bleeding

hemostasis

You've identified a priority problem for pt's plan of care as "impaired skin integrity"- what etiology should you identify for plan? noncompliance with turning schedule poor nutritional intake impaired phys motility impaired adjustment

impaired physical motility

Which goal would you include in a care plan for pt with defining characteristics of impaired skin integrity? pt's skin will remain intact pt's motor function will be restored impaired skin integrity will not occur

pt's skin will remain intact

Sacral area has remained red for 2 hours + doesn't blanch when tested. How would you document this? unusual mottling dependent sacral rubor reactive hyperemia

reactive hyperemia

Pt at increased risk of impaired skin integrity due to continuous exposure to body fluids. Which body fluids put the client at LOWEST risk for skin breakdown? Select all that apply. Stool Saliva Urine Gastric juices Purulent exudate Serosanguineous drainage

saliva, Serosanguineous drainage