skin integrity and wound care

A nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac drain in place. Which of the following statements indicates that the client understands? a) "I will alternate between positive and negative pressure every 2 hours." b) "I will squeeze the chamber and apply the cap to maintain negative pressure." c) "I will check and empty the drain every 6 hours." d) "I will apply a dressing at the end of the drain to catch any drainage."

" I will squeeze the chamber and apply the cap to maintain negative pressure."

You are 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 of the following responses is most appropriate? a) "Wounds heal better when a moist wound bed is maintained." b) "Allowing a scab to form would prevent us from observing the wound for signs of infection." c) "This wound is too large for a scab to form over it, so a moist dressing is the best alternative." d) "You may be correct. I will check with your primary health care provider."

"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 of the following responses by the nurse is most appropriate? a) "Your wound will heal slowly as granulation tissue forms and fills the wound." b) "Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." c) "As soon as the infection clears, your surgeon will staple the wound closed." d) "If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention."

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

Drag and Drop question - Click and drag the following steps to place them in the correct order. Question: You are preparing to irrigate a patient's wound. Arrange the following steps in the correct order. Carefully remove the soiled dressing. Don a mask, gown, and eye protection. Gently direct a stream of solution into the wound. Fill the irrigation syringe with warmed irrigation solution. Dry the surrounding skin with gauze dressings. Don sterile gloves.

1. Don a mask, gown, and eye protection 2. Carefully remove the soiled dressing 3. Don sterile gloves 4. Fill the irrigation syringe with warmed irrigation solution 5. Gently direct a stream of solution into the wound 6. Dry the surrounding skin with gauze dressing

Question: A nurse is providing wound care for a client who has a pressure ulcer on the right buttock. Which of the following is the correct order of nursing interventions the nurse should perform during this dressing change? Apply wound covering Apply sterile gloves Give pain medication Cleanse the wound with normal saline Use nonsterile gloves Remove old dressing

1. give pain medication 2.use nonsterile gloves 3. remove old dressing 4. apply sterile gloves 5. cleanse the wound with normal saline 6apply wound covering

Choice Multiple question - Select all answer choices that apply. Which actions would a nurse be expected to perform when applying a saline-moistened dressing to a patient's wound? (Select all that apply.) a) Gently press to loosely pack the moistened gauze into the wound; if necessary, use forceps or cotton-tipped applicators to press gauze into all wound surfaces. b) Apply one dry, sterile gauze pad over the wet gauze, and then place an ABD pad over the gauze pad. c) Put on clean gloves and squeeze excess fluid from the gauze dressing before packing it tightly in the wound. d) Position the patient so the wound cleanser or irrigation solution will flow from the clean end of the wound toward the dirtier end. e) Carefully and gently remove the soiled dressings; if there is resistance, use a silicone-based adhesive remover to help remove the tape. f) Using clean technique, open the supplies and dressings and place the fine-mesh gauze into the basin, pouring the ordered solution over the mesh to saturate it.

1.Position the patient so the wound cleanser or irrigation solution will flow from the clean end of the wound toward the dirtier end. 2.Carefully and gently remove the soiled dressings; if there is resistance, use a silicone-based adhesive remover to help remove the tape. 3.Gently press to loosely pack the moistened gauze into the wound; if necessary, use forceps or cotton-tipped applicators to press gauze into all wound surfaces.

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? a) White blood cell count 14,800 mm3 b) Albumin 2.8 mg/dL c) Blood urea nitrogen (BUN) 7 mg/dL d) Hemoglobin A1C 5%

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. )

used in infected or noninfected wounds with moderate to heavy drainage; used with moist wound beds with red and yellow tissue.

Alginates

A nurse is caring for a client who has a 6-cm × 8-cm wound that was received in a motor vehicle accident. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist with a yellow and red wound bed. Which of the following dressings does the nurse anticipate is best to be ordered by the primary care provider? a) Hydrogel b) Alginate c) Transparent d) Hydrocolloid

Aliginate

A nurse is admitting a client to a long term care facility. Which of the following should the nurse plan to use to assess the client for risk of pressure ulcer development? a) Glascow scale b) Braden scale c) Morse scale d) FLACC scale

Braden Scale

A nurse is cleaning the wound of a gunshot victim. Which of the following is a recommended guideline for this procedure? a) Once the wound is cleaned, dry the area with an absorbent cloth. b) Clean the wound from the top to the bottom, and center to outside. c) Clean the wound from the bottom to the top, and outside to center. d) Use clean technique to clean the wound.

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

Upon review of a postoperative patient's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? a) Laxatives b) Corticosteroids c) Antihypertensive drugs d) Potassium supplements

Corticosteroids

a process where cells are dehydrated. This leads to cell death and delays healing.

Desiccation

localized wound dehydration.

Desiccation

A nurse is caring for a client who has a Jackson-Pratt drain. Which of the following is the order in which the nurse should carry out these interventions? Change dressing to drain site Empty the drain chamber's contents Use a gauze pad to clean the drain's outlet Measure and record the character and amount of drainage Change gloves Fully compress the chamber and replace the cap

Empty the drain chamber's contents Use a gauze pad to clean the drain's outlet Fully compress the chamber and replace the cap Measure and record the character and amount of drainage Change gloves Change dressing to drain site

complete separation of the wound, with protrusion of viscera through the incisional area.

Evisceration

Choice Multiple question - Select all answer choices that apply. Which actions would a nurse be expected to perform when applying a saline-moistened dressing to a patient's wound? (Select all that apply.) a) Using clean technique, open the supplies and dressings and place the fine-mesh gauze into the basin, pouring the ordered solution over the mesh to saturate it. b) Gently press to loosely pack the moistened gauze into the wound; if necessary, use forceps or cotton-tipped applicators to press gauze into all wound surfaces. c) Carefully and gently remove the soiled dressings; if there is resistance, use a silicone-based adhesive remover to help remove the tape. d) Position the patient so the wound cleanser or irrigation solution will flow from the clean end of the wound toward the dirtier end. e) Put on clean gloves and squeeze excess fluid from the gauze dressing before packing it tightly in the wound. f) Apply one dry, sterile gauze pad over the wet gauze, and then place an ABD pad over the gauze pad.

Gently press to loosely pack the moistened gauze into the wound; if necessary, use forceps or cotton-tipped applicators to press gauze into all wound surfaces. • Carefully and gently remove the soiled dressings; if there is resistance, use a silicone-based adhesive remover to help remove the tape. • Position the patient so the wound cleanser or irrigation solution will flow from the clean end of the wound toward the dirtier end.

The nurse is caring for a client in the emergency department who cut herself while preparing dinner at her home. The nurse understands the client's wound is in which phase of the following phases of wound healing? a) Inflammatory phase b) Hemostasis phase c) Maturation phase d) Proliferation phase

Hemostasis phase

the initial phase after an injury which stimulates other cells to come to the wound to begin with other phases of wound healing.

Hemostasis phase

What type of dressing has the advantages of remaining in place for three to seven days, resulting in less interference with wound healing? a) Hydrogels b) Alginates c) Hydrocolloid dressings d) Transparent films

Hydrocolloid dressings

used with light to moderate drainage in wounds with necrosis or slough.

Hydrocolloids

used with dry wounds or wounds with minimal drainage.

Hydrogels

decreases dead space by collecting drainage

Jackson-Pratt drain

drain used after breast removal, abdominal surgery

Jackson-Pratt drain

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? a) Utilize the culture swab to obtain cultures from multiple sites. b) Stroke the culture swab on surrounding skin first. c) Keep the swab and inside of the culture tube sterile. d) Cleanse the wound after obtaining the wound culture.

Keep the swab and inside of the culture tube sterile

localized wound overhydration or excessive moisture.

Maceration

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? a) Pick the crusts off the sutures with the forceps before removing them. b) Wash the sutures with warm, sterile water and an antimicrobial soap before removing them. c) Moisten sterile gauze with sterile saline to loosen crusts before removing sutures. d) Do not attempt to remove the sutures because they need more time to heal.

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

death of tissue in the wound.

Necrosis

after incision and drainage of abscess, in abdominal surgery

Penrose drain

provides sinus tract

Penrose drain

A nurse is caring for a client with laceration wounds on the knee. The nurse notes that the client is in remodeling phase of wound repair. Which of the following statements describes this phase of wound recovery? a) Period during which the wound undergoes changes and maturation b) Process by which damaged cells recover and re-establish normal function c) Physiological defense immediately after the tissue injury d) Period during which new cells fill and seal a wound

Period during which the wound undergoes changes and maturation

involves wound edges that are well approximated or close together.

Primary intention

A nurse is caring for a client at a wound care clinic. The client has a 5-cm × 6-cm abdominal wound dehiscence. Which of the following types of wound repair would the nurse expect with this wound? a) Tertiary intention b) Desiccation c) Primary intention d) Secondary intention

Secondary intention

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.

Stage I

pressure ulcer involves partial thickness loss of dermis and presents as a shallow, open ulcer. could present as a blister, abrasion, or shallow crater.

Stage II

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 III

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.

Stage IV

for bile drainage, after gallbladder surgery

T-tube drain

scale is used to evaluate pain in clients.

The FLACC scale

used to assess a client's neurological status quickly. This is typically used in emergency departments and critical care units.

The Glascow scale

used to assess the client's risk for falls

The Morse scale

the regenerative phase in which granulation tissue is formed. The maturation phase involves collagen remodeling.

The proliferation phase

A female patient who is being treated for self- inflicted wounds tells the nurse that she is anorexic. What criteria would alert the health care worker to her nutritional risk? a) Body weight decrease of 5% b) Total lymphocyte count of 1,500/mm3 c) Arm muscle circumference 90% of standard d) Albumin level of 3.5 mg/dL

Total lymphocyte count of 1500/mm3

used with wounds having minimal drainage, small size, and partial thickness

Transparent dressings

allows exchange of oxygen between wound and environment. They are best for small, partial-thickness wounds with minimal drainage. (less)

Transparent films

What is the most accurate definition of a wound? a) a disruption in normal skin and tissue integrity b) any trauma resulting in serious damage and pain c) a change in the function of internal organs d) any injury that results in changes in nervous tissue

a disruption in normal skin and tissue integrity

The nurse considers the impact of shearing forces in the development of pressure ulcers in patients. Which patient would be most likely to develop a pressure ulcer from shearing forces? a) A patient who lifts himself up on his elbows b) A patient who lies on wrinkled sheets c) A patient who must remain on his back for long periods of time d) A patient sitting in a chair who slides down

a patient sitting in a chair who slides down

The nurse is assessing the wounds of patients in a burn unit. Which wound would most likely heal by primary intention? a) A wound left open for several days to allow edema to subside b) A surgical incision with sutured approximated edges c) A wound healing naturally that becomes infected. d) A large wound with considerable tissue loss allowed to heal naturally

a surgical incision with sutured approximated edges

friction; rubbing or scraping epidermal layers of skin; top layer of skin abraded

abrasion

absorbs exudate and maintain a moist wound environment. They are best for wounds with heavy exudate

alginates

You are caring for a patient who has a heavy exudating wound that needs autolytic debridement. Which of the following wound dressings/products is most appropriate to use on the wound? a) Transparent film, such as Tegaderm b) A hydrogel dressing such as Aquasorb c) An antimicrobial dressing, such as SilvaSorb d) An alginate dressing, such as AlgiCell

an alginate dressing, such as AlgiCell (Antimicrobial dressings are appropriate for chronic wounds at risk for infection.)

injury and underlying ischemia, resulting from underlying conditions, such as atherosclerosis or thrombosis

arterial ulcer

The healthcare 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? a) Assess the client's mental status. b) Assess the wound for active bleeding. c) Assess the client for claustrophobia. d) Assess for the use of antihypertensives.

assess the wound for active bleeding

results from a blow, force, or strain caused by trauma. skin is not broken, but soft tissue is damaged, and internal injury and hemorrhage may occur

closed wounds

blunt instrument, overlying skin remains intact, with injury to underlying soft tissue, possible resultant bruising and/or hematoma

contusion

Which of the following actions should the nurse perform when applying negative pressure wound therapy? a) Test the seal of the completed dressing by briefly attaching it to wall suction. b) Increase the negative pressure setting until drainage is brisk. c) Irrigate the wound thoroughly using normal saline and clean technique. d) Cut foam to the shape of the wound and place it in the wound

cut foam to the shape of the wound and place it in the wound

the partial or total separation of wound layers as a result of excessive stress on unhealed wounds

dehiscence

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? a) Infection of the wound b) Evisceration of the viscera c) Dehiscence of the wound d) Herniation of the wound

dehiscence of the wound

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 client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? a) Necrosis b) Desiccation c) Maceration d) Evisceration

desiccation

injury and underlying diabetic neuropathy, peripheral arterial disease, diabetic foot structure

diabetic ulcers

wound completely separates with protrusion of viscera through the incisional area

evisceration

-appearance of skin -recent changes in skin -activity/mobility -nutrition -pain elimination

factors to assess skin

an abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ/ vessel to another

fistula

occurs immediately after the initial injury. involves blood vessels constriction and blood clotting begins through platelet activation and clustering

hemostasis phase

occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment; provide minimal to moderate absorption of drainage; maintain a moist wound environment; and may be left in place for three to seven days, thus resulting in less interference with healing.

hydrocolloid dressing

maintains a moist wound environment and are best for partial or full-thickness wounds.

hydrogels

cutting or sharp instrument, wound edges in close approximation and aligned

incision

follows hemostasis and is the phase in which white blood cells move into the wound to remove debris and to release growth factors.

inflammatory phase

follows hemostasis; lasts about 4-6 days. WBC move to wound. acute inflammation

inflammatory phase

planned invasive therapy or treatment; purposefully created for therapeutic purpose; clean edges and controlled bleeding

intentional wounds

albumin level <3.2 mg/dL (normal, 3.5-5 mg/dL), prealbumin <19 mg/dL (normal 16-40 mg/dL), body weight decrease of 5% to 10%. Additional laboratory tests to consider in patients at risk for or presenting with pressure ulcers include: total lymphocyte count <1,800/mm3 (normal, 1,000- 4,000/mm3), hemoglobin A1C >8% (normal <6%), glucose >120 mg/dL (normal 70-120 mg/dL). Although one of the options is body weight decrease of 5%, it is not the best answer. The best answer is total lymphocyte count of 1,500/mm3. (less)

lab levels: nutritional risk

tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue

laceration

-pressure -desiccation -maceration -trauma -edema -infection -necrosis

local factors affecting wound healing

final stage of wound healing. scar appears

maturation phase

broken skin surface, providing a portal of entry for microorganisms. bleeding, tissue damage, increased risk for infection and delayed healing

open wounds

-hemostasis -inflammatory -proliferation -maturation

phases of wound healing

compromised circulation secondary to pressure or pressure combined with friction

pressure ulcer

the regenerative phase in which granulation tissue is formed.

proliferation phase

new tissue is built to fill the wound space. capillaries grow across the wound. granulation tissue forms

proliferation phases

-pain -anxiety and fear -activities of daily living -changes in body image

psychological effects of wounds and pressure ulcers

blunt or sharp instrument puncturing the skin; intentional or accidental

puncture

-immobility -nutrition and hydration -moisture -mental status -age

risk for pressure ulcer development

In these wounds, the wound edges are not well approximated and will require more tissue replacement.

secondary intention

intact skin with nonblanchable redness of a localized area

stage I pressure ulcer

A patient's pressure ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure ulcer? a) Stage IV b) Stage I c) Stage II d) Stage III

stage II

partial-thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough

stage II pressure ulcer

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 of the following stages should the nurse assign to this client's wound? a) Stage III b) Stage IV c) Stage II d) Stage I

stage III

full thickness loss of dermis. visible subcutaneous fat. slough present

stage III pressure ulcer

full thickness tissue loss with exposed bone, tendon, or muscle. slough or eschar may be present.

stage IV pressure ulcer

A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage? a) Reduces swelling and inflammation b) Maintains a moist environment c) Supports the area around the wound d) Keeps the wound clean

supports the area around the wound

-age -circulation -oxygenation -nutritional status -medication and health status -immunosuppression

systemic factors affecting wound healing

Tertiary intention involves wounds that are left open for a period of time and then closed.

tertiary intention

A Penrose drain typically exits a patient's skin through a stab wound created by the surgeon. a) True b) False

true

-Penrose -t-tube -Jackson- Pratt -Hemovac -Gauze

types of drains

A nurse is assessing wound drainage during the immediate postoperative period for a client who has had a gall bladder removed. In addition to assessing the dressing, where should the nurse check for drainage? a) On the output sheet b) Under the skin c) In the axilla d) Under the client

under the client

accidental ; occur from unexpected trauma; contamination likely; jagged edges, uncontrolled bleeding

unintentional wounds

full thickness tissue loss in which the base of the ulcer is covered by slough and eschar in the wound bed

unstageable pressure ulcer

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 of the following actions should the nurse perform to prevent a pressure ulcer? a) Elevate the head of the bed 90 degrees. b) Place a foot board on the bed. c) Use pillows to maintain a side lying position as needed. d) Provide incontinent care every four hours as needed.

use pillows to maintain a side lying position as needed

injury and poor venous return, resulting from underlying conditions, such as incompetent valves or obstruction

venous ulcer

-infection -hemorrhage -dehiscence and evisceration -fistula formation

wound complications