Tissue Integrity & Assessments

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

A. 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.

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? A. Desiccation B. Maceration C. Necrosis D. Evisceration

A. Desiccation Desiccation is localized wound dehydration. Maceration is localized wound overhydration or excessive moisture. Necrosis is death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area.

Two nurses, an RN and a wound care nurse, are discussing care of a client's wound that has nonviable tissue in the base. The wound care nurse recommends that the RN utilize a dressing that would promote autolytic debridement of the wound. Which dressing should the nurse select? A. Hydrocolloid B. Wet to dry C. Negative wound pressure therapy D. Telfa

A. Hydrocolloid The nurse should select the hydrocolloid dressing to promote autolytic debridement of the wound. Wet to dry dressings promote mechanical debridement. Telfa pads are nonstick and do not promote debridement. Negative wound pressure therapy is not utilized to promote debridement.

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? A. Packing the wound bed with sterile saline-soaked dressing and covering it with a dry dressing B. Covering the well-approximated wound edges with a dry dressing C. Cleaning the wound with sterile saline and applying cyanoacrylate tissue adhesive D. Cleaning the wound with soap and water, then leaving it open to the air

A. 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.

Which type of healing occurs when the edges are not approximated and the wound fills with granulation tissue? A. First-intention B. Second-intention C. Third-intention D. Cellular necrosis

B. Second-intention In second-intention healing, the edges are not approximated and the wound fills with granulation tissue. In first-intention healing, the wound edges are approximated, as in a surgical wound. In third-intention healing the wound edges are not approximated and healing is delayed. Cellular necrosis is part of the inflammatory process.

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound? A. stage I pressure ulcer B. stage II pressure ulcer C. stage III pressure ulcer D. stage IV pressure ulcer

B. stage II pressure ulcer A stage II pressure ulcer is a break in the skin that extends into the epidermis or the dermis. A stage I pressure ulcer is area of non-blanchable redness that may become cyanotic. A stage III pressure ulcer extends into the subcutaneous tissue. A stage IV pressure ulcer extends into the muscle or bone; most of the true tissue damage isn't easily seen.

A client with diabetes mellitus has a foot ulcer. The physician orders bed rest, a wet-to-damp dressing change every shift, and blood glucose monitoring before meals and at bedtime. Why are wet-to-damp dressings used for this client? A. They contain exudate and provide a moist wound environment. B. They protect the wound from mechanical trauma and promote healing. C. They debride the wound and promote healing by secondary intention. D. They prevent the entrance of microorganisms and minimize wound discomfort.

C. They debride the wound and promote healing by secondary intention. For this client, wet-to-damp dressings are most appropriate because they clean the foot ulcer by debriding exudate and necrotic tissue, thus promoting healing by secondary intention. Moist, transparent dressings contain exudate and provide a moist wound environment. Dry, sterile dressings protect the wound from mechanical trauma and promote healing. Hydrocolloid dressings prevent the entrance of microorganisms and minimize wound discomfort.

When preparing a client with a draining vertical incision for ambulation, where should a nurse apply the thickest portion of a dressing? A. at the top of the wound B. in the middle of the wound C. at the base of the wound D. over the total wound

C. at the base of the wound When a client is ambulating, gravity causes the drainage to flow downward. Covering the base of the wound with extra dressing will contain the drainage. Applying the thickest portion of the dressing at the top, in the middle, or over the total wound won't contain the drainage. Remediation:

When a client is ambulating, gravity causes the drainage to flow downward. Covering the base of the wound with extra dressing will contain the drainage. Applying the thickest portion of the dressing at the top, in the middle, or over the total wound won't contain the drainage. A. prevent the spread of the infection. B. debride the wound. C. keep the wound moist. D. reduce pain.

C. keep the wound moist. Wet-to-damp dressings keep the wound bed moist, which helps promote the growth of granulation tissue. Because dead tissue adheres to a dry dressing, wet-to-dry dressings are used for debriding wounds. Wet-to-damp dressings don't prevent the spread of infection. Although these dressings provide a soothing, cool feeling, they don't relieve pain.

Which assessment is most supportive of the nursing diagnosis, impaired skin integrity related to purulent inflammation of dermal layers as evidenced by purulent drainage and erythema? A. a heart rate of 88 beats/minute B. wound healing by primary intention C. oral temperature of 101° F (38.3° C) D. dry and intact wound dressing

C. oral temperature of 101° F (38.3° C) The nursing diagnosis indicates that the client's wound, which has purulent drainage, is infected. In response to the infection, the client's temperature would be elevated. A heart rate of 88 beats/minute, healing by primary intention, and a dry, intact dressing demonstrate normal assessment findings.

A hospital client has an aggressive fungal infection in the right eye that necessitates evisceration (removal of the eye). Consequently, the client requires twice-daily packing and dressing changes to the orbit. Which of the nurse's actions in the care of this client most clearly demonstrates interpersonal skills? a. Ensuring the client's privacy during dressing changes and providing an explanation during the procedure b. Documenting the condition of the client's orbit and the procedure of the dressing change in an accurate and timely manner c. Understanding the anatomy and physiology of the affected parts of the client's body d. Maintaining aseptic technique when performing the dressing change

a. Ensuring the client's privacy during dressing changes and providing an explanation during the procedure A central aspect of a nurse's interpersonal skills is maintaining privacy and dignity, as well as keeping clients informed during their care. Documentation is an outcome of legal/ethical skills, whereas knowledge of anatomy and physiology demonstrates cognitive skill. The maintenance of asepsis involves technical skill.

During a routine examination of a client's fingernails, the nurse notes a horizontal depression in each nail plate. When documenting this finding, the nurse should use which term? a. Splinter hemorrhage b. Beau's line c. Paronychia d. Clubbing

b. Beau's line Beau's line is a horizontal depression in the nail plate. Occurring alone or in multiples, these depressions result from a temporary disturbance in nail growth. A splinter hemorrhage is a linear red or brown streak in the nail bed. Paronychia refers to an inflammation of the skinfold at the nail margin. Clubbing describes an increased angle between the nail plate and nail base.

During a routine checkup, a nurse observes the client's skin to be tight and shiny. Which of the following is the correct indication of this sign? a. Sebum deficiency b. Fluid retention c. Dehydration d. Protein deficiency

b. Fluid retention Tight, shiny skin suggests fluid retention. Loose, dry skin may indicate dehydration. Tight, shiny skin does not suggest protein deficiency or sebum deficiency.

Which statement indicates that a client with diabetes mellitus understands proper foot care? a. "I'll schedule an appointment with my physician if my feet start to ache." b. "I'll rotate insulin injection sites from my left foot to my right foot." c. "I'll go barefoot around the house to avoid pressure areas on my feet." d. "I'll wear cotton socks with well-fitting shoes."

d. "I'll wear cotton socks with well-fitting shoes." The client demonstrates understanding of proper foot care if he states that he'll wear cotton socks with well-fitting shoes because cotton socks wick moisture away from the skin, helping to prevent fungal infections, and well-fitting shoes help avoid pressure areas. Aching isn't a common sign of foot problems; however, a tingling sensation in the feet indicates neurovascular changes. Injecting insulin into the foot may lead to infection. The client shouldn't go barefoot. Doing so can cause injury.

For healing by secondary intention, a client's wound has been packed with medicated dressings. The nurse assesses the wound. Which finding indicates wound healing? a. The tissue surrounding the wound is red and hot. b. The wound drainage is serous. c. The skin around the wound is edematous. d. The granulation tissue is at the wound edges.

d. The granulation tissue is at the wound edges. Connective tissue develops and fills in (or approximates) the wound edges from granulation tissue. Thus, evidence of granulation tissue indicates wound healing. Edematous surrounding tissue and serous drainage are insufficient evidence that the wound is healing. Surrounding tissue which is red and hot is more indicative of infection.