Tissue integrity Module 3

Clubbing

abnormal curving of the nails that is often accompanied by enlargement of the fingertips

The nurse and client are looking at the client's heel pressure injury. The client asks, "Why does my heel look black?" What is the nurse's appropriate response? "This is normal tissue." "That is necrotic tissue, which must be removed to promote healing." "That is called undermining, a type of tissue erosion." "That is old clotted blood underneath the wound"

"That is necrotic tissue, which must be removed to promote healing."

A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage? *mixture of serum and red blood cells *large numbers of red blood cells *clear, watery blood *white blood cells, debris, bacteria

*large numbers of red blood cells

You're working on a medical surgical floor. You have the following patients below. Select all the patients below that are at risk for a pressure injury:*

A. A 19 year old female who is a quadriplegic. B. A 35 year old male with a BMI of 13.6 that is incontinent of stool and has a right leg splint. C. A 55 year old female who has controlled diabetes and is ambulating three times a day. D. A 76 year old male with an elevated ammonia level and is excessively sweaty. E. A 45 year old with a Braden Scale score of 7. ABDE The only patient not at risk for a pressure injury is the patient in option B. Remember altered sensory perception, any type of moisture issue (incontinence, sweating etc.), immobility, poor nutrition, altered mental status (high ammonia level can cause confusion and drowsiness), Braden scale score less than 9 are all risk factors for a pressure injury.

You're educating a group of nursing students about the different stages of a pressure injury. Which statement is correct about a stage 3 pressure injury?*

A. There is full loss of skin tissue that can extend to the muscle, bone, or tendon. B. A hallmark of a stage 3 pressure injury is that the skin will be intact but it not blanch. C. The skin will not be intact and there will be full loss of skin tissue that can extend to the subcutaneous tissue. D. The wound edges will never roll away (epibole) as with a stage 2 pressure injury. C***

The nurse is caring for a patient with extensive bullous lesions on the trunk and back. Prior to initiating skin care, what is a priority for the nurse to do? Wash the lesions vigorously. Apply cold compresses. Administer analgesic pain medication. Rupture the bullous lesions.

Administer analgesic pain medication.

Which condition is an example of wound healing by secondary intention? Abdominal wound with staples An infected burn of the arm Sacral skin tear closed with Steri-Strip Leg laceration with sutures

An infected burn of the arm

Which term refers to a graft derived from one part of a client's body and used on another part of that same client's body? Autograft Allograft Homograft Heterograft

Autograft

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action? A: removing excess drainage and wet tissue to prevent maceration of surrounding skin B: removing dead or infected tissue to promote wound healing C: removing purulent drainage from the wound bed in order to accurately assess it D: stimulating the wound bed to promote the growth of granulation tissue

B

While performing a skin assessment on a patient who is immobile, you note a purplish black area on the patient's left heel. The skin is intact. On palpation the site feels heavy and spongy. You suspect this may be?* A. Stage 1 pressure injury B. Deep-tissue injury C. Stage 4 pressure injury D. Stage 2 pressure injury

B. Deep-tissue injury Deep-tissue injuries presents as purplish or blackish areas over skin that is intact. The fatty tissue below is injured. Also, may look like a black blistered area and may feel heavy or squishy.

An 86 year old female patient is immobile and is in the right lateral recumbent position. As the nurse you know that which sites below are at most risk for pressure injury in this position?* A. Sacral B. Patella C. Ankle D. Ear E. Elbow F. Hip G. Heel H. Shoulder

B. Patella (knee) C. Ankle D. Ear F. Hip H. Shoulder The right lateral recumbent position is where the patient is positioned on their right side. Therefore, the ankle, ear, hip, knee, and shoulders are sites where a pressure injury can occur.

Dehiscence

Bursting open of a wound, especially a surgical abdominal wound

An unresponsive client has been brought to the emergency room by EMS. While assessing this client, the nurse notes that the client's nail beds, lips, and oral mucosa are a cherry-red color. What should the nurse suspect? Uremia Jaundice Anemia Carbon monoxide poisoning

Carbon monoxide poisoning

A nurse is assessing the skin of a client who has been diagnosed with bacterial cellulitis on the dorsal portion of the great toe. When reviewing the client's health history, the nurse should identify what comorbidity as increasing the client's vulnerability to skin infections? Rheumatoid arthritis Gout Chronic obstructive pulmonary disease Diabetes

D

How would you as the nurse stage figure 3:* A. Stage 1 B. Stage 3 C. Stage 2 D. Unstageable E. Stage 4

D. Unstageable This pressure injury is unstageable. Note the slough and eschar in the wound bed. As the nurse you are unable to assess the depth of the wound, therefore, it is currently unstageable.

After teaching a group of students about the structure of the skin, the nursing instructor determines that the teaching was successful when the group identifies which of the following as the true skin? Dermis Stratum corneum Papillary layer Epidermis

DERMIS

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? Evisceration Maceration Desiccation Necrosis

Desiccation

You have a new admission. While performing a head-to-toe assessment on your patient, you note the following wound (see figure 1 above) on the patient's right heel. You document this as a: A. Stage 1 Pressure Injury B. Stage 3 Pressure Injury C. Unstageable D. Deep-Tissue Injury E. Stage 2 Pressure Injury F. Stage 4 Pressure Injury

E. Stage 2 Pressure Injury This represents a stage 2 pressure injury (formerly known as a pressure ulcer). The skin is visibly damaged and NOT intact with PARTIAL loss of the dermis. No subq (fatty tissue) is visible. These wounds may be opened with a superficial red/pink ulcer or may have the formation of an opened or closed blister.

Wheal*

Elevated mass with irregular borders *Hives, insect bites

Nodule

Elevated palpable solid mass, deeper into dermis than papule 1-2cm = nodule >2cm = tumor Lipoma, squamous cell carcinoma, carcinoma

Cyst*

Encapsulated fluid filled or semisolid mass in subcutaneous tissue or dermis *Sebaceous cyst

The nurse is performing an assessment of a client's full thickness pressure injury to the coccyx. The nurse observes that the wound bed is black and will consequently document what finding? Gangrene Eschar Granulation tissue Erythema

Eschar

Which type of healing occurs when granulation tissue is not visible and scar formation is minimal? First intention Fourth intention Second intention Third intention

First intention

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? Fluid retention Sebum deficiency Protein deficiency Dehydration

Fluid retention

After completing a skin assessment of an older adult patient, the nurse documents evidence of lentigines, which indicate which of the following? Itchy spots Freckles Dryness Yellowish waxy deposits

Freckles

A client requires debridement of necrotic tissue. Which stage(s) of pressure injury requires the nurse to perform this procedure? Select all the apply. stage II stage III stage I stage IV

III, IV

The nurse is performing a physical examination of a patient and observes a well-healed old scar on the right shoulder. The scar is hypertrophied, elevated, and irregular without any redness or irritation. The patient states, "I had shoulder surgery about 5 years ago." The nurse documents this finding as which of the following? Keloid Nodule Cicatrix Lichenification

Keloid

The nurse observes an African-American patient with a large hypertrophied area of scar tissue on the left ear lobe. What does the nurse document this finding as? Atrophy Scar Keloid Lichenification

Keloid

While reviewing an older adult's medical record, the nurse notes that the patient has solar lentigo. he nurse interprets this as which of the following? Liver spots Hypertrophied scar tissue Bright red moles Dark discoloration of the skin

Liver spots

Which of the following could be a possible cause of cyanosis? Fever Low tissue oxygenation Carbon monoxide poisoning Anemia

Low tissue Oxygenation

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues? Surgical Natural Enzymatic Mechanical

Natural

Macule

Nonpalpable, flat skin color change <1cm = macule >1cm = patch Freckles, bruises, bruising, petechiae, port-wine stains, birth mark

Vesicle

Palpable elevated mass containing serous fluid <1cm = vesicle >1cm = bulla Herpes, blisters, varicella, poison ivy, burns

Papule

Palpable solid elevation of skin <1cm = papule >1cm = plaque Moles, warts, psoriasis

When measuring the size, depth, and wound tunneling of a client's stage 4 pressure injury, what action should the nurse perform first? Measure the width of the wound with a disposable ruler. Perform hand hygiene. Assess the condition of the visible wound bed. Insert a swab into the wound at 90 degrees.

Perform hand hygiene.

A nurse documents the presence of granulation tissue in a healing wound. Which of the following is the best description for the tissue? Pale yet able to blanch with digital pressure Pink to red and soft, noting that it bleeds easily Necrotic and hard White with long, thin areas of scar tissue

Pink to red and soft, noting that it bleeds easily

•A nurse is caring for an older adult recovering from a hip replacement. Which three assessment findings put the client at risk for pressure injury? a.The client has a delayed response when answering questions. b.The client has a poor appetite. c.The client has trouble controlling their urine. d.The nurse applies lotion to the client after bathing every other day. e.The client has pain uncontrolled by prescribed medications. The client uses a pillow to elevate their heels off the bed.

Power Point

Braden Scale

Pressure ulcers Scale lower the number, higher the risk 6 Areas of concern scored 1-4 less than 17 = risk for pressure ulcers

Pustule*

Pus-filled vesicle or bulla *Acne, impetigo

A client has a boil that is located in the left axillary area and is elevated with a raised border, and filled with pus. How would the nurse document this type of lesion? Vesicle Cyst Pustule Macule

Pustule

An older adult client's skin has become dry and flaked. Which of the following is the cause of this condition? Reduction in melanin production Reduction in sebum production Reduction in estrogen production Reduction in the elasticity of the skin

Reduction in sebum production

When conducting a skin assessment, the nurse notes a purple macular lesion on the client's right upper extremity. The nurse differentiates the lesion as a petechia or ecchymosis based on location. erythema. size. exudate.

SIZE

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

Second intention

The patient is 75 years old and weighs 95 lbs. The patient is confused and has right and left leg contractures. You're developing a plan of care for a patient who is at risk for pressure injury development. The patient is 75 years old and weighs 95 lbs. The patient is confused and has right and left leg contractures. In addition, the patient has a urinary tract infection and is incontinent of urine. PT Diet: aspiration precautions, honey thick liquid, pureed foods.

Select all the nursing intervention you will include in the patient's plan of care to prevent a pressure injury: Select all that apply. A. When feeding the patient keep the head of bed elevated at 45' degree and avoid elevating the foot of the bed. B. Apply barrier cream as needed to the skin daily. C. Turn the patient every 4 hours. D. Keep linens and gowns dry and wrinkle free. E. Use a wedge pillow for the right and left legs daily. B, D, and E. Option A is wrong because when the patient is sitting up you want to prevent them from sliding down in the bed. This can cause friction and shear, which can lead to a pressure injury. Raising the foot of the bed when the HOB is elevated will help prevent the patient from sliding down. Option C is wrong because you will need to turn the patient every 2 hours NOT every 4 hours. Option E is beneficial for the leg contractures to prevent a pressure injury to the knees and ankles.

The nurse is having difficulty seeing a client's rash. Which action(s) should the nurse perform to facilitate the assessment? Select all that apply.

Stretch the skin gently; Point a penlight laterally across the affected part.

A client is coming to the office to have a growth removed by the doctor. The client asks "What does cryosurgery do to the growth?" What is the correct response? Through the application of extreme cold, the tissue is destroyed. Removes the entire growth Freezes the growth, so the physician can remove it at the next appointment Lasers the growth off

Through the application of extreme cold, the tissue is destroyed.

The nurse is assessing a client with diabetes and notes an area on the client's right foot as inflamed, necrotic, and eroded. The client states he accidentally slammed his foot in a door 2 weeks ago. The nurse would document this finding as a(n): Fungus Ulceration Abscess Pustule

Ulceration

Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer? Using sterile technique during the dressing change Debriding the wound three times per day Cleaning the wound with a povidone-iodine solution Applying a heating pad

Using sterile technique during the dressing change

Which term refers to a condition characterized by destruction of melanocytes in circumscribed areas of the skin? Lichenification Hirsutism Vitiligo Telangiectases

Vitiligo

A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for? Hypotension Phlebitis Contractures Wound dehiscence

Wound dehiscence

The nurse is reading the physician's report of an elderly client's physical examination. The client demonstrates xanthelasma, which refers to which symptom? Dark discoloration of the skin Liver spots Bright red moles Yellowish waxy deposits on the eyelids

Yellowish waxy deposits on the eyelids

Undermining wound

a hollow between the skin surface and the wound bed, resulting from death of the underlying tissue

Koilonychia (spoon nail)

a malformation of the nails in which the outer surface is concave or scooped out like the bowl of a spoon

tunneling wound

a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation

The health care provider prescribes negative-pressure wound therapy for a client with a pressure injury. Before initiating the treatment, it is important for the nurse to implement which nursing assessment? assessing the client's mental status assessing the client for claustrophobia assessing for the use of antihypertensives assessing the wound for active bleeding

assessing the wound for active bleeding

•Skin is thinner and weaker

before age 2

•Serous •Sanguineous •Serosanguineous •Purulent

clear bloody/red pink/blood/fluid pus

The nurse is assessing a client for acute inflammation of a wound. Which symptom does the nurse attribute to the acute inflammatory response? pallor tissue necrosis hypothermia edema

edema

undermining

erosion of tissue from underneath intact skin at wound edge

A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area? debridement silvadene application allograft escharotomy

escharotomy

petechiae

pinpoint purple or red spots from minute hemorrhages under the skin

A nurse is caring for a client in a wound care clinic. The client has a wound on the left forearm from a roofing accident. During wound care, the nurse notes that the wound base is beefy red and bleeds easily during wound cleansing. Which stage of wound healing should the nurse recognize in this client's wound? maturation phase inflammatory phase hemostasis proliferation phase

proliferation phase

A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion? Ulcer Scale Crust Scar

scale

Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The area of intermediate burn injury is the zone in which blood vessels are damaged, but tissue has the potential to survive. This is called the zone of: hypotension. coagulation. stasis. hyperemia.

stasis.

Risk factors for Impaired Skin Integrity

•Age •Lifestyle and occupational variables •Changes in nutritional state •Reduced sensation •Chronic illness •Hospitalization

What affects skin integrity?

•Impaired circulation •Poor nutrition •Broken skin •Age •Comorbidities •Very thin or very obese people •Fluid volume deficit •Excessive moisture •Jaundice •Skin diseases

skin and mucus membranes are not fully developed

•Infant's

-have delayed maturation of epithelial cells, leading to decreased elasticity

•Older adults

*their skin becomes more resistant to injury and infection

•When children get older, > 2 Thru Adolescence

You receive report that your patient who will be admitted to your unit has a stage 4 pressure injury. Which figure above represents this type of injury?* A. Figure 1 B. Figure 2 C. Figure 3 D. Figure 4

B. Figure 2

The nurse is assisting with the collection of a Tzanck smear. What is the suspected diagnosis of the patient? Herpes zoster Seborrheic dermatosis Psoriasis Fungal infection

Herpes zoster

A client with an abdominal surgical wound sneezes and then states, "Something doesn't feel right with my wound." The nurse asses the upper half of the wound edges, noticing that they are no longer approximated and the lower half remains well approximated. The nurse would document that following a sneeze, the wound eviscerated. dehisced. pustulated. hemorrhaged.

dehisced.