102 Skin Integrity and Wound Care

An emaciated older adult with dementia develops a large pressure ulcer after refusing to change position for extended periods of time. The family blames the nurses and threatens to sue. What is considered when determining the source of blame for the pressure ulcer? 1 The client should have been turned regularly. 2 Older clients frequently develop pressure ulcers. 3 The nurse is not responsible to the client's family. 4 Nurses should respect a client's right not to be moved.

1.The client should ha e been turned regularly.

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

2

Which term should the nurse use to describe a flat, poorly defined mass on the sole over a bony prominence caused by pressure? 1 Plantar wart 2 Callus 3 Ingrown nail 4 Hypertrophic ungual labium

2. Callus

What is the etiology for the development of pressure ulcers in an 80-year-old client? 1 Atrophy of the sweat glands 2 Decreased subcutaneous fat 3 Stiffening of the collagen fibers 4 Degeneration of the elastic fibers

2. Decreased subcutaneous fat

A nurse is caring for a client with quadriplegia. Which nursing intervention will decrease the occurrence of pressure ulcers? 1 Avoiding leg massages 2 Frequent repositioning of client 3 Increasing fiber content in food 4 Encouraging weight-bearing exercises

2. Frequent repositioning of client

A primary healthcare provider is treating the red-color wound of a client caused by pressure ulcers. Which dressings are beneficial for wound recovery? Select all that apply. 1.Absorptive dressings 2.Hydrocolloid dressings 3.Transparent film dressings 4.Moist gauze dressings with antibiotics 5.Telfa dressings with antibiotic ointment

2. Hydrocolloid dressings 3. Transparent film dressings 5. Telfa dressings with antibiotic ointment

A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force? 1.Maintain the head of the bed at 35 degrees or less. 2.With the help of another staff member, use a drawsheet when lifting the client in bed. 3.Reposition the client at least every 2 hours and support the client with pillows. 4.At least once every 8 hours, perform passive range-of-motion exercises of all extremities.

2. With the help of another staff member, use a drawsheet when lifting the client in bed.

A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. Which data should the nurse use to determine a client's score on this scale? Select all that apply. 1 Age 2 Anorexia 3 Hemiplegia 4 History of diabetes 5 Urinary incontinence

2.Anorexia 3.Hemiplegia 4.History of diabetes 5.Urinary incontinence

The nurse instructs self-management tips on the safety and quality care for skin cleaning to a client with a pressure ulcer. Which statement of the client shows ineffective learning? 1 "I will use tepid rather than hot water." 2 "I will clean my skin as soon as soiling occurs." 3 "I will apply powders and talc on the perineum." 4 "I will pat my skin gently rather than rubbing it dry."

3. "I will apply powders and talc on the perineum."

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

The nurse teaches a client about cleaning the skin to prevent pressure ulcers. Which statement made by the client indicates the nurse needs to follow up? 1 "I should gently pat the skin." 2 "I should use mild, heavily fatted soap." 3 "I should wash with tepid rather than hot water." 4 "I should apply powders or talc on a perineum wound."

4. "I should apply powders or talc on a perineum wound."

A registered nurse teaches a client and the caregiver about pressure ulcer care. Which statement made by the caregiver indicates the need for further teaching? 1 "I should inspect the client's skin daily." 2 "I should manage the client's incontinence as quickly as possible." 3 "I should properly dispose of the client's contaminated dressings." 4 "I should not worry about what the client eats."

4. "I should not worry about what the client eats"

The primary healthcare provider treats a client with a pressure ulcer. While assessing the client, the nurse identifies exposed bone and tendons. Which stage does the nurse document for this pressure ulcer? 1 Stage I 2 Stage II 3 Stage III 4 Stage IV

4. Stage IV

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer? 1 Stage I 2 Stage II 3 Stage III 4 Unstageable

4. Unstageable

A client is being treated for pressure ulcers. The primary healthcare provider advises the client to eat foods with high amounts of vitamin C. What is the role of vitamin C in wound healing? 1 Vitamin C aids in the process of epithelialization. 2 Vitamin C helps in the synthesis of immune factors. 3 Vitamin C increases the metabolic energy required for inflammation. 4 Vitamin C is required for collagen production by fibroblasts.

4. Vitamin C is required for collagen production by fibroblasts.

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)

D

A client with a spinal cord injury tends to assume the low Fowler position excessively. In which area of the body will the nurse most likely discover a pressure ulcer?

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.

The __ tool is used to assess the wound status

Bates-Jensen

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

Which type pf wound is caused by a blunt instrument that causes injury to underlying soft tissue with the overlying skin remaining intact?

Contusion

Skin disease that may cause lesions that require special care

Eczema

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.

-Unbroken and healthy skin and mucous membranes defend against harmful agents -Resistance to injury is affected by age, amount of underlying tissues, and injury -Adequately nourished and hydrated body cells are resistant to injury -Adequate circulation is necessary to maintain cell life

Factors Affecting the Skin

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

GNASC tool

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)

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

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.

Yellowish, itchy skin

Jaundice

Does tylenol have an anti-inflammatory effect?

No- pt should take prescribed NSAIDs

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

In which phase of wound healing is new tissue built to fill the wound space, primarily through the action of fibroblasts?

Proliferation Phase

8 Function of the Skin

Protection Body Temperature Psychosocial Sensation Vitamin D Production Immunologic Absorption Elimination

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

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

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

Secondary

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)

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.

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

T or F: Blood vessels in the skin dilate to dissipate heat

True

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

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

macerated

What is a good descriptor for the periwound?

undermining

What is occurring in these 2 pictures?

Tunneling

What is occurring in this picture?

undermining

What is occurring in this picture?

Pseudomonas

What is the blue-green stuff called in this wound?

Arterial insufficiency wound

What kind of wound is pictured?

Burn

What kind of wound is pictured?

Neuropathic/ diabetic wound

What kind of wound is pictured?

Venous insufficiency wound

What kind of wound is pictured?

A- transitioning from inflammation to proliferation B- in proliferative phase

What stage of healing is A in? B in?

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)

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)

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

What is the first line of defense against microorganisms?

intact skin

eschar

necrotic tissue (brown/black)

Hemostasis Inflammatory Proliferation Maturation

phases of wound healing

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

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

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

3 pressure-related factors contribute to pressure ulcer development:

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

Types of wounds

-Intentional or unintentional -Open or closed -Acute or chromic -Partial thickness, full thickness, complex

list the 4 steps of wound healing

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

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.

Which disorder of the foot is caused by continual pressure over bony prominences? 1 Corn 2 Plantar wart 3 Hammer toe 4 Hallux rigidus

1. Corn

Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers? 1 Incontinence and inability to move independently 2 Periodic diaphoresis and occasional sliding down in bed 3 Reaction to just painful stimuli and receiving tube feedings 4 Adequate nutritional intake and spending extensive time in a wheelchair

1. Incontinence and inability to move independently

A nurse is evaluating the practice of a home health aide who is caring for a client who has paraplegia. Which behavior indicates understanding about the nursing team's responsibility in relation to pressure ulcers? 1.Inspecting the skin daily 2.Providing a rubber cushion on which to sit 3.Massaging body lotion over reddened areas 4.Applying a heating pad to bony prominences

1. Inspecting the skin daily

The nurse instructs a client about the safety measures and precautions when taking care of a pressure ulcer. During a follow-up visit, the nurse finds increased tissue necrosis with damaged capillary beds. Which action of the client does the nurse expect is the reason for the client's condition? Select all that apply. 1 Massaging the reddened skin areas 2 Placing pillows between two bony surfaces 3 Using donut-shaped pillows for pressure relief 4 Keeping the head of the bed below 30 degrees 5 Using a bed pillow under the ankles to keep the heels off the bed surface

1. Massaging the reddened skin areas 3. Using donut-shaped pillows for pressure relief

Which key feature does the nurse associate with a stage 2 pressure ulcer? 1 Presence of nonintact skin 2 Development of sinus tracts 3 Damage to the subcutaneous tissues 4 Appearance of a reddened area over a bony prominence

1. Presence of non intact skin

A nurse is caring for a client with a chronic venous stasis ulcer. A negative-pressure wound treatment device has been prescribed to hasten wound healing. Which nursing action is most appropriate when caring for this client? 1 Replace the wound sponge every 48 hours. 2 Transport the client to the large oxygen pressure chamber. 3 Overlap the edges of intact skin with the sponge. 4 Set the negative vacuum pressure to intermittent.

1. Replace the wound sponge every 48 hours.

During an admission assessment the nurse discovers that a client has a stage 1 pressure ulcer. Which is the priority nursing action? 1.Turn and reposition the client every 2 hours. 2.Cover the ulcer with an occlusive transparent dressing. 3.Clean the ulcer with hydrogen peroxide and leave it open to the air. 4.Provide the client with a diet high in vitamin C, zinc, and protein.

1. Turn and reposition the client every 2 hours.

The nurse is teaching a client about sleeping positions to follow to prevent pressure ulcers. Which statement made by the client indicates effective learning? Select all that apply. 1 "I should use pressure-relieving pads." 2 "I should place a rubber ring under the sacral area." 3 "I should place pillows between two bony surfaces." 4 "I should keep the head of the bed elevated above 30 degrees." 5 "I should keep my heels off the bed surface using a bed pillow under the ankles."

1."I should use pressure-relieving pads." 3."I should place pillows between two bony surfaces." 5."I should keep my heels off the bed surface using a bed pillow under the ankles."

The registered nurse is teaching a nursing student about interventions that reduce the risk of pressure ulcers in a client. Which statements made by the nursing student indicate effective learning? Select all that apply. 1 "I will elevate the head of the client's bed to 30 degrees." 2 "I will instruct the client to take baths in lukewarm water." 3 "I will advise the client to apply talc directly to the perineum." 4 "I will ensure that the client's fluid intake is 2000 to 3000 mL/day." 5 "I will teach the client to refrain from eating a high-protein and calorie diet."

1."I will elevate the head of the client's bed to 30 degrees." 2."I will instruct the client to take baths in lukewarm water." 4."I will ensure that the client's fluid intake is 2000 to 3000 mL/day."