7215 test 1 ch 11 (wound healing)
Stage 3 or 4 (full skin thickness injury) pressure ulcer acquired after admission to a health care setting is considered a ____ _____ _____
serious reportable event (SRE)
• Dryness is an enemy of wound healing t or f
t
Nonblanchable Erythema = what stage of pressure ulcer
1
Full-thickness loss can extend to muscle, bone, or supporting structures • Bone,tendon,or muscle may be visible or palpable • Undermining and tunneling may also occur what stage pressure ulcer
4
Full-thickness skin loss = what stage of pressure ulcer
3
Full-thickness tissue loss = what stage of pressure ulcer
4
nutrition therapy for wound healing
Diet high in protein, carbohydrates, and vitamins with moderate fat
wounds can be classified by 2 things
cause depth
what nutritional measures facilitate wound healing?
diet high in protein, carbohydrate, and vitamins with moderate fat intake is necessary to promote healing
Intact skin with non-blanchable redness of a localized area usually over bony prominence what stage pressure ulcer
1
• Purple or maroon localized area of discolored intact skin or blood-filled blister • Evolution may include a thin blister over dark wound bed what stage pressure ulcer
Suspected Deep Tissue Injury
• Lasts 3 to 5 days • Edges of incision are aligned • Blood fills the incision area, which forms matrix for WBC migration • Acute inflammatory reaction occurs what phase is this? • Initial phase (Hemostasis/Inflammation) • Granulation (Proliferation) phase • Maturation (Modeling) phase
• Initial phase (Hemostasis/Inflammation)
primary intention phases
• Initial phase (Hemostasis/Inflammation) • Granulation (Proliferation) phase • Maturation (Modeling) phase
Clinical Manifestations Infection
• Leukocytosis • Fever • Increased ulcer size, odor, or drainage • Necrotic tissue • Indurated, warm, painful
• Begins 7 days after injury and continues for several months/years • Fibroblasts disappear as wound becomes stronger • Mature scar forms what phase is this? • Initial phase (Hemostasis/Inflammation) • Granulation (Proliferation) phase • Maturation (Modeling) phase
• Maturation (Modeling) phase
Partial Thickness = what stage of pressure ulcer
2
A postoperative patient is now able to eat and is requesting a snack. What snack should the nurse recommend for the patient that will facilitate wound healing? Apple Custard Popsicle Potato chips
b
• Full-thickness skin loss • Subcutaneous tissue may be visible but bone, tendon, or muscle are not • Presents as deep crater with possible undermining of adjacent tissue • Ulcer depth ulcer varies by location what stage pressure ulcer
3
Systemic manifestations of inflammation include an
increased WBC count with a shift to the left, malaise, nausea and anorexia, increased pulse & respiratory rate, and fever
Stage II through IV pressure ulcers are considered ____ and the nurse needs to assess for s/s of ____
contaminated infection
What are some risk factors associated with the development of a pressure ulcer
a) Non-ambulatory b) Bedrest c) Poor nutrition d) Rubbing/friction
Drug therapy to decrease the inflammatory response and lower body temp involves the use of ?
aspirin, acetaminophen, some nonsteroidal anti-inflammatory drugs (NSAIDs), antihistamines, and corticosteroids
assessment tool for pressure ulcer
braden scale
Complications of wound healing
Adhesions - bands of scar tissue between or around organs Contractions - more than usual amount of contraction --> deformity, shortening Dehiscence - reopening of wound Evisceration - reopening of the wound with intestines protruding through Excess Granulation Tissue - granulation above surface of the wound Fistula Formation - abnormal passage between two areas Infection - introduction and overgrowth of infectious organisms Hemorrhage - difficulty with wound healing or clotting process leads to excessive blood loss Hypertrophic Scars - large, raised, red, hard Keloid - excess of scar tissue, bigger than wound, tumor- like
A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is most appropriate? a. Elevate the ankle above heart level. b. Apply a warm moist pack to the ankle. c. Assess the ankles range of motion (ROM). d. Assess whether the patient can bear weight on the affected ankle.
a
A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurses highest priority? a. Maintaining the patients blood glucose within a normal range b. Ensuring that the patient has an adequate dietary protein intake c. Giving antipyretics to keep the temperature less than 102 F (38.9 C) d. Redressing the surgical incision with a dry, sterile dressing twice daily
a
A patient with an open leg wound has a white blood cell (WBC) count of 13, 500/L and a band count of 11%. What action should the nurse take first? a. Obtain wound cultures. b. Start antibiotic therapy. c. Redress the wound with wet-to-dry dressings. d. Continue to monitor the wound for purulent drainage.
a
A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102°F. Which parameter would the nurse monitor, other than temperature, if the patient requires this medication? Pain level Intake and output Oxygen saturation Level of consciousness
b
pressure ulcer most common sites
sacrum and heels
Boggy or edematous tissue may indicate a stage I pressure ulcer t or f
t
• An ulceration may feel warm initially, then become cooler t or f
t
Suction removes drainage and speeds healing
Negative-pressure wound therapy (NPWT)
A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8 F (38.7 C). Which action by the nurse is most appropriate? a. Apply a cooling blanket. b. Notify the health care provider. c. Give the prescribed PRN aspirin (Ascriptin) 650 mg. d. Check the patients oral temperature again in 4 hours.
d Mild to moderate temperature elevations (less than 103 F) do not harm the young adult patient and may benefit host defense mechanisms. The nurse should continue to monitor the temperature. Antipyretics are not indicated unless the patient is complaining of fever-related symptoms. There is no need to notify the patients health care provider or to use a cooling blanket for a moderate temperature elevation
Localized injury to skin and/or underlying tissue (usually over bony prominences)
pressure ulcer
prevention for pressure ulcers
mobilize • Remove excessive moisture • Avoid massage over bony prominences • Use lift sheets
3 phases of wound healing
primary, secondary, or tertiary intention
Local response to inflammation includes
redness, heat, pain, swelling, and loss of function
is the replacement of lost cells and tissues with cells of the same type
regeneration
Healing includes the 2 major components of _____ and ____
regeneration & repair
healing as a result of lost cells being replaced by connective tissue; more common; usually results in scar formation
repair
Full-thickness tissue loss in which actual depth of ulcer is completely obscured by slough or eschar • Slough or eschar must be removed to expose the base of the wound for true depth to be determined what stage pressure ulcer
unstageable
• Fibroblasts migrate into site & secrete collagen -> Granulation tissue • Pink and vascular • Contraction of the wound edges • Epithelial regeneration and migration what phase is this? • Initial phase (Hemostasis/Inflammation) • Granulation (Proliferation) phase • Maturation (Modeling) phase
• Granulation (Proliferation) phase
Purposes of wound management
• Protecting a clean wound • Cleaning a wound • Treating infection
Contributing Factors pressure ulcer
• Shearing force: Pressure exerted on skin when it adheres to bed and skin layers slide in direction of body movement • Moisture: Excessive increases risk for skin breakdown
pt teaching for wound healing
• Teach signs and symptoms of infection • Note changes in wound color or amount of drainage • Provide medication teaching
• Partial-thickness loss of dermis • Shallow open ulcer with red pink wound bed • Presents as an intact or ruptured serum- filled blister what stage pressure ulcer
2
A patient who has an infected abdominal wound develops a temperature of 104 F (40 C). All the following interventions are included in the patients plan of care. In which order should the nurse perform the following actions?(Put a comma and a space between each answer choice [A, B, C, D]). a. Administer IV antibiotics. b. Sponge patient with cool water. c. Perform wet-to-dry dressing change. d. Administer acetaminophen (Tylenol
ADBC
After the unlicensed assistive personnel (UAP) bathed the patient, she then told the nurse about a reddened area on the patient's coccyx. After assessing the area, what should be included in the plan of care? Reposition every 2 hours. Measure the size of the reddened area. Massage the area to increase blood flow. Evaluate the area later to see if it is better.
a
The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider? a. Blood glucose 136 mg/dL b. Oral temperature 101 F (38.3 C) c. Patient complaint of increased incisional pain d. Separation of the proximal wound edges by 1 cm
d
The nurse should plan to use a wet-to-dry dressing for which patient? a. A patient who has a pressure ulcer with pink granulation tissue b. A patient who has a surgical incision with pink, approximated edges c. A patient who has a full-thickness burn filled with dry, black material d. A patient who has a wound with purulent drainage and dry brown areas
d
pressure ulcer care
Document • Relieve pressure • NO massage • Debride • Cleanse with nontoxic solutions • Keep ulcer bed moist
A nurse is caring for a patient who has a pressure ulcer that is treated with debridement, irrigations, and moist gauze dressings. How should the nurse anticipate healing to occur? a. Tertiary intention b. Secondary intention c. Regeneration of cells d. Remodeling of tissues
b
occurs when wound edges separate to the extent that intestines protrude through wound Keloid Hypertrophic Scars Evisceration "Proud Flesh Dehiscence Contractions Adhesions
Evisceration
excess results in deformity; frequently seen with major burns Keloid Hypertrophic Scars Evisceration "Proud Flesh Dehiscence Contractions Adhesions
Contractions
bands of scar tissue around organs; usually in abdominal cavity; may cause intestinal obstruction Keloid Hypertrophic Scars Evisceration "Proud Flesh Dehiscence Contractions Adhesions
Adhesions
separation and disruption of previously joined wound edges; usually occurs when primary healing site bursts open; can be caused by infection, obesity (adipose tissue not as vascular so slower to heal), pocket of fluid formation, granulation tissue not strong enough to withstand forces imposed on wound Keloid Hypertrophic Scars Evisceration "Proud Flesh Dehiscence Contractions Adhesions
Dehiscence
inappropriately large, raised red and hard scars (overabundance of collagen is produced during healing) Keloid Hypertrophic Scars Evisceration "Proud Flesh Dehiscence Contractions Adhesions
Hypertrophic Scars
great protrusion of scar tissue that extends beyond wound edges and may form tumor-like masses; permanent without any tendency to subside; thought to be hereditary often in dark-skinned people (particularly African Americans) Keloid Hypertrophic Scars Evisceration "Proud Flesh Dehiscence Contractions Adhesions
Keloid
• Wounds that occur from trauma, ulceration, and infection have large amounts of exudate and wide, irregular wound margins with extensive tissue loss • Edges cannot be approximated • Results in more debris, cells, and exudate what wound healing is needed here?
Secondary intention
• Delayed primary intention due to delayed suturing of the wound • Occurs when a contaminated wound is left open and sutured closed after the infection is controlled what wound healing is needed here?
Tertiary intention
An 85-year-old patient is assessed to have a score of 16 on the Braden Scale.Based on this information, how should the nurse plan for this patient's care? a. Implement a 1-hr turning schedule with skin assessment. b. Place DuoDerm on the patient's sacrum to prevent breakdown. c. Elevate the head of bed to 90 degrees when the patient is supine. d. Continue with weekly skin assessments with no special precautions
a
The nurse observes a patient experiencing chills related to an infection. What is the priority action by the nurse? Provide a light blanket. Encourage a hot shower. Monitor temperature every hour. Turn up the thermostat in the patient's room.
a
To which patient should the nurse plan to administer round-the-clock antipyretic drugs? A 76-yr-old patient with bacterial meningitis and a temperature of 104.2°F An 82-yr-old patient after hip replacement surgery and a temperature of 100.4°F A 14-yr-old patient with infectious mononucleosis and a temperature of 101.6°F A 59-yr-old patient with an acute myocardial infarction and a temperature of 99.8°F
a
When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing? a. The patient takes insulin daily. b. The patient states that the ulcers are very painful. c. The patient has had the heel ulcers for the last 6 months. d. The patient has several old incisions that have formed keloids.
a
Which patient is most at risk for the development of a pressure ulcer? An older patient who is septic, bedridden, and incontinent An obese woman with leukemia who is receiving chemotherapy A middle-aged thin man in a halo cast after a motor vehicle accident An adult with type 1 diabetes mellitus admitted in diabetic ketoacidosis
a
A patient has an open surgical wound on the abdomen that contains deep pink granulation tissue. How would the nurse document this wound? a. Red wound b. Y ellow wound c. Full-thickness wound d. Stage III pressure ulcer
a The description is consistent with a red wound. A stage III pressure ulcer would expose subcutaneous fat. A yellow wound would have creamy colored exudate. A full-thickness wound involves subcutaneous tissue
Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative pressure wound therapy? a. Low serum albumin level b. Serosanguineous drainage c. Deep red and moist wound bed d. Cobblestone appearance of wound
a With negative pressure therapy, serum protein levels may decrease, which will adversely affect wound healing. The other findings are expected with wound healing.
A nurse is caring for a patient with diabetes who is scheduled for amputation of his necrotic left great toe. The patient's WBC count is 15.0 × 106/μL, and he has coolness of the lower extremities, weighs 75 lb more than his ideal body weight,and smokes two packs of cigarettes per day. Which priority nursing diagnosis addresses the primary factor affecting the patient's ability to heal? a. Imbalanced nutrition: obesity related to high-fat foods b. Impaired tissue integrity related to decreased blood flow secondary to diabetes and smoking c. Ineffective peripheral tissue perfusion related to narrowed blood vessels secondary to diabetes and smoking d. Ineffective individual coping related to indifference and denial of the long-term effects of diabetes and smoking
b
A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5° F temperature, slight erythema at the incision margins, and 30 mL serosanguineous drainage in the Jackson-Pratt drain. Based on this assessment, what conclusion would the nurse make? a. The abdominal incision shows signs of an infection. b. The patient is having a normal inflammatory response .c. The abdominal incision shows signs of impending dehiscence. d. The patient's physician must be notified about her condition.
b
A patient had abdominal surgery last week and returns to the clinic for follow-up. The nurse assesses thick, white, malodorous drainage. How should the nurse document this drainage? Serous Purulent Fibrinous Catarrhal
b
A patient in the unit has a 103.7° F temperature. Which intervention would be most effective in restoring normal body temperature? a. Use a cooling blanket while the patient is febrile. b. Administer antipyretics on an around-the-clock schedule. c. Provide increased fluids and have the UAP give sponge baths. d. Give prescribed antibiotics and provide warm blankets for comfort.
b
A patient is seen in the emergency department for a sprained ankle. What initial interventions should the nurse teach the patient for treatment of this soft tissue injury? Warm, moist heat and massage Rest, ice, compression, and elevation Antipyretic and antibiotic drug therapy Active movement and exercise to prevent stiffness
b
A patient with pneumonia has a fever of 103°F. What nursing actions will assist in managing the patient's febrile state? Administer aspirin on a scheduled basis around the clock. Provide acetaminophen every 4 hours to maintain consistent blood levels. Administer acetaminophen when the patient's oral temperature exceeds 103.5°F. Provide drug interventions if complementary and alternative therapies have failed.
b
The nurse assesses a patients surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate? a. Obtain wound cultures. b. Document the assessment. c. Notify the health care provider. d. Assess the wound every 2 hours.
b
The nurse assessing a patient with a chronic leg wound finds local signs of erythema and the patient complains of pain at the wound site. What would the nurse anticipate being ordered to assess the patient's systemic response? a. Serum protein analysis b. WBC count and differential c. Punch biopsy of center of wound d. Culture and sensitivity of the wound
b
The patient has inflammation and reports feeling tired, nausea, and anorexia. The nurse explains to the patient that these manifestations are related to inflammation in what way? Local response Systemic response Infectious response Acute inflammatory response
b
Which intervention should the nurse include in the plan of care for a patient who is paraplegic with a stage III pressure ulcer? Keep the pressure ulcer clean and dry. Maintain protein intake of at least 1.25 g/kg/day. Use a 10-mL syringe to irrigate the pressure ulcer. Irrigate the pressure ulcer with hydrogen peroxide.
b
A patient arrives in the emergency department reporting fever for 24 hours and lower right quadrant abdominal pain. After laboratory studies are performed, what does the nurse determine indicates the patient has a bacterial infection? Increased platelet count Increased blood urea nitrogen Increased number of band neutrophils Increased number of segmented myelocytes
c
A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound is yellow and involves subcutaneous tissue. How should the nurse classify this pressure ulcer? a. Stage I b. Stage II c. Stage III d. Stage IV
c
A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment? Frequent examination of the character and quantity of exudate Monitoring for signs and symptoms of local or systemic infections Assessment of the patient's circulation distal to the location of the dressing Assessment of the range of motion of the ankle and the patient's activity tolerance
c
A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? a. Skin flushing b. Muscle cramps c. Rising body temperature d. Decreasing blood pressure
c
After receiving a change-of-shift report, which patient should the nurse assess first? a. The patient who has multiple black wounds on the feet and ankles b. The newly admitted patient with a stage IV pressure ulcer on the coccyx c. The patient who has been receiving chemotherapy and has a temperature of 102 F d. The patient who needs to be medicated with multiple analgesics before a scheduled dressing change
c
An 82-year-old man is being cared for at home by his family. A pressure ulcer on his right buttock measures 1 × 2 × 0.8 cm in depth, and pink subcutaneous tissue isc ompletely visible on the wound bed. Which stage would the nurse document o nthe wound assessment form? a. Stage Ib. Stage IIc. Stage IIId. Stage IV
c
An older adult patient is transferred from the nursing home with a black wound on her heel. What immediate wound therapy does the nurse anticipate providing to this patient? Dress it with an absorbent dressing for exudate. Handle the wound gently and let it dry out to heal. Debride the nonviable, eschar tissue to allow healing. Use negative-pressure wound (vacuum) therapy to facilitate healing.
c
The nurse assesses impaired skin integrity in this patient. How will the nurse document this? Stage I Stage II Stage III Stage IV
c
The nurse is providing care to a patient with an open abdominal wound after surgery. What teaching should the nurse provide to the patient regarding the healing process? The wound will be stapled together until it heals. The healing will contract the area to close the wound. The wound will be left open and heal from the edges inward. The wound will be sutured after the current infection is controlled.
c
Which one of the orders should a nurse question in the plan of care for an elderly immobile stroke patient with a stage III pressure ulcer? a. Pack the ulcer with foam dressing .b. Turn and position the patient every hour. c. Clean the ulcer every shift with Dakin's solution. d. Assess for pain and medicate before dressing change
c
A patients 4 3-cm leg wound has a 0.4 cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound? a. Dry gauze dressing (Kerlix) b. Nonadherent dressing (Xeroform) c. Hydrocolloid dressing (DuoDerm) d. Transparent film dressing (Tegaderm)
c The wound requires debridement of the necrotic areas and absorption of the yellow-green slough. A hydrocolloid dressing such as DuoDerm would accomplish these goals. Transparent film dressings are used for red wounds or approximated surgical incisions. Dry dressings will not debride the necrotic areas. Nonadherent dressings will not absorb wound drainage or debride the wound.
A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care? a. The new nurse uses a hydrocolloid dressing (DuoDerm) to cover the ulcer. b. The new nurse inserts a sterile cotton-tipped applicator into the pressure ulcer. c. The new nurse irrigates the pressure ulcer with sterile saline using a 30-mL syringe. d. The new nurse cleans the ulcer with a sterile dressing soaked in half-strength peroxide.
d
A patient is postoperative after a breast reduction and arrives for a follow-up appointment at the clinic. The nurse assesses excess soft pink tissue from the surgical incision site. What complication of wound healing does the nurse recognize this to be? Adhesion Contractions Keloid formation Excess granulation tissue
d
A patient with rheumatoid arthritis has been taking corticosteroids for 11 months. Which nursing action is most likely to detect early signs of infection in this patient? a. Monitor white blood cell count. b. Check the skin for areas of redness. c. Check the temperature every 2 hours. d. Ask about fatigue or feelings of malaise.
d
A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is being cared for at home by his mother. To prevent further tissue damage, what instructions are most important for the nurse to teach the mother? a. Change the patients bedding frequently. b. Use a hydrocolloid dressing over the ulcer. c. Record the size and appearance of the ulcer weekly. d. Change the patients position at least every 2 hours.
d
After the home health nurse teaches a patients family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed? a. The family member uses a lift sheet to reposition the patient. b. The family member uses clean tap water to clean the wound. c. The family member places contaminated dressings in a plastic grocery bag. d. The family member dries the wound using a hair dryer set on a low setting.
d
The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)? a. The patient who has increased tenderness and swelling around a leg wound b. The patient who was just admitted after suturing of a full-thickness arm wound c. The patient who needs teaching about home care for a draining abdominal wound d. The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer
d
The nurse is caring for a patient who is immunocompromised while receiving chemotherapy for advanced breast cancer. What signs and symptoms will the nurse teach the patient to report that may indicate an infection? Fever and chills Increased blood pressure Increased respiratory rate General malaise and fatigue
d
The nurse will perform which action when doing a wet-to-dry dressing change on a patients stage III sacral pressure ulcer? a. Soak the old dressings with sterile saline 30 minutes before removing them. b. Pour sterile saline onto the new dry dressings after the wound has been packed. c. Apply antimicrobial ointment before repacking the wound with moist dressings. d. Administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change.
d