Ch. 29 - Wound Care & Skin Integrity

Which stratum is the outermost layer of the patient's epidermis? Lucidum Corneum Spinosum Germinativum

Corneum Rationale The epidermis is the outermost layer of the skin, subdivided into five layers. The stratum corneum is the outermost layer of epidermis. It is made up of flattened dead cells. The stratum lucidum is located between the stratum granulosum and the stratum corneum. The stratum spinosum is located between the stratum granulosum and stratum basale. The stratum germinativum is the innermost layer of the epidermis.

Which nursing intervention would prevent venous stasis in a patient who has a lower limb wound? Raising the bed height to a higher level Elevating the patient's leg for 30 minutes Ensuring the bandage is clean and rolled Exposing the wound for some time before wrapping it

Elevating the patient's leg for 30 minutes Rationale Elevation of the leg allows gravity to assist in venous drainage from the peripheral leg veins. Raising the patient's bed may prevent discomfort for the nurse but does not promote venous return. The use of a clean and rolled bandage helps decrease the spread of microorganisms, and the rolled bandage facilitates easy application. Exposing the wound helps position the wounded limb properly before applying the bandage.

How does the nurse classify a stab wound based on skin integrity and the depth of the wound? Closed, deep Open, superficial Open, full-thickness Closed, partial-thickness

Open, full-thickness Rationale A stab wound is a sharp, cutting, penetrating injury that is deeper than it is wide. Because a stab wound involves cutting of the skin surface, it is an open wound. A stab wound may display a small opening on the skin but it penetrates into the subcutaneous layer, which is a characteristic of full-thickness wounds. Therefore the nurse should classify the wound as an open, full-thickness wound. Superficial wounds involve only the epidermis. A partial-thickness wound involves the epidermis and dermis. The skin in closed wounds remains intact.

What is *debridement*?

Removal or dead or necrotic tissue (non-viable tissue)

Which factor does the Braden Scale evaluate for? Skin integrity at bony prominences, including any wounds Risk factors that place the patient at risk for skin breakdown The amount of repositioning that the patient can tolerate The factors that place the patient at risk for poor healing

Risk factors that place the patient at risk for skin breakdown Rationale The Braden Scale measures factors in six subscales that can predict the risk of pressure ulcer development. It does not assess skin or wounds, patient tolerance of repositioning, or poor healing factors.

What stage of pressure injury is the following? Red-pink wound without slough. Serosanguineous-filled blisters Partial loss of dermis thickness.

Stage II

Which process occurs during the proliferative phase of wound healing in a patient? Homeostasis Wound cleaning Scar tissue formation Granulation tissue formation

Granulation tissue formation Rationale The wound is repaired during the proliferative phase. This phase involves the formation of granulation tissue to fill the wound. The inflammatory phase includes the process of homeostasis and wound cleaning. Formation of scar tissue occurs during the maturation phase, as the scar tissue gives strength to the repaired wound.

During the follow-up visit after an appendectomy, the patient reports a popping sensation at the site of the surgical suture. The nurse finds that there is excessive drainage from the wound. Which interventions would the nurse follow for this patient? (Select all that apply.) Use Lactated ringer's solution to clean the wound. Apply heat to the incision for 15 minutes every 4 hours. Instruct the patient to cough and deep breathe to reduce anxiety. Moisten gauze with sterile normal saline and cover the wound. Notify the primary health care provider about the patient's condition.

Moisten gauze with sterile normal saline and cover the wound. Notify the primary health care provider about the patient's condition. Rationale A popping sensation at the site of the sutures and excessive drainage from the sutures indicate that the patient is at risk of or has developed wound dehiscence. In this situation, the nurse should moisten some gauze with sterile normal saline and cover the wound to prevent any spread of infection. The nurse should notify the primary health care provider and anticipate that the health care provider will assess the wound further. Lactated ringer's solution is a sterile fluid used for fluid resuscitation and not appropriate to use for wound cleansing. The nurse should not provide heat therapy to the patient because heat therapy causes vasodilation and increases the chances of bleeding. Coughing and deep breathing would cause further pressure to the wound, aggravating the situation.

What are the three most important facets of the skin / integumentary systme?

1). Protection 2). Absorption 3). Excretion

What is an assessment that should be performed on a patient that presents with an *eviscerating wound*?

The client should be assessed for SHOCK. Eviscerating injuries can lead to shock.

What is healing by *primary intention*?

Closing wound with minimal edema, time, separation of wound edges and scar formation. Also no local infection

What are contraindications to using *HEAT* therapy?

For areas of active bleeding. For an acute localized inflammation Over a large area if a patient has cardiovascular problems.

The nurse is caring for a bedridden patient. During the physical examination, the nurse observes that the patient has intact, nonblistered skin with nonblanchable erythema at the sacral area. Which stage of pressure injury does the nurse suspect in the patient? I II III IV

I Rationale A pressure ulcer is a localized injury caused by complete or partial obstruction of the blood flow to the soft tissue at the site of the injury. Intact, nonblistered skin with nonblanchable erythema is a manifestation of a stage I pressure ulcer. Symptoms of a stage II pressure ulcer include shallow and superficial pink wounds and intact or ruptured blisters. A full-thickness wound and the presence of undermining or tunneling in the wound are symptoms of a stage III pressure ulcer. A deep wound and infection of the bone are symptoms of a stage IV pressure ulcer.

A patient is admitted with a stage II pressure ulcer. Which 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. Rationale A stage II pressure ulcer has a partial thickness loss of dermis and is shallow. It has a red-pink wound bed without slough. The subcutaneous fat is visible in a stage III ulcer due to a full-thickness tissue loss. A stage III and IV wound involves undermining and tunneling. A stage IV wound extends to the muscles and bones, as there is a full-thickness tissue loss.

The nurse understands that dehiscence of a wound may occur if there is partial or total separation of the wound layers. Which patients would be at increased risk of wound dehiscence? (Select all that apply.) A malnourished patient An obese patient A young adult A female patient A patient with wound infection

A malnourished patient An obese patient A patient with wound infection Rationale A malnourished patient may have poor wound healing, which may lead to wound dehiscence. Obesity may increase strain on surgical incisions. In addition, fat tissue has poor wound healing. Infection interferes with the wound healing process and may increase the risk of wound dehiscence. A young adult may have a better wound healing and have less risk of wound dehiscence. Gender may not affect wound healing and dehiscence.

When repositioning an immobile patient, the nurse notices redness over a bony prominence. Which condition is indicated when a reddened area blanches on fingertip touch? <p>When repositioning an immobile patient, the nurse notices redness over a bony prominence. Which condition is indicated when a reddened area blanches on fingertip touch?</p> 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 Rationale When repositioning an immobile patient, it is important to assess all bony prominences for the presence of redness, which can be the first sign of impaired skin integrity. Pressing over the area compresses the blood vessels in the area; and, if the integrity of the vessels is good, the area turns lighter in color and then returns to the red color. However, if the area does not blanch when pressure is applied, tissue damage is likely. This is not a local skin infection requiring antibiotics or sensitive skin that requires special bed linen. Stage III pressure injuries are full-thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to muscle, bone, or connective tissue.

A nurse is managing wound care for a patient with a stage III pressure ulcer on the elbow. The nurse cleans the area and removes all the dead, nonviable tissue from the wound. Which term is used to describe this process? Irrigation Debridement Hemostasis Cleansing

Debridement Rationale Removal of nonviable necrotic tissue from the wound is called debridement, which can be accomplished chemically, mechanically, autolytically, or surgically. Debridement rids the wound of dead tissues that are ideal for bacterial growth and minimizes the risk of infection. Irrigation involves cleaning the wound with a cleaning solution under pressure to remove bacteria and exudates from the wound bed and maintain moisture. Hemostasis is the control of bleeding from a wound. Cleansing is not used to describe the process of removal of dead tissue from the wound.

What stage of pressure injury is the following? Purple or maroon localized area of discolored intact skin or blood-filled blister caused by damage to underlying soft tissue from pressure and/or shear.

Deep tissue injury

A nurse observes a wound with intermittent suturing. What is the defining characteristic of intermittent suturing? The suture is stronger and deeper. Each suture is tied and knotted individually. The suture line is made from one continuous piece of material. The suture has the first tie or knot at the beginning and the second knot at the end of the line.

Each suture is tied and knotted individually. Rationale There are three primary methods of suturing: intermittent suturing, continuous suturing, and retention suturing. An intermittent suture is tied and knotted individually, and a single piece of thread is used for one suture. Stronger and deeper sutures are made in retention suturing, which means that the sutures will remain or be retained within the body. Continuous suturing, made from one continuous piece of material, has the first tie or knot at the beginning of the wound and its second at the opposite end of the wound.

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part? Binder Ice bag Elastic bandage Absorptive diaper

Ice bag Rationale An ice bag helps constrict excess fluid in tissues, which prevents edema. The blood vessels become constricted, which helps control bleeding. The ice bag can also decrease pain where it is placed. Binders and bandages are placed over wound dressings to secure a dressing or splint, to provide support and protection to the healing wound, to apply pressure to reduce bleeding, or to immobilize a body part. Absorptive diapers protect the skin form excess moisture.

What stage of pressure injury is the following? Discoloration of the skin, warmth, edema, hardness, pain. Intact skin Nonblanchable erythema

Stage I

What stage of pressure injury is the following? Visible subcutaneous fat Presence of slough Loss of full-thickness adipose tissue

Stage III

A long-term care facility encourages nurses to assess patients at risk of developing pressure ulcers based on six subscales: moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. Which tool is the facility using for risk assessment of pressure ulcer development? GNASC tool Braden Scale Bates-Jensen tool WOCN scale

Braden Scale Rationale The Braden Scale is a widely used tool for risk assessment of pressure ulcer development and is composed of six subscales, which are moisture, sensory perception, activity, mobility, nutrition, and friction or shear. The GNASC tool is used to assess stage I pressure ulcers in patients with dark skin tone. The Bates-Jensen tool is used to assess the wound status. WOCN or the Wound, Ostomy, and Continence Nurses Society does not provide any measurement or assessment tools.

The nurse is caring for an elderly patient. During the assessment the nurse finds that the patient is susceptible to developing a decubitus ulcer. Which interventions would the nurse follow to prevent decubitus ulcer in this patient? (Select all that apply.) Change the patient's position once every 2 hours. Elevate the head of the bed to a 50-degree angle. Prevent the patient's inner knees from pressing onto each other. Avoid using pillows to elevate the patient's legs. Avoid placing the patient in positions that increase stress on bony prominences.

Change the patient's position once every 2 hours. Prevent the patient's inner knees from pressing onto each other. Avoid placing the patient in positions that increase stress on bony prominences. Rationale The skin is affected by aging, and wound healing becomes slow, increasing the risk of decubitus ulcer. The nurse should change the patient's position at least every 2 hours to reduce the impact of shear forces on a particular area of the skin for a long time. The nurse should keep the patient's inner knees from pressing onto each other to prevent pressure on the medial condyle of the tibia. The nurse should not place the patient in positions that increase stress on bony prominences, as these areas are most likely to develop pressure ulcers. The nurse should elevate the head of the patient's bed to no more than 30 degrees to reduce the effects of shear. The heels are susceptible to breakdown due to their small surface area and the lack of a subcutaneous cushion. Therefore the nurse should position the patient's legs on pillows so that the pressure on the heels is relieved.

The nurse instructs the trainee nurse to clean a patient's open-wound drainage. The trainee nurse cleans the wound in a horizontal motion, away from the drain. After cleansing the wound, the nurse applies drain sponges, sterile 4×4s, and an absorbent pad over the wound. Which action of the trainee nurse indicates the need for additional teaching? Applying sterile 4×4s and an ABD pad over the wound Cleaning the wound in a horizontal motion Cleaning the wound away from the drain Applying drain sponges over the wound after cleansing

Cleaning the wound in a horizontal motion Rationale An open-wound should be cleaned in a circular motion so that the entire wounded area is cleaned thoroughly. Wound cleaning in a horizontal motion is not a proper method of cleaning because the whole wound will not be cleaned properly by this method. The nurse should apply drain sponges, sterile 4×4s, and an absorbent pad over the wound after cleansing to maintain sterility and dryness. The nurse should clean the wound from the site of the drain outward and away from the drain to ensure proper removal of all wound debris and to prevent cross-contamination.

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first? Allow the area to be exposed to air until all drainage has stopped. Place several cold packs over the area, protecting the skin around the wound. Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration. Cover the area with sterile gauze, place a tight binder over it, and ask the patient to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly.

Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration. Rationale If a patient has an opening in the surgical incision and a portion of the small bowel is noted, the small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist. The area should not be exposed to air as this can cause damage or death to the exposed bowel. Cold packs should not be placed over the area as the area needs to be kept moist and clean. A binder should not be placed over the area, and the patient should remain in bed and taken to surgery immediately to repair the damage; this is not a minor opening.

The primary health care provider instructs the nurse to apply a bandage on a patient's injured leg. The nurse finds that the patient is anxious. Which nursing action would be taken first in this situation? Explain the procedure to the patient. Notify the primary health care provider. Apply the bandage to the patient immediately. Elevate the patient's leg for 15 minutes before applying the bandage.

Explain the procedure to the patient. Rationale Sometimes the patient feels uncomfortable and becomes anxious when a bandage is placed over wound dressings to provide support. In this situation, the nurse should explain the procedure to the patient. This relieves the patient's anxiety and facilitates the patient's cooperation. Anxiety is a normal reaction to a medical procedure. Nurses are accustomed to managing patient anxiety associated with bandaging, and the health care provider does not need to be notified. The patient is anxious; therefore the nurse should not apply the bandage to the patient immediately because the patient may feel uncomfortable. Elevating the leg 15 minutes before applying a bandage is a secondary intervention. It promotes venous return and reduces edema. This would be advisable but does not reduce anxiety.

The nurse makes an introduction and explains the procedure of wound care to the patient. The nurse then performs hand hygiene and checks the patient's treatment plan. Which specific intervention facilitates the patient's cooperation with wound care? Making an introduction Performing hand hygiene Checking the care plan of the patient Explaining the wound care procedure

Explaining the wound care procedure Rationale Explaining the wound care procedure helps reduce anxiety and promotes patient cooperation. The nurse's introduction helps the patient develop a trusting relationship with the nurse. Performing hand hygiene helps prevent infection. Checking the patient's care plan helps ensure that appropriate treatment is provided.

Which stage of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and pain? I II III IV

I Rationale A stage I pressure ulcer does not have a break in the skin but has a redness that does not blanch. Depending on the skin color, there may be a discoloration; the area may feel warm because of the vasodilation or cool if blood is constricted in the area; and the tissue may feel firm if there is edema in the area or soft if the blood flow is compromised. The patient may report pain in the area. A partial-thickness wound that involves the epidermis and/or dermis but does not extend below the level of the dermis is called a stage II pressure injury. It is shallow and superficial, with a pink wound bed. Intact or ruptured blisters that are the result of pressure also are considered to be stage II pressure injuries. Stage III pressure injuries are full-thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to muscle, bone, or connective tissue. There may be undermining or tunneling present in the wound. Another full-thickness wound is a stage IV pressure injury. This wound is deeper than a stage III pressure injury and involves exposure of muscle, bone, or connective tissue (such as tendons or cartilage).

The registered nurse is preparing a care plan for a patient with severe wounds. Which duties does the registered nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. Observation of changes in skin integrity Observation of changes in dietary intake Evaluation of the patient's skin and wound Measurement of the patient's body temperature Evaluation of effectiveness of the treatment plan

Observation of changes in skin integrity Observation of changes in dietary intake Measurement of the patient's body temperature Rationale The registered nurse should delegate any tasks that are repetitive and simple and do not involve nursing judgment to the UAP. Therefore the nurse can delegate tasks such as observation of skin integrity and dietary intake and measurement of body temperature to the UAP. Tasks that require planning and evaluation are done by a registered nurse. Therefore the registered nurse must not delegate tasks such as evaluation of the wound and effectiveness of the treatment plan.

While assessing a patient who has a sacral pressure ulcer, the nurse finds that it is a stage II pressure ulcer. Which finding in the patient led the nurse to this conclusion? Presence of a pink wound bed Presence of nonblanchable erythema Presence of a tunnel in the wound Presence of a lip around the wound

Presence of a pink wound bed Rationale In a stage II pressure ulcer, the thickness of the dermis is lost. The skin forms an open wound that extends to the deeper layers of the skin. The presence of a pink wound bed is caused by the rupture of blood vessels around the wound. The presence of nonblanchable erythema at the site of the wound is characteristic of a stage I pressure ulcer. This is caused by excessive vasodilation. Undermining and tunneling in the wound are typical of a stage III pressure ulcer. A tunnel is a narrow passage that extends outward from the edge of the wound. Undermining refers to an area of tissue loss along the edges of the wound, forming a "lip" around the wound.

The edges of a patient's appendectomy incision are approximated, and no drainage is noted. Which type of healing would be applied? Granulation Primary intention Tertiary intention Secondary intention

Primary intention Rationale Primary intention is the use of sutures or other wound closures to approximate the edges of an incision or a clean laceration. This reduces the risk of infection. Granulation tissue is formed to fill the gap between the edges of a wound and eventually fills in the surface of the wound. Healing by tertiary intention occurs with ulcers and wounds and results in scar formation. Secondary intention wound healing occurs slower than primary intention.

Which factor increases the risk of wound infection? Absence of necrotic tissue Absence of foreign body in the wound Reduced local tissue defenses Adequate blood supply

Reduced local tissue defenses Rationale Reduced local defenses may prevent any counter activity against the microorganisms infecting the wound. Absence of necrotic tissue decreases the risk of infection by improving the blood supply. A foreign body in the wound increases the risk of infection by acting as a port of entry for the microorganisms. Adequate blood supply is important for preventing infection.

Which clinical finding is an indication for a binder to be placed around a surgical patient 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 Rationale A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreasing stress from coughing and movement. Collection of wound drainage, reduction of abdominal swelling, and stimulation of peristalsis are not indications for abdominal binders.

The primary health care provider has recommended vacuum-assisted therapy (VAC) to a patient to treat a diabetic ulcer. During VAC, the alarm suddenly starts beeping. Which possible cause would the nurse assess to identify the reason for the alarm? Whether the canister is empty Whether there is an air leak in the dressing Whether the canister is tipped at 35 degrees Whether the irrigating solution has reached 90°F

Whether there is an air leak in the dressing Rationale In VAC, localized subatmospheric pressure draws wound edges toward the center, reduces wound edema and bacterial colonization, and promotes wound healing. The alarm may start beeping when there is an air leak in the dressing. Ensuring that the dressing is airtight with no leaks is the priority concern for effective operation of the wound VAC. The alarm would also sound if the canister were full. The alarm will also sound if the canister is tipped to more than 45 degrees. The standard temperature of the irrigation solution is 90° to 95°F; reaching 90°F will not cause the alarm to sound.

What is paraben?

Acts as an *estrogen agonist*

Which phrase 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 Rationale A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing. Like foams, alginates are useful in the highly exudative wound. They are made from brown seaweed fibers and are highly absorbent, capable of absorbing up to 20 times their weight. Premoistened gauze contains normal saline and not a gelling agent. Enzymatic debridement is achieved through the application of topical agents containing enzymes that work by breaking down the fibrin, collagen, or elastin present in devitalized tissue, thus allowing for its removal.

A nurse is changing the dressing of a patient with a drain placed at the surgical site. The nurse notices that the collecting device has minimal drainage, which is much less than expected. Which suspicion does the nurse have based on this observation? Accelerated wound healing Need for advancing the drain Dislodged tube of the drain Blockage in the drainage tube

Blockage in the drainage tube Rationale When there is a sudden decrease in the amount of drainage through a drain, the nurse should suspect a blocked drain. The nurse should inspect the drain and tubing and inform the health care provider. A sudden decrease in the drainage does not indicate accelerated wound healing. The drain needs to be advanced when there is a gradual decrease in the drainage. A dislodged drain would be visually evident.

Which description best fits that of serous drainage from a wound? Fresh bleeding Thick and yellow Beige to brown and foul smelling

Clear, watery plasma Rationale Serous fluid generally is serum and presents as an almost clear fluid. Sanguineous drainage usually indicates bleeding and is bright red. Purulent drainage usually is thick and indicates infection. It can be yellow, greenish, or beige.

Which process is described as the removal of devitalized tissue from a wound? Debridement Pressure reduction Negative pressure wound therapy Sanitization

Debridement Rationale Debridement is the removal of nonliving tissue, cleaning the wound to move toward healing. Pressure reduction is decreasing stress on a body part. Negative-pressure wound therapy (NPWT), or vacuum-assisted p1355 closure (VAC), uses negative pressure to remove excess wound fluid, stabilize the wound edges, and stimulate granulation tissue. Sanitization is the destruction of pathogenic and other kinds of microorganisms.

What are contraindications to using *COLD* therapy?

If the site of injury is edematous In the presence of neuropathy If the patient is shivering If the patient has impaired circulation

What stage of pressure injury is the following? Presence of Escher Exposure of bone, tendon, or muscle. Full-thickness subcutaneous tissue loss

Stage IV

What stage of pressure injury is the following? A full-thickness tissue loss in which the actual depth of the ulcer is completely obscured by: Slough (yellow, tan, gray, green, brown) Escher (tan, brown, black)

Unstageable

What is healing by *secondary intention*?

Wounds are left open and allowed to heal by scar formation (ex: trauma, burns, infected wounds, pressure ulcers, etc.); Tissue loss occurs and wound edges are jagged