Chapter 48: Skin Integrity and Wound Care (Skin Integrity and Wound Care - Implementation and Evaluation)

Which is the most effective intervention for compromised skin integrity?

*A. Preventing breakdown* B. Administering medication C. Implementing wound care D. Monitoring wound healing Rationale: The most effective intervention for compromised skin integrity and wound care is prevention of skin breakdown. Whereas administering medication, implementing wound care, and monitoring wound healing are all important nursing actions, prevention is the first step. Pg. 1205

Which size tape should the nurse use to stabilize a large dressing?

A. 1.3 cm (1/2 in) B. 2.5 cm (1 in) C. 5 cm (2 in) D. 7.5 cm (3 in) Rationale: Pg.

An elderly patient with hemiparalysis had an incontinent episode and the nurse is called to help the patient. What steps does the nurse take to ensure proper skin care when cleaning? Select all that apply.

A. Elevate the head of the bed to 45 degrees. B. Do not completely dry the skin. *C. Apply moisture barrier ointment.* *D. Use a nonionic surfactant to clean the skin.* E. Clean the skin with soap and hot water. Rationale: After an incontinent episode, the patient's skin should be cleaned properly, dried, and have a moisture barrier applied. It helps to maintain the skin's integrity and prevent a risk of pressure ulcers. After completely drying the skin, a moisture barrier should be applied to prevent excess moisture and bacteria in the wound. A nonionic surfactant should be used to clean the skin gently. Elevating the head of the bed to 30 degrees or less decreases the chance of pressure ulcer development. The skin should be completely dry to avoid excess moisture. Soap and hot water are to be avoided. Pg. 1203-1204

Which patient is at risk for systemic infection if heat is applied as a form of therapy?

A. Pediatric patient B. Spinal cord injury patient C. Patient with arteriosclerosis *D. Patient with an abscessed tooth* Rationale: The patient with an abscessed tooth is at risk for rupture and systemic injury if heat is applied during therapy. The pediatric patient, spinal cord injury patient, and patient with arteriosclerosis are at risk for burns, not systemic infection, with the application of heat. Pg. 1220

Which nursing action evaluates patient and family knowledge related to a pressure-redistribution surface?

A. Explaining the reasons for the prescription B. Teaching common errors associated with the prescription C. Noting the minimum layers of linen to be used with the prescription *D. Asking the participants to discuss possible sensations associated with the prescription* Rationale: When evaluating patient and family knowledge related to a pressure-redistribution surface the nurse should ask the patient and family to discuss possible sensations associated with using the surface. Explaining the reasons for the surface, teaching common errors, and noting the minimum layers of linen with use are all teaching strategies but do not evaluate patient and caregiver understanding. Pg. 1209

Which nursing interventions minimize the risk for pressure ulcer development? Select all that apply.

*A. Repositioning the patient every two hours* *B. Using a draw sheet to assist with repositioning* C. Conducting a nutritional assessment every 8 hours *D. Applying barrier creams for patients who are incontinent* *E. Providing education related to preventing skin breakdown* Rationale: Three major areas of nursing interventions for prevention of pressure ulcers are: (1) skin care and management of incontinence, such as applying barrier creams for patients who are incontinent; (2) mechanical loading and support devices, which include proper positioning and the use of therapeutic surfaces, such as repositioning the patient every 2 hours and using a draw sheet during repositioning; and (3) education, such as information related to preventing skin breakdown. Conducting a nutritional assessment is important; however, this is a part of assessment and is not necessary every 8 hours. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. Pg. 1205

Which of a novice nurse's actions would necessitate intervention when providing care for a patient who is prescribed negative-pressure wound therapy?

*A. Retaining hair around the wound* B. Using a skin barrier around the wound C. Drying around the wound thoroughly D. Filling uneven wound surfaces with a hydrocolloid product Rationale: Retaining hair around the wound edges can cause an air leak, so this action requires correction. Using a skin barrier, drying around the wound thoroughly, and filling uneven wound surfaces with a hydrocolloid product are all appropriate and will help maintain an airtight seal. Pg. 1215

Which dressing is inappropriate for a patient with a clean stage II pressure ulcer?

*A. Silver* B. Hydrogel C. Silicone D. Hydrocolloid Rationale: Silver impregnated dressings are used for infected wounds and should be discontinued when wounds are clean. Use hydrocolloid dressings for clean Category/Stage II pressure ulcers in body areas where they will not roll or melt. Hydrogel dressings may be used on stage II pressure ulcers, especially those with a dry bed. Consider using silicone dressings as a wound contact layer to promote atraumatic dressing changes. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer Pg. 1213

Which nursing action is appropriate when providing care to a patient who exhibits no risk for skin breakdown?

*A. Using a standard surface* B. Using a pillow under the calves C. Using an active support surface D. Using a pressure-redistribution seat cushion Rationale: An appropriate nursing action for a patient who is at no risk for skin breakdown is to use a standard surface. The patient who is at risk for skin breakdown would benefit from using a pillow under the calves, an active support surface, and a pressure-redistribution seat cushion. Pg. 1209

The 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. What does the nurse suspect based on this observation?

A. Accelerated wound healing B. Need for advancing the drain C. Dislodged tube of the drain *D. 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. Pg. 1199

Which adjuvant treatment is only considered for patients diagnosed with an unstageable pressure ulceration?

A. Support hydration B. Nutritional support *C. Surgical consultation for debridement* D. Evaluation of pressure-redistribution needs Rationale: A surgical consult for debridement is only considered for the patient who is diagnosed with an unstageable pressure ulcer. Supporting hydration, nutritional support, and evaluation of pressure-redistribution needs are all appropriate for patients diagnosed with pressure ulcers that have been staged. Pg.1213

Which dressing should the nurse use to protect and absorb moisture when providing care to a patient with a pressure ulcer?

A. Gauze B. Adherent film C. Calcium alginate *D. Hydrogel covered with foam* Rationale: Hydrogel covered with foam is appropriate for a pressure ulcer that requires protection and the absorption of moisture. A gauze dressing is often used for a clean stage II or IV ulcer. Adherent film dressings are appropriate for unstageable ulcers, and calcium alginate dressings are used when the ulcer is producing significant exudate. Pg. 1213

A 56-year-old hemiplegic patient lives in a long-term care facility. On examination, the nurse notices a bedsore on the skin over his sacrum. What factors are true regarding the development of bed ulcers? Select all that apply.

*A. Chronic immobility can cause bed ulcers.* B. Excessive moisture prevents bedsores. C. Nutrition has no effect on bedsore incidence. *D. Edema of the skin can cause bedsores.* *E. Dehydration of the body can cause bedsores.* Rationale: Many factors influence the formation of bed ulcers in this patient. A patient who is immobile, or who only walks occasionally, is at risk of developing pressure areas. Exposure to excessive moisture, which can lead to edema, increases the risk of bedsores. Fluid imbalance increases the patient's risk for pressure ulcers. Excessive moisture macerates the skin and increases the risk of developing pressure ulcers. Decreased nutritional status is linked to pressure ulcer formation and poor wound healing. Pg. 1192-1193, 1221

Which nursing intervention is appropriate for a patient who is at risk for skin breakdown due to moisture?

*A. Keep the skin dry and free of maceration* B. Provide a pressure-redistribution surface C. Consult a dietician for nutritional assessment D. Provide a trapeze to facilitate movement in bed Rationale: Whereas all of these interventions are appropriate for a patient who is at risk for skin breakdown, the one specific to a patient at risk for skin breakdown due to moisture is to keep the skin dry and free of maceration. Providing a pressure-redistribution surface is appropriate for a patient who is at risk for skin breakdown due to decreased sensory perception. Consulting a dietician for a nutritional assessment is appropriate for a patient who is at risk for skin breakdown due to poor nutrition. Providing a trapeze to facilitate movement in bed is appropriate for a patient who is at risk for skin breakdown due to friction and shear. Pg. 1206

Which nursing actions are appropriate when removing tape from the patient's skin during wound care? Select all that apply.

*A. Loosen the ends* *B. Pull the tape in the direction of hair growth* *C. Use adhesive remover to loosen the tape* D. Apply hard traction to the skin next to the wound E. Gently pull the outer end perpendicular to the skin surface Rationale: Appropriate nursing actions when removing tape from the patient's skin during wound care include loosening the ends, pulling the tape in the direction of hair growth, and using adhesive remover to loosen the tape. The application of light, not hard, traction is appropriate for minimizing pulling of the skin. It is appropriate to gently pull the outer end parallel, not perpendicular, to the skin surface. Pg. 1215

What might the nurse anticipate for a patient with new-onset bowel incontinence that is causing compromised skin integrity?

A. A new prescription for a diuretic. *B. A change in dietary prescription.* C. The implementation of timed voiding. D. The implementation of physical therapy. Rationale: New onset bowel incontinence is often treated with a change in diet. A nurse would expect a new prescription for a diuretic if the patient needed increased urine output, but this would not improve bowel incontinence. The implementation of timed voiding is more appropriate for urinary, not bowel, incontinence. The implementation of physical therapy would be appropriate for a patient with impaired mobility, but not bowel incontinence. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer. Pg. 1206

Which nursing intervention is appropriate for a patient who is at risk for infection due to a surgical incision at the right hip?

A. Applying moisture barrier cream *B. Obtaining a wound culture as needed* C. Providing analgesics prior to wound care D. Using correct repositioning techniques Rationale: Whereas all of these interventions are appropriate for a patient with impaired skin integrity, the intervention that is specific to a patient at risk for infection is obtaining a wound culture as needed. Applying a moisture barrier is appropriate when the patient's skin integrity is compromised due to limited mobility. Providing analgesics and using correct repositioning techniques are appropriate interventions for impaired physical mobility related to incisional pain. Pg. 1205

A patient is at risk for bedsores. The nurse obtains an air mattress for the patient. What is an advantage of the air mattress?

A. It encourages movement. B. It keeps the skin cool and dry. C. It reduces friction and pulling on the skin. *D. It distributes body weight over a larger area.* Rationale: Air matresses are used to reduce pressure points by distributing weight over a larger area. Air mattresses do not encourage movement but provide support. Air mattresses only relieve the pressure on pressure points and cannot reduce friction and pulling nor keep the skin cool and dry. Pg. 1205-1206

Which nursing action during removing tape from the patient's skin during wound care requires correction?

A. Loosening the ends B. Pulling the tape in the direction of hair growth C. Using adhesive remover to loosen the tape *D. Applying hard traction to the skin next to the wound* Rationale: The application of light, not hard, traction is appropriate in order to minimize pulling of the skin. Loosening the ends, pulling the tape in the direction of hair growth, and using adhesive remover to loosen the tape are appropriate actions for removing tape from the patient's skin during wound care. Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question. Pg. 1215

The nurse is caring for a patient who is diagnosed with venous stasis ulcers. Which support surface should the nurse anticipate for this patient?

A. Low-air-loss bed B. Nonpowered bed *C. Lateral rotation* D. Air-fluidized bed Rationale: The lateral rotation support surface provides passive motion, turning the patient from side to side on a low-air-loss surface. This type of surface is used in the treatment and prevention of pulmonary, venous stasis, and urinary complications associated with immobility. Low-air-loss, nonpowered, and air-fluidized bed surfaces are used to treat and prevent other types of skin breakdown. Pg. 1208

Which dressing will the nurse use for a patient with a clean stage III pressure ulcer?

A. None B. Adherent film C. Composite film *D. Calcium alginate* Rationale: The nurse would use a calcium alginate dressing for a patient with a clean stage III pressure ulcer. No dressing is only appropriate for an intact stage I pressure ulcer. An adherent film dressing is appropriate for an unstageable pressure ulcer. A composite film dressing is appropriate for a clean stage II pressure ulcer. Pg. 1213

Which nursing actions are teaching strategies for patients and families who will be working with a pressure-redistribution surface? Select all that apply.

*A. Explaining the reasons for the prescription* *B. Teaching common errors associated with the prescription* *C. Noting the minimum layers of linen to be used with the prescription* D. Asking the patients and caregivers to discuss possible sensations associated with the prescription E. Requesting a return demonstration of turning and repositioning techniques with the prescription Rationale: Teaching strategies for a patient and family who will be using a pressure-redistribution surface include explaining the reasons for the prescriptions, teaching common errors associated with the prescription, and noting the minimum layers of linen to be used with the prescription. Asking the participants to discuss possible sensations associated with the prescription and requesting a return demonstration of turning and repositioning techniques with the prescription are evaluation, not teaching, strategies. Pg. 1209

Which nursing intervention is appropriate for a patient who is at risk for skin breakdown due to decreased sensory perception?

A. Keep the skin dry and free of maceration *B. Provide a pressure-redistribution surface* C. Consult a dietician for nutritional assessment D. Provide a trapeze to facilitate movement in bed Rationale: Whereas all of these interventions are appropriate for a patient who is at risk for skin breakdown, the one that applies specifically to a patient at risk for skin breakdown due to decreased sensory perception is to provide a pressure-redistribution surface. Keeping the skin dry and free of maceration is appropriate for a patient who is at risk for skin breakdown due to moisture. Consulting a dietician for a nutritional assessment is appropriate for a patient who is at risk for skin breakdown due to poor nutrition. Providing a trapeze to facilitate movement in bed is appropriate for a patient who is at risk for skin breakdown due to friction and shear. Pg. 1206

Which nursing action is appropriate when providing care to a patient who has intact skin but is at high risk for impaired skin integrity of the heels?

A. Avoid prolonged elevation of the head of the bed B. Order a standard hospital foam mattress C. Consider an alternating pressure support surface *D. Place a pillow under the calves* Rationale: The nursing action that is appropriate for a patient who has intact skin but is at high risk for impaired skin integrity of the heels is to place a pillow under the calves to decrease the risk for heel breakdown. Avoiding prolonged elevation of the head of the bed is appropriate for a high-risk patient who already has a pressure ulcer. Ordering a standard hospital foam mattress is appropriate for a high-risk patient who is not at risk for impaired skin integrity. Considering an alternating pressure support surface is appropriate for a patient who is already diagnosed with an ulcer. Pg. 1209

Which nursing action is appropriate when framing the periwound area with skin sealant?

A. Extending the sealant 1 to 2 cm (0.4 to 0.8 in) beyond the wound edges B. Extending the sealant 2 to 4 cm (0.8 to 1.6 in) beyond the wound edges *C. Extending the sealant 3 to 5 cm (1.2 to 2 in) beyond the wound edges* D. Extending the sealant 4 to 6 cm (1.6 to 2.4 in) beyond the wound edges Rationale: Extending the sealant 3 to 5 cm (1.2 to 2 in) beyond the wound edges is an accurate nursing action when framing the periwound area with skin sealant. Extending it to 1 to 2 cm (0.4 to 0.8 in) or 2 to 4 cm (0.8 to 1.6 in) is not enough. Extending it to 4 to 6 cm (1.6 to 2.4 in) is more than necessary. Pg. 1215

The 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. What term is used to describe this process?

A. Irrigation *B. Debridement* C. Hemostasis D. Cleansing 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 removal process of dead tissue from the wound. Pg. 1206-1207

Which statement is true about wet-to-dry dressings for mechanical debridement of a wound?

A. It should be removed when partially dry. B. It should be completely wet when applied. *C. It should be only moist, not wet, when applied.* D. It should be left in place for at least 12 hours Rationale: Wet-to-dry dressings used for mechanical debridement of wounds should be moist, not wet. The application of moist gauze hydrates the wound and helps with quick drying. The gauze should be removed when totally dried so that it sticks to the necrotic tissue. It may not cause bleeding when removed. The dressing is positioned in the wound and held in place by an outer dressing or gauze wrap for 4 to 6 hours. This much time would be needed for the gauze to dry and stick to the underlying tissue. Study Tip: Try to decrease your workload and maximize your time by handling items only once. Most of us spend a lot of time picking up things we put down rather than putting them away when we have them in hand. Going straight to the closet with your coat when you come in instead of throwing it on a chair saves you the time of hanging it up later. Discarding junk mail immediately and filing the rest of your bills and mail as they come in rather than creating an ever-growing stack saves time when you need to find something quickly. Filing all items requiring further attention in some fashion helps you remember to take care of things on time rather than being so engrossed in your schoolwork that you forget about them. Many nursing students have had their power or telephone service cut off because the bill simply was forgotten or buried in a pile of old mail. Pg. 1207-1208

Which nursing intervention is appropriate for a patient who is at risk for skin breakdown due to poor dietary intake?

A. Keep the skin dry and free of maceration B. Provide pressure-redistribution surface *C. Consult a dietician for nutritional assessment* D. Provide a trapeze to facilitate movement in bed Rationale: Whereas all of these interventions are appropriate for a patient who is at risk for skin breakdown, the the one specific to a patient at risk for skin breakdown due to poor dietary intake is to consult a dietician for a nutritional assessment. Keeping the skin dry and free of maceration is appropriate for a patient who is at risk for skin breakdown due to moisture. Providing a pressure-redistribution surface is appropriate for a patient who is at risk for skin breakdown due to decreased sensory perception. Providing a trapeze to facilitate movement in bed is appropriate for a patient who is at risk for skin breakdown due to friction and shear. Pg. 1206

The nurse is providing care to a patient with a pressure ulcer that is covered in eschar. Which dressing prescription will the nurse use for this patient?

A. None *B. Adherent film* C. Composite film D. Calcium alginate Rationale: A pressure ulcer covered in eschar is an unstageable pressure ulcer. The nurse would use an adherent film dressing because it will facilitate softening of the eschar to allow for debridement. No dressing is appropriate for an intact stage I pressure ulcer. A composite film dressing is appropriate for a clean stage II pressure ulcer. A calcium alginate dressing is appropriate for a clean stage III or stage IV pressure ulcer. Pg. 1213

A patient with multiple fractures has casts that make it difficult to move voluntarily. The nurse notices red skin in the spinal area that blanches on applying pressure. What measures does the nurse take to decrease the risk of development of pressure ulcers in this patient? Select all that apply.

A. Position the patient in the most comfortable position and do not move. B. Cover the hyperemic skin area with a sterile dressing and apply antiseptics. *C. Check the skin around the casts regularly for any signs of deteriorated skin condition.* *D. Take care to avoid friction injuries during repositioning, bathing, or transferring of the patient.* *E. Use good hygiene techniques to ensure the patient's skin is clean and dry after bowel movements.* Rationale: When the nurse suspects a developing pressure ulcer, other areas should be checked for deteriorated skin condition, especially around casts. It helps in early detection and prompt treatment. The nurse should ensure that the skin of the patient is clean and dry and not overly moistened for prolonged periods. Excess moisture increases the risk of pressure ulcers. When repositioning, bathing, or transferring the patient, care should be taken to avoid friction injuries to the affected area or other areas. The patient should be repositioned at regular intervals to relieve pressure and avoid pressure being exerted on one or the same body parts constantly. The area of hyperemic skin should not be covered, but inspected at regular intervals for abnormal hyperemia, induration, or nonblanching. Pg. 1187, 1196