Chapter 8: Skin Integrity and Wound Care
perform hand hygiene, PPE, moisten a sterile, flexible, applicator with saline and insert it gently into wound a 90 degree angle with the tip down, and mark point on
To decide the depth of the of a wound, do what?
Reduce the time interval between changes to prevent drying of the materials, which may disrupt healing tissue
The nurse notes that the wound dressing is dry upon removal, what should they do?
115-125 degrees F
Water for heat application should be what temperature for older children and adults?
Dehiscence
What is the accidental separation of wound edges, especially a surgical wound?
Promote tissue repair and regeneration to restore skin integrity
What is the goal of wound care?
Antimicrobial dressings
What kind of wound dressing has antibacterial or antimicrobial action, reduces infection, prevents infection?
Hydrogels
What kind of wound dressing/product maintain a moist wound enviornment, minmal absoprtion of drainage, faciliatate autolytic debridment, don't adhere to wound, reduce pain, most require a secondary dressing to secure?
Negative-pressure wound therapy (NPWT)
What promotes wound healing and wound closure through appliction of uniform negative pressure on the wound bed, it results in reduciton of bacteria in wound and removal of excess wound fluid, while providing a moist wound healing enviornment, the negative pressure results in mecanical tension on the wound tissues, stimulating cell proliferation, blood flow to wounds and the growth of new blood vessels ?
dehiscence, infection, hemorrhage, evisceration
Wound complications include what?
primary intention
Wounds healing from what kind of intention have clean straight line with little loss of tissue; wound edges are well approximated with sutures ; usually heal rapidly with minimal scaring?
4-8 hours
A hemovac drain should be empties every ____ to _____ hours or when it is half full, to keep the the suctioning?
eschar
A suspected deep tissue injury may evolve and become covered by a thin layer of what?
Inspect tubing for kinks or obstruction; assess the patient for changes in condition, remove the dressing and assess the site, often if the tubing becomes blocked with a blood clot or drain age particles, the wound drainage, will leak around exit site of the drain, cleanse the area and redress the site, notify the primary care provider of the findings and document the event in the patient's record
A patient with a JP drain in the right lower quadrant following abdominal surgery; the record indicates that it has been draining seroanguinoues fluid, 40 to 50 mL every shift, while performing your initial assessment, you note that the dressing around the drain site is saturated with seroguineous secretions and there is minimal drainage the collection chamber, what should you do?
Assess for signs of obstructed bile flow, including chills, fever, tachycardia, nausea, right upper quandrant fullness and pain, jaundice, dark foam urine and clay colored stools. Obtain vital signs, notify primary care provider of situation and findings, and document; fluishing T-tube of three way value may be ordered
A patient's T-tube has been consistently draining 30-50 mL a shift, but now there is no output for the current shift, you check the tube and site and don't observe kinks or other exterior obstructions, what do you do?
painful, firm, boggy, warmer, or cooler as compared to adjacent tissue
A suspected deep tissue injury may preceded by tissue that is what?
skin color, pulses distal to the site, evidence of edema, and presence of sensation, assess
Before applying a warm moist compress assess what?
patients skin and patient's response to heat at frequent intervals, according to facility policy, do not exceed the prescribed length of time for the application of heat
Before applying heat, should assess what?
Pain (might need to administer analgesia, and give appropriate time for it to set in before beginning dressing change, about 30 minutes or so)
Before beginning wound dressing change should assess the patient's what?
their ability to ambulate to the bathroom and maintain a sitting position for 15 to 20 minutes, inspect perineal/rectal area for swelling, drainage, redness, warmth, and tenderness; assess bladder fullness and encourage patient to void before sitz bath
Before doing sitz bath, should assses what?
amount of drainage, primary practitioners preference, nature of wound and particular wound care product being used
The frequency of need to change a dressing depends on what?
ask the patient to hit the call bell to summon a coworker to provide the missing supplies
The nurse has set up dressing supplies, removed the old dressing and put on on sterile gloves to clean the wound the nurse then realizes that a necessary part of dressing material has been forgotten; what should/can the nurse do?
discard this swab, obtain additional supplied needed, and a new culture swab, clean wound then obtain culture
The nurse inserted the culture swab into the patient's wound to obtain the specimen and the nurse realizes the wound wasnt cleaned, what do you do?
Stop the heat application, remove the compress, assess the patient for other symptoms, obtain vital sings, report the findings to primary care provider and document the event in the patient's record
The nurse is monitoring a patient with a warm compress; procedure requires that the nurse check the area of application every 5 minutes for tissue tolerance, the nurse notes excessive redness and slight maceration of the surrouding skin, and the patient verbalizes increased discomfort, what do you do?
stop procedure, administer analgesic as ordered, obtain new supplies, and begin procedure has elapsed for pain medication to take effect
The patient experiences pain when the wound irrigation is begun, what should you do?
staging of the wound
The presence of eschar in would precludes what?
per facility policy or medical order, apply moist saline compresses to loosen crusts before attempting to remove the staples
The staples are stuck to the wound because of dried blood or secretions; what should you do?
patient's age, nutritional status, and wound location.
The time frame of removal of sutures and staples varies depending on what?
notify primary care provider or wound care specialist, whao may order the wound to be packed, pack them loosely
The wound assessment reveal several dpressions or crater-like areas on inspection of a wound, what do you do?
Stage III pressure ulcer
There are five stages of pressure ulcers, what stage is it when there is full-thickness tissue los, subcutaneous fat may be visible, but bone, tendon or muscle are not exposed; slough may be present, but doesn't obscure the depth of tissue loss; may induce undermining or tunneling; depth of this stage depends on location; bridge of nose, ear, occiput, and malleolus do not have subq tissue and stage II ulcers at these locations can be shallow; in contrast area with large amount of tissue like buttock can develop pressure ulcers in this stage?
Unstageable pressure ulcer
There are five stages of pressure ulcers, what stage is it when there is full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, grey, green or brown) and or eschar (tan, brown, or black in the wound bed; until enough slough and/or eschar is removed to expose the base of the wound, the true depth and therefore the stage cannot be determined; stable (dry, adherent, intact and erythema or movement) eschar on the heals severes as the body natural biological cover; should not be removed?
Stage IV pressure ulcer
There are five stages of pressure ulcers, what stage is it when there is full-thickness tissue loss with exposed bone, tendon or muscle; exposed bone/tendon is visible and directly palpable; slough or eschar may be present on some parts of the wound bed; often includes undermining or tunneling; depth varies via anatomic location, ie bridge of nose, ear, occiput, and malleolus do not have subq tissue and stage II ulcers at these locations can be shallow; in contrast area with large amount of tissue like buttock can develop pressure ulcers in this stage?
Stage I pressure ulcer
There are five stages of pressure ulcers, what stage is it when there is intact skin with non blanch-able redness of a localized area usually over a bony prominence; with dark pigmented skin color may differ from surrounding area; may be painful, firm, soft, warmer, or cooler?
Stage II pressure ulcer
There are five stages of pressure ulcers, what stage is it when there is partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough; presents as a shiny or dry shallow ulcer without slough or brusining; may also present as an intact or open/rupture serum filled blister?
determine direction, moisten cotton tip applictor with saline solution, gently inset into sight where tunneling occurs, view direction of applicator as if where hands on clock, determine depth by marking the point of the swab that is even with the wound's edge and grasp applicator where it corresponds with wound's margin, measure and document depth
To evaluate wound tunneling should do what?
draw shape, describe it, measure the length, width and diameter
To measure the size of the wound do what?
increased swelling, redness, drainage, warmth, foul odor?
Signs of infection are what?
105-110 degrees F
Water for heat application should be what temperature for infants, young children, older adults, and patients with diabetes or those who are unconscious?
infected wounds and non infected wounds, wounds with moderate to heavy exudate, partial and full thickness wounds, tunneling wounds, moist red and yellow wounds?
What are alginate dressings used for?
Draining, exuding and nonhealing wounds to protect form bacterial contamination and reduce contamination, acute and chronic wounds
What are antimicrobial dressings used for?
Undermining
What are areas of tissue destruction underneath intact skin along the margins of a wound; associate with stage 3 or 4 pressure ulcers?
partial to full thickness wounds, infected and noninfected wounds, skin grafts, donor sites, tunneling wounds, moist red and yellow wounds, wounds with minimal to heavy exudate
What are collagen dressing used for?
partial to full-thickness wounds, wounds with minimal to heavy exudate, necrotic tissue, mixed (granulation and necrotic tissue) wounds, infected wounds
What are comopsite dressings used for?
partial and fullthickness wounds, shallow, dehydrated wounds, wounds with eschar, wounds with viscous exudate
What are contact layer dressings used for?
Alldress, Covaderm, Stratasorb
What are different examples of composite dressings?
silvasorb, acticoat, excilon, silverlon
What are different kinds of antimicrobial dressings?
BGC matrix, stimulen, Promogran matrix
What are different kinds of collagen dressings?
Adaptic touch, profore WCL, telfa clear
What are different kinds of contact layer dressings?
Intrasite gel, clearsite, hypergel, aquasorb
What are examples of hydrogel dressings?
bioclusive, dermaview, meflim, ployskin, opsite
What are examples of transparent films?
absorb light to heavy amounts of drainage, use around tubes and drains
What are foams used for?
partial to full thickness wounds, wounds with light to moderate drainage, wounds with necrosis or slough, not for infected wounds
What are hydrocolloid dressings used for?
partial to full thickness wounds, necrotic wounds, burns, dry wounds, wounds with minimal exudate, infected wounds
What are hydrogel dressings used for?
commonly used after a surgical procedure or for drainage of an abscess
What are penrose drains usually used for?
sorbsan, curasorb, algicell, aquacel
What are some examples of alginate dressings?
Lyofoam, allevyn, mepilex, optifoam
What are some examples of foams?
duoderm, comfeel, primacol, exuderm
What are some examples of hydrocolloid dressings?
wounds with minimal drainage, wounds that are small; partial thickness, stage 1 pressure ulcers, cover dressings for gels, foams and gauze, secure intravenous caths, nasal, cannulas, chest tube and CVC's
What are transparent films for wounds used for?
if dressing is intact, presence of drainage, bleeding or saturation of dressing, wound surrounding tissues (not color, temp, presence of edema, maceration)
What do you assess for with JP drain?
Penrose drain
What drain is hollow, open-ended rubber tube, allowsfluid to drain via capillary action into absorbent dressings?
T-tube
What is a biliary drain that is sometimes placed in common bile duct after removal of gallbladder, or portion of bile duct; it drains bile while surgical site is healing?
sinus tract
What is a cavity or channels underneath a wound that has the potential for infection?
Sitz bath
What is a method of applying tepid or warm water to the perineal or rectal areas by sitting in a basin filled with this water; can help relieve pain and discomfort in the perineal area, such as after childbirth or surgery and can increase circulation to the tissues, promoting healing?
tunneling
What is a passageway or opening that may be visible at skin level, but with most of the tunnel under the surface of the skin?
epithelization
What is a stage of wound healing in which epithelial cells move across the surface of a wound margin; tissue color ranges from the color of ground glass to pink?
eschar
What is a thick, leathery scab or dry crust composed of dead cells and dried plasma?
exudate
What is fluid that accumulates in a wound when it starts to heal; characterized by irregular surface like rasberries?
approximated wound edges
What is it referred to when the edges of a wound are lightly pulled together epithelialization of the wound margins; edges touch and wound is closed?
Suspected deep tissue injury
What is it when there is a purple or maroon localized of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and or shear?
maceration
What is softening of tissue due to excessive moisture?
Jackson pratt drain (Jp drain)
What kind of drain collects wound drainage in bulblike device that is compressed to create gently suction, it consists of perforated tubing connected to portable vaccum uint; after procedure the surgeon places on end of the drain in our near the area to be drained?
Penrose drain
What kind of drain is inserted into or near a wound when it is anticipated that a collection of fluid in a closed area would delay healing?
Hemovac drain
What kind of drain is placed into a vascular cavity where blood drainage is expected after surgery such as with abdominal and orthopedic surgery, consists of a peforated tubing connected to a portable vaccum unit; suction is maintained by compressing a spring-like device in the collection unit?
Hydrocolloid dressing
What kind of dressing is wafer-shaped, absorbes drainage, maintains a moist wound surface, and decrease the risk for infection by covering the wound surface?
Alginates
What kind of wound dressing absorbs exuadte, maintain a moist wound enviornment, facilitate autolytic debridement, require secondary dressing, left on for 1 to 3 days?
Hydrocolloid dressing
What kind of wound dressing are occlusive or semi-occlusive, limiting exchange of O2, b/w wound and dressing, minimal to moderate absorption of drainage, maintain a moist wound enviornement, are self-adheavie, provide coushioning, facilitate atolytic debridement, may be left in place for 3-7 days?
Composite wound dressing
What kind of wound dressing combines with two or more physically distinct products in a single dressing with several functions, allow exchange of O2 b/w wound and enviornment, may facilitate autolytic debridment, provide physical bacterial barrier and absorptive layer, semiadherent or non adherent, primary or secondary dressing?
Collagen dressings
What kind of wound dressing is absorbent, mantain a moist wound enviornment, dont adhere to wound, compatible with topical agents, conform well to the wound surface, require secondary dressing to secure?
Contact layer dressings
What kind of wound dressing is placed in contact with base of wound, protecting base from trauma during dressing change, allow exudate to pass to a secondary dressing, not intended to be changed with every dressing change, may be used with topical medication and gauze dressing?
Transparent film
What kind of wound dressing/product allows the exchange of oxygen b/w wound and dressing, are self adhesive, protect against contamination, maintain a moist wound, facilitate autolytic debridement, may remain in place for 24 hrs to 72 hrs, allow visualization of wound?
Foam dressings
What kind of wound dressing/product maintains a moist wound enviornment, don't adhere to wound, insulate wound, highly absorbant, can be left in place for 7 days, some need secondary dressing?
A warm moist compress
What promotes circulation, encourage healing, decreased edema, promote consolidation of exuadate and decrease pain and discomfort; softens crusted material and is less drying to skin; penetrates tissues more deeply than dry heat; moisture conducts heat, a low temperature setting is needed on the heating device
at risk patients
Stage I pressure ulcer indicate what?
if dressing is intact, presence of drainage, bleeding or saturation of dressing, wound surrounding tissues (not color, temp, presence of edema, maceration)
When assess penrose drain, assess for what things?
if dressing is intact, presence of drainage, bleeding or saturation of dressing, wound surrounding tissues (not color, temp, presence of edema, maceration)
When assess t-tube drain, assess for what things?
Use cleansing sterile applicators, start at insertion site, and moving in circular motion toward opening, use each applicator only once
When cleaning drain site of T-tube drain, what do you do?
Use cleansing sterile applicators, start at insertion site, and moving in circular motion toward opening, use each applicator only once
When cleaning drain site what do you do?
intact skin at wound edges
When collecting a wound culture, carefully insert the swab into the wound, and press and rotate the swab several times over the wound surfaces, but avoid touch the swab to what?
without touching outlet valve, pull of cap, empty it completely into container, and then use gauze pad to clean outlet and fully compress container with one hand while replace cap (creates pressure for drain)
When emptying JP drain do what?
outlet
When emptying bags from T-tubes, without touching the what, pull of the cap and empty bag content completly into container, and use gauze to wipe off the outlet and replace the cap?
Use a gentle, continous pulling motion to remove the suture, if the suture still does not come out, do not use excessive force, report findings to the primary care provider and document the event in the patient's record
When going to remove sutures, resistance is met when attempting to pull suture through the tissue, what should you do?
basin
When irrigating wound, use nondominant hand to gently apply pressue to ________ against the skin below the wound to form seal with the skin?
drainage, presence of sutures, stapes, drains, and tubes
When looking at wound note what extra things?
color, amount, type, odor, consistency
When observing drainage of wound, note what?
edges, color
When performing a general wound assessment, you should asses the wounds appearance by inspecting the ________ and the ________ of the wound and surrounding area?
DC therapy, obtain vital signs, assess for other symptoms, notify the primary care provider and document the event in the patient's record
When performing a skin assessment during therapy, the nurse notes increased pallor at the treatment site and sluggish capillary refill, and the patient reports alterations in sensation at the application site, what should you do?
touch the outside of the tube with the swab
When placing the swab back in the culture tube, you have to make sure to not do what?
Provide site care as order, notify the primary care provider, document the findings and interventionsw
When preparing to change a dressing on a penrose drain site, the nurse's assessment reveals that the drain is completely out, lying in the dressing material, what do you do?
notify primary care physician or wound care specialist, a diffrent treatment modality may need to be used and/ or debriement may be necessary
When removing a patient's dressing the assessment reveals eschar in the wound, what do you do?
report findings to primary care provider and document the event in the patient's record, apply adhesive wound closure strips according to facility policy or medical order
When removing staples, the wound edges appear approximated before staple removal but pull apart afterward, what should you do?
to keep wounds moist, which promotes healing and protects the wound from contamination and trauma
Why are guaze and other dressing moistened with saline solutions and placed in wounds?
primary, secondary and tertiary
Wound heal what three kinds of intentions?
clean the area of pathogens and other debris and to promote wound healing
Wound irrigations are ordered to do what?
tertiary intention
Wounds healing by delayed primary intention or what are left open for several days to allow edema or infection to resolve or exudates to drain; they are then closed?
infected
Wounds healing from primary intention that become what acutally heal by secondary intention; these wounds generate greater inflammatory reaction and more granulation tissue; these have larger scares and are less likely to shrink to a flat line as they heal?
Secondary intention
Wounds healing from what kind of intention are large wounds with considerable tissue loss; edges are not appoximated; healing occurs by formation of grannulation tissue; the wounds have longer healing time and larger scar?
moisten sterile gauze with sterile saline and gently loosen crusts before removing sutures
You go to remove sutures, and they are crusted with dried blood or secretions, making them difficult to remove; do what?
Assess the patient for any new and abnormal signs or symptoms and assess the surgical site and drain site, apply a sterile dressing with gauze and tape to the drain site, notify the primary care provider of the findings and document the event in the patient's record
Your patient calls your into the room and says I found this in the bed when I went to get up, he has his Jackson-pratt drain in his hand; it completely removed from patient; do what?
pressure, healing
Overpacking may increase ____________ and interfere with tissue ______________.
This diverts bile into the duodenu to aid in digestion and is accomplished by truning the three way acess valve so the drain is closed to drainage bag or occulding the tube with clamp
Patient has a T-tube placed after surgery; the surgeon has asked that the tube be clamped for 1 hour before and after meals; why would you do this?
A, D, B, G, H, C, I, F, K, J, E, L, M
Place these steps for cleaning a wound and changing dressing: A. identify patient, perform hand hygiene, and put on PPE, B. adjust bed to appropriate height C. after removing dressing note presence, amount, type, color and odor of any drainage from the wound D. Assess patient's pain E. Apply several dry guaze pads on the wet guaze F. irrigate wound, starting from top and working way down, take off gloves and put on new ones G. place absorbant pad under patient H: open all supplies, place fine mesh gauze into basin and pour orded solution over it, put on clean gloves I. Assess wound for tunneling, necrosis, eschar, undermining, granulation, drainage, stage J. take wet gauze, squeeze extra fluid out and use cotton applicator to line inner base of wound K. dry surrounding area L. place new dressing on and secure it M. label dressing with time, date, and initials
assess patient for other signs and symptoms of infection, pain maliase, fever, paresthesias. Place new dressing on wound, report finding to primary care provider and document the event, and be prepared to get wound culture
The chart states wound has approximated edges, is clean, staples and drainage intact, has no inflammation, edema or erythema. After dressing removed you see edges are not approximated, staples are missing, inflammation, swelling and has purulent drainage, What do you do?
5 minutes
Reassess the treatment area every ______ minutes, or according to facility policy?
No, usually performed by surgeon or other advanced practice professional with 24 to 48 hrs after surgery
Can a nurse preform the first dressing change of a surgical wound?
No, use a different swab
Can you use a swab for two collections at different sites?
true
Caring for T-tube is a sterile technique, true or false?
stop procedure, assess patient for other symptoms, obtain vitals, report finding to primary care provider and document the event in patient's record
During the wound irrigation the nurse notes bleeding from the wound , this has not been documented before as happening during previous irrigations, what do you do?
reddened, slightly swollen and bruised initially
Edges should be approximated, but can be slightly what for a week?
30 minutes
For a moist compress leave for up to how many minutes?
breast and abdominal surgeries
JP drains are usually used for what two surgery's?
1 inch
Keep the tip of the syringe at least how high above wound?
20 minutes
After ______ minutes or the prescribed amount of time, remove the ice and dry the skin?
pre-slit gauze under/around the drain, taking care not to dislodge drain
After done cleaning penrose drain, dry skin with gauze in same manner, and then apply what?
30 seconds
After placing cold therapy, remove the ice and assess the site for redness after how many seconds, and ask about the patient about presence of burning sensations?
place a skin protector on insicion first, and dont put closure strips directly on incision
After removing sutures, and before placing closure strips on incision, you should do what?
remove contaiminated gloves and put on new sterile gloves, or if you didnt bring second pair, i would hit the call light and ask for a coworker to bring me new sterile gloves
After the nurse has put on sterile gloves, the patient moves too close to the edge of the bed and the nurse must support her with his hands to prevent the patient from falling. If nothing else in the sterile field is touched, you should do what?
Heat application
Application of what accelerates the inflammatory response, promoting healing; is used to reduce muscle tension and to relieve muscle spasm and joint stiffness; also helps relieve pain, chronic pain, help treat infections, surgical wounds, inflammation, arthritis , joint pain, muslce pain and crhonic pain?
Applying cold therapy
Application of what constricts the peripheral blood vessles reducing blood flow to tissues and decreasing the local release of pain-producing substances; reduces formation of edema, and inflammation, reduces muscle spasm, and promotes comfort by slowing the transmission of pain stimuli; reduces bleeding and hematoma formation, the appllication of this is appropriate after direct trauma, for dental pain, for muscel spasms, after muscle sprains, and for the treatment of chronic pain?
discard the swab , obtain new one and collect specimen again
As the nurse prepares to insert the culture swab into the wound, the nurse inadvertently touches the swab to patients bedclothes, what do you do?
Follow facility policy and medical orders related o advacing penrose drains, Document assements, and intervention, notify primary care provider of findings and interventions
Assessment of a Penrose drain site reveals the drain has slipped back into incision, what should you do?
cleanse site, as ordered, obtain vitals, including their temp. Document care and assessments, notify primary provider of findings
Assessment of a penrose drain site reveals significantly increased edema, erythema, and drainage from the site in addition to drainage via drain: what should you do?
No, that is actually the body's natural cover
Does eschar on heal wounds need to be removed?
delayed healing, infection, complication
Expected to be pain for about 2-3 days, but increased pain or continous pain can suggest what?
Yes
Is cleaning the penrose drain a sterile procedure?
paper tape
Sense the skin of older adults is less elastic and more sensitive, what kind of tape should be used?
together
Surgical sutures and surgical staples are removed when enough tensile strength has developed to hold the wound edges ___________ during the healing?
every 4-8 hours and when they are half full of drainage of air
A JP drain should be emptied how often?
