Evolve Chapter 48 Skin Integrity and Wound Care

What is the normal lab value of Albumin?

3.5-5.0

The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient with a Stage IV pressure ulcer b. A patient with a Braden Scale score of 18 c. A patient with appendicitis using a heating pad d. A patient with an incision that is approximated

ANS: C The nurse should see the patient with an appendicitis first. Warm applications are contraindicated when the patient has an acute, localized inflammation such as appendicitis because the heat could cause the appendix to rupture. Although a Stage IV pressure ulcer is deep, it is not as critical as the appendicitis patient. The total Braden score ranges from 6 to 23; a lower total score indicates a higher risk for pressure ulcer development. A score of 18 can be assessed later. A healing incision is approximated (closed); this is a normal finding and does not need to be seen first.

The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a Stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed.How should the nurse document this ulcer in the patient's medical record? a. Stage I pressure ulcer b. Healing Stage II pressure ulcer c. Healing Stage III pressure ulcer d. Stage III pressure ulcer

ANS: C When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage and is labeled with the words "healing stage" or healing Stage III pressure ulcer. Once an ulcer has been staged, the stage endures even as the ulcer heals. This ulcer was labeled a Stage III, and it cannot return to a previous stage such as Stage I or II. This ulcer is healing, so it is no longer labeled a Stage

The nurse is completing a skin risk assessment using the Braden Scale. The patient has slight sensory impairment, has skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. Which score will the nurse document for this patient? a. 15 b. 17 c. 20 d. 23

ANS: C With use of the Braden Scale, the total score is a 20. The patient receives 3 for slight sensory perception impairment, 4 for skin being rarely moist, 3 for walks occasionally, 3 for slightly limited mobility, 4 for intake of meals, and 4 for no problem with friction and shear.

What is superficial with little bleeding and is considered a partial-thickness wound. The wound often appears "weepy" because of plasma leakage from damaged capillaries

Abrasion

Which term is used to describe deteriorated skin condition related to prolonged, unrelieved pressure on a body part? Select all that apply. One, some, or all responses may be correct. A) Skin tag B) Bedsore C) Skin wound D) Pressure sore E) Pressure ulcer F) Decubitus ulcer

B, D, E, F Rationale: Bedsore, pressure sore, pressure ulcer, and decubitus ulcer are the terms used to describe loss of or deteriorated skin condition because of pressure. A pressure injury is the most current terminology used. A skin tag is not a result of deteriorated skin condition. A skin wound is a general term used to describe any wound or abnormality of the skin, not only pressure-related injuries.

Which part of Debridement is the : Excision/ removal of eschar and necrotic tissue, via surgery in a sterile OR.

Surgical

A long-term care facility encourages nurses to assess patients at risk of developing pressure injuries based on six subscales: moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. Which tool is the long-term care facility using for risk assessment of pressure injury development? 1) Gaskin's Nursing Assessment of Skin Color (GNASC) tool 2) Braden scale 3) Bates-Jensen Wound Assessment Tool (BWAT) 4) Wound, Ostomy, and Continence Nurses Society (WOCN) scale

2) Braden Scale Rationale: The Braden scale is a widely used tool for risk assessment of pressure injury development and is composed of six subscales that are moisture, sensory perception, activity, mobility, nutrition, and friction or shear force. The GNASC tool is used to assess stage 1 pressure injuries in patients with dark skin tone. The BWAT is used to assess the wound status. WOCN does not provide any measurement or assessment tools.

Which finding contributes to delayed wound healing in a client with a stage 3 pressure injury? 1) Urine output 40 mL/hr 2) Urine output 25 mL/hr 3) Urine output 50 mL/hr 4) Urine output 75 mL/hr

2) Urine output 25 mL/hr

Arrange the phases of wound healing in the correct order. 1) Remodeling 2) Hemostasis 3) Inflammatory phase 4) Proliferation phase

2, 3, 4, 1 Rationale: The hemostasis phase is characterized by constriction of the injured blood vessels and aggregation of platelets to stop bleeding. The blood clots form a matrix for further tissue repair. The inüammatory phase involves secretion of histamine by damaged tissue and mast cells. The surrounding capillaries dilate and the serum rich in white blood cells reaches the wound. The release of growth factors attracts ûbroblasts that synthesize collagen. This phase establishes a clean wound bed. The main activities during the proliferative phase include proliferation of blood vessels and epithelialization with contraction of wound. In the remodeling phase, the collagen scar continues to reorganize and gain strength for several months.

Which of the following nursing activities apply to an MDRPI? (Select all that apply.) 1. Assess skin under devices every 2 hours. 2. Cushion at risk areas (e.g., ears, nose with foam or protective dressing). 3. Choose correct size of device. 4. Observe for erythema or irritation that conforms to pattern or shape of device. 5. Observe under casts and splints.

2, 3, 4, 5

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.) 1. Collection of wound drainage 2. Provision of support to abdominal tissues when coughing or walking 3. Reduction of abdominal swelling 4. Reduction of stress on the abdominal incision 5. Stimulation of peristalsis (return of bowel function) from direct pressure

2, 4

Place the steps when performing wound irrigation of a large open wound in the correct sequence. 1. Use slow, continuous pressure to irrigate wound. 2. Attach 19-gauge angiocatheter to syringe. 3. Fill syringe with irrigation fluid. 4. Place biohazard bag near bed. 5. Position angiocatheter over wound.

4, 3, 2, 5, 1

The nurse is completing an assessment of the patient's skin's integrity. Which assessment is the priority? a. Pressure points b. Breath sounds c. Bowel sounds d. Pulse points

ANS: A Observe pressure points such as bony prominences. The nurse continually assesses the skin for signs of ulcer development. Assessment for tissue pressure damage includes visual and tactile inspectionof the skin. Assessment of pulses, breath sounds, and bowel sounds is part of a head-to-toe assessment and could influence the function of the body and ultimately skin integrity; however, this assessment is not a specific part or priority of a skin assessment.

The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. Which risk factor will the nurse assess for that predisposes apatient to pressure ulcer development? a. Decreased level of consciousness b. Adequate dietary intake c. Shortness of breath d. Muscular pain

ANS: A Patients who are confused or disoriented or who have changing levels of consciousness are unable to protect themselves. The patient may feel the pressure but may not understand what to do to relieve the discomfort or to communicate that he or she is feeling discomfort. Impaired sensory perception, impaired mobility, shear, friction, and moisture are other predisposing factors. Shortness of breath, muscular pain, and an adequate dietary intake are not included among the predisposing factors.

A nurse is assigned most of the patients with pressure ulcers. The nurse leaves the pressure ulcer open to air and does not apply a dressing. To which patient did the nurse provide care? a. A patient with a clean Stage I b. A patient with a clean Stage II c. A patient with a clean Stage III d. A patient with a clean Stage IV

ANS: A Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14 days do not require a dressing. A composite film, hydrocolloid, or hydrogel can be utilized on a clean Stage II. A hydrocolloid, hydrogel covered with foam, calcium alginate, and gauze can be utilized with a clean Stage III. Hydrogel covered with foam, calcium alginate, and gauze can be utilized with a clean Stage IV. An unstageable wound covered with eschar should utilize a dressing of adherent film or gauze with an ordered solution of enzymes.

The nurse is caring for a patient with a healing Stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse? a. Complete the head-to-toe assessment, including current treatment, vital signs, and laboratory results. b. Notify the health care provider by utilizing Situation, Background, Assessment, and Recommendation (S c. Consult the wound care nurse about the change in status and the potential for infection. d. Check with the charge nurse about the change in status and the potential for infection.

ANS: A The patient is showing signs and symptoms associated with infection in the wound. The nurse should complete the assessment: gather all data such as current treatment modalities, medications, vital signs including temperature, and laboratory results such as the most recent complete blood count or white cell count. The nurse can then notify the primary care provider and receive treatment orders for the patient. It is important to notify the charge nurse and consult the wound nurse on the patient's status and on any new orders.

. Which nursing observation will indicate the patient is at risk for pressure ulcer formation? a. The patient has fecal incontinence. b. The patient ate two thirds of breakfast. c. The patient has a raised red rash on the right shin. d. The patient's capillary refill is less than 2 seconds.

ANS: A The presence and duration of moisture on the skin increase the risk of ulcer formation by making it susceptible to injury. Moisture can originate from wound drainage, excessive perspiration, and fecal or urinary incontinence. Bacteria and enzymes in the stool can enhance the opportunity for skin breakdown because the skin is moistened and softened, causing maceration. Eating a balanced diet is important for nutrition, but eating just two thirds of the meal does not indicate that the individual is at risk. A raised red rash on the leg again is a concern and can affect the integrity of the skin, but it is located on the shin, which is not a high-risk area for skin breakdown. Pressure can influence capillary refill, leading to skin breakdown, but this capillary response is within normal limits.

The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial actions should the nurse take to decreasethis risk? a. Use gentle cleansers, and thoroughly dry the skin. b. Use therapeutic bed and mattress. c. Use absorbent pads and garments. d. Use products that hold moisture to the skin.

ANS: A Use cleansers with nonionic surfactants that are gentle to the skin. After you clean the skin, make sure that it is completely dry. Absorbent pads and garments are controversial and should be considered only when other alternatives have been exhausted. Depending on the needs of the patient, a specialty bed may be needed, but again, this does not provide the initial defense for skin breakdown. Use only products that wick moisture away from the patient's skin.

The nurse is caring for a patient with a wound healing by full-thickness repair. Which phases will the nurse monitor for in this patient? (Select all that apply.) a. Hemostasis b. Maturation c. Inflammatory d. Proliferative e. Reproduction f. Reestablishment of epidermal layers

ANS: A, B, C, D The four phases involved in the healing process of a full-thickness wound are hemostasis, inflammatory, proliferative, and maturation. Three components are involved in the healing process of a partial-thickness wound: inflammatory response, epithelial proliferation (reproduction) and migration, and reestablishment of the epidermal layers.

The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.) a. "Can you easily change your position?" b. "Do you have sensitivity to heat or cold?" c. "How often do you need to use the toilet?" d. "What medications do you take?" e. "Is movement painful?" f. "Have you ever fallen?"

ANS: A, B, C, E Changing positions is important for decreasing the pressure associated with long periods of time in the same position. If the patient is able to feel heat or cold and is mobile, she can protect herself by withdrawing from the source. Knowing toileting habits and any potential for incontinence is important because urine and feces in contact with the skin for long periods can increase skin breakdown. Knowing whether the patient has problems with painful movement will alert the nurse to any potential for decreased movement and increased risk for skin breakdown. Medications and falling are safety risk questions.

The nurse is caring for a patient who will have both a large abdominal bandage and anabdominal binder. Which actions will the nurse take before applying the bandage and binder? (Select all that apply.) a. Cover exposed wounds. b. Mark the sites of all abrasions. c. Assess the condition of current dressings. d. Inspect the skin for abrasions and edema. e. Cleanse the area with hydrogen peroxide. f. Assess the skin at underlying areas for circulatory impairment.

ANS: A, C, D, F Before applying a bandage or a binder, the nurse has several responsibilities. The nurse would need to inspect the skin for abrasions, edema, and discoloration or exposed wound edges. The nurse also is responsible for covering exposed wounds or open abrasions with a dressing and assessing the condition of underlying dressings and changing if soiled, as well as assessing the skin of underlying areas that will be distal to the bandage. This checks for signs of circulatory impairment, so that a comparison can be made after bandages are applied. Marking the sites of all abrasions is not necessary. Although it is important for the skin to be clean, and even though it may need to be cleaned with a noncytotoxic cleanser, cleansing with hydrogen peroxide can interfere with wound healing.

The nurse is caring for a patient with a surgical incision that eviscerates. Which actions will the nurse take? (Select all that apply.) a. Place moist sterile gauze over the site. b. Gently place the organs back. c. Contact the surgical team. d. Offer a glass of water. e. Monitor for shock.

ANS: A, C, E The presence of an evisceration (protrusion of visceral organs through a wound opening) is a surgical emergency. Immediately place damp sterile gauze over the site, contact the surgical team, do not allow the patient anything by mouth (NPO), observe for signs and symptoms of shock, and prepare the patient for emergency surgery.

The nurse is collaborating with the dietitian about a patient with a Stage III pressure ulcer. Which nutrient will the nurse most likely increase after collaboration with the dietitian? a. Fat b. Protein c. Vitamin E d. Carbohydrate

ANS: B Protein needs are especially increased in supporting the activity of wound healing. The physiological processes of wound healing depend on the availability of protein, vitamins (especially A and C), and the trace minerals of zinc and copper. Wound healing does not require increased amounts of fats or carbohydrates. Vitamin E will not be increased for wound healing.

The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. Which health care team member will the nurse consult? a. Respiratory therapist b. Registered dietitian c. Case manager d. Chaplain

ANS: B Refer patients with pressure ulcers to the dietitian for early intervention for nutritional problems. Adequate calories, protein, vitamins, and minerals promote wound healing for the impaired skin integrity. The nurse is the coordinator of care, and collaborating with the dietitian would result in planning the best meals for the patient. The respiratory therapist can be consulted when a patient has issues with the respiratory system. Case management can be consulted when the patient has a discharge need. A chaplain can be consulted when the patient has a spiritual need.

The nurse is caring for a patient who has experienced a total abdominal hysterectomy. Which nursing observation of the incision will indicate the patient is experiencing a complication of wound healing? a. The site is hurting. b. The site is approximated. c. The site has started to itch. d. The site has a mass, bluish in color.

ANS: D A hematoma is a localized collection of blood underneath the tissues. It appears as swelling, change in color, sensation, or warmth or a mass that often takes on a bluish discoloration. A hematoma near a major artery or vein is dangerous because it can put pressure on the vein or artery and obstruct blood flow. Itching is not a complication. Incisions should be approximated with edges together; this is a sign of normal healing. After surgery, when nerves in the skin and tissues have been traumatized by the surgical procedure, it is expected that the patient will experience pain.

A nurse is assessing a patient's wound. Which nursing observation will indicate the wound healed by secondary intention? a. Minimal loss of tissue function b. Permanent dark redness at site c. Minimal scar tissue d. Scarring that may be severe

ANS: D A wound healing by secondary intention takes longer than one healing by primary intention. The wound is left open until it becomes filled with scar tissue. If the scarring is severe, permanent loss of function often occurs. Wounds that heal by primary intention heal quickly with minimal scarring. Scar tissue contains few pigmented cells and has a lighter color than normal skin.

Mrs. Stone's right foot decubitus is a stage III injury. List in order the stages of pressure injuries. A) Full-thickness skin loss B) Nonblanchable redness or intact skin C) Full-thickness tissue loss D) Partial-thickness skin loss or blister

Answer: B, D, A, C Rationale: The stages of pressures injuries as developed by European Pressure Ulcer Advisory Panel (EPUAP) and the National Pressure Ulcer Advisory Panel (NPUAP) are: stage I: nonblanchable redness or intact skin; stage II: partial-thickness skin loss or blister; stage III: full-thickness skin loss (fat visible); and stage IV: full-thickness tissue loss (muscle/bone visible).

When repositioning Mrs. Stone in bed or moving her from the bed to the wheelchair, James is careful to lift her right leg as opposed to dragging it across the bed to prevent ____________ and _____________ that may lead to injuries to epidermis and tissue necrosis.

Answer: Friction and shear Rationale: Shear causes tissue capillaries to stretch, thus causing tissue necrosis deep in the tissues. Friction causes redness or a "burn" to the top layer of skin.

Which criteria does the Braden Scale evaluate? A) Skin integrity at bony prominences, including any wounds B) Risk factors that place the patient at risk of pressure injury C) The amount of repositioning that the patient can tolerate D) The factors that place the patient at risk of poor wound healing

B) Risk factors that place the patient at risk of pressure injury Rationale: The Braden Scale measures factors in six subscales that can predict the risk of pressure injury development. It does not assess skin or wounds, repositioning, or wound healing.

Which sign is an early indication of pressure that resolves without tissue loss if the pressure is eliminated? A) Pallor or molting B) Dark red or purple discoloration C) Blanchable erythema D) Nonblanchable erythema

C) Blanchable erythema Rationale: Blanchable erythema is an early indication of pressure that resolves without tissue loss if the pressure is removed. Pallor or molting is a sign of persistent hypoxia. Dark red or purple discoloration may indicate potential damage to blood vessels and tissue. Nonblanchable erythema is a sign of a stage 1 pressure injury.

Which blood cells are known as garbage cells? A)Neutrophils B) Erythrocytes C) Macrophages D) T lymphocytes

C) Macrophages Rationale: Macrophages are called garbage cells because they ingest bacteria, dead cells, and debris from wounds. Neutrophils ingest bacteria and small debris. Erythrocytes are red blood cells. T lymphocytes are cells that play an important role in immunity.

Which role does vitamin A play in wound healing? A) Quickens fibroplasia B) Acts as an antioxidant C) Promotes wound closure D) Acts as immune function

C) Promotes Wound Closure Rationale: Vitamin A promotes epithelialization, wound closure, inflammatory response, angiogenesis, and collagen formation. Protein quickens fibroplasia and acts as immune function. Vitamin C acts as an antioxidant.

On assessing your patient's sacral pressure injury, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. Which stage would be applied to this patient's pressure injury? A) Stage 2 B) Stage 4 C) Unstageable D) Suspected deep tissue damage

C) unstageable Rationale: To determine the stage of a pressure injury, you examine the depth of the tissue involvement. Because the assessed pressure injury was covered with necrotic tissue, the depth could not be determined. Thus, this pressure injury cannot be staged. A stage 2 pressure injury would show partial-thickness skin loss and a stage 4 full thickness. A suspected deep tissue injury is an area of purplish, maroon, intact skin or a blood-filled blister.

Which part of Debridement is the : Excising very thin layers of necrotic skin until bleeding occurs.

Tangential

What is the removal of devitalized tissue from a wound called? 1. Debridement 2. Pressure distribution 3. Negative-pressure wound therapy 4. Sanitization

1

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? 1. A local skin infection requiring antibiotics 2. Sensitive skin that requires special bed linen 3. A Stage 3 pressure injury needing the appropriate dressing 4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

1

The nurse is teaching a client with a stage 1 pressure injury on the greater trochanter of the left hip. What should be included in teaching? 1) Change positions every hour 2) Change positions every 4 hours 3) Change positions every hour while awake 4) Change positions only when the patient requests

1) Change positions every hour

Medical adhesives, such as tape securing a wound dressing, cause MARSI. Which of the following interventions reduce the risk for MARSI? 1. Gently loosen the ends of the tape and gently pull the outer end parallel with the skin surface toward the wound. 2. Change dressing only when saturated. 3. Apply adhesive remover. 4. Use Montgomery ties to secure the dressing. 5. Immobilize area of wound.

1, 3, 4

Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) 1. Use a transfer device (e.g., transfer board). 2. Have head of bed elevated when transferring patient. 3. Have head of bed flat when repositioning patient. 4. Raise head of bed 60 degrees when patient is positioned supine. 5. Raise head of bed 30 degrees when patient is positioned supine.

1, 3, 5

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 small bowel sections are observed at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.) 1. Notify the health care provider. 2. Allow the area to be exposed to air until all drainage has stopped. 3. Place several cold packs over the area, protecting the skin around the wound. 4. Cover the area with sterile, saline-soaked towels immediately. 5. Cover the area with sterile gauze and apply an abdominal binder.

1, 4

Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) 1. Frequent position changes 2. Keeping the buttocks exposed to air at all times 3. Using a large absorbent diaper, changing when saturated 4. Using an incontinence cleaner 5. Applying a moisture barrier ointment

1, 4, 5

The nurse is caring for patients who need wound dressings. Match the type of dressing the nurse applies to its description. a. Absorbs drainage through the use of exudate absorbers in the dressing b. Very soothing to the patient and do not adhere to the wound bed c. Barrier to external fluids/bacteria but allows wound to "breathe" d. Manufactured from seaweed and comes in sheet and rope form e. Oldest and most common absorbent dressing 1. Gauze 2. Transparent 3. Hydrocolloid 4. Hydrogel 5. Calcium alginate

1. ANS:E 2. ANS:C 3. ANS:A 4. ANS:B 5. ANS:D

Match the pressure injury stages with the correct definition. ___ 1. Stage 1 ___ 2. Stage 2 ___ 3. Stage 3 ___ 4. Stage 4 ___ 5. Unstageable pressure injury a) Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist, and may also present as an intact or ruptured serum-filled blister. Adipose tissue (fat) and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD), including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive-related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). b) Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep-tissue pressure injury. c) Full-thickness skin and tissue lo

1b, 2a, 3d, 4c, 5e

What stage would you find Eschar (black/brown) dead necrotic tissue and slough (yellow and stringy) *These wounds need to be debrided before a stage is made*

Unstageable

Being bed ridden, incontinence, poor nutrition, diabetic neuropathy, liver cirrhosis (Low albumin) are all

Causes and risks of pressure injuries

What stage would you find the fatty tissue is injured below the skin (dark purple, and sometimes open wound)

Deep Tissue

Which part of Debridement is the Application of a topical enzyme ointment such as santyl directly on the wound to remove necrotic tissue.

Enzymatic

Which parameter would be measured to determine the protein deûciency in the patient with a wound? Select all that apply. One, some, or all responses may be correct. A) Serum albumin B) Serum transferrin C) Serum pre-albumin D) Hemoglobin levels E) Serum creatinine levels

A, B, C Rationale: Serum albumin is a biochemical indicator of protein deûciency and malnutrition. Serum transferrin levels also indicate protein status in the body. Serum prealbumin is the best indicator of nutritional status, not only reüecting what the patient has ingested but also what the body has metabolized. Hemoglobin levels indicate the oxygen-carrying capacity of the blood. Serum creatinine levels indicate kidney function.

Which ûnding is characteristic of a stage 3 pressure injury? Select all that apply. One, some, or all responses may be correct. A) It has full-thickness skin loss. B) The subcutaneous fat may be visible. C) The wound may present as an open, serum-filled blister. D) There may be a reddish-pink wound bed without slough. E) The bone, tendon, and muscle are not exposed.

A, B, E Rationale: A stage 3 pressure injury has a full-thickness skin loss involving the epidermis and dermis. Because of this, the subcutaneous fat may be visible. However, the wound is not deep enough to expose the bone, tendon, or the muscle. A wound with an open, serum-filled blister or one having a reddish-pink wound bed without slough is a stage 2 pressure injury.

The nurse assesses a patient's abdominal wound and ûnds that the wound is in the proliferative phase of healing. Which change in the wound might have led the nurse to this conclusion? Select all that apply. One, some, or all responses may be correct. A) The wound is filled with granulation tissue. B) There is localized redness, edema, warmth, and throbbing. C) The wound contracts to reduce the area that requires healing. D) There is vasodilation of the surrounding capillaries and exudation of serum. E) There is re-epithelialization of the wound surface.

A, C, E In the proliferative phase, fibroblasts and the cells that synthesize collagen provide the matrix for granulation. The wound contracts to reduce the area that requires healing during the proliferative phase. The epithelial cells migrate to the edges to resurface the wound, thus causing re-epithelialization. Vasodilatation of the surrounding capillaries and exudation of serum happen during the inflammatory phase. The inflammatory phase is also characterized by localized redness, edema, warmth, and throbbing.

The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. Which action will the nurse take next? a. Call the health care provider; a blockage is present in the tubing. b. Chart the results on the intake and output flow sheet. c. Do nothing, as long as the evacuator is compressed. d. Remove the drain; a drain is no longer needed.

ANS: A Because a drainage system needs to be patent, look for drainage flow through the tubing, as well as around the tubing. A sudden decrease in drainage through the tubing may indicate a blocked drain, and you will need to notify the health care provider. The health care provider, not the nurse, determines the need for drain removal and removes drains. Charting the results on the intake and output flow sheet does not take care of the problem. The evacuator may be compressed even when a blockage is present.

The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which action should the nurse take first? a. Provide analgesic medications as ordered. b. Avoid accidentally removing the drain. c. Don sterile gloves. d. Gather supplies.

ANS: A Because removal of dressings is painful, if often helps to give an analgesic at least 30 minutes before exposing a wound and changing the dressing. The next sequence of events includes gathering supplies for the dressing change, donning gloves, and avoiding the accidental removal of the drain during the procedure.

The nurse is caring for a patient in the burn unit. Which type of wound healing will the nurse consider when planning care for this patient? a. Partial-thickness repair b. Secondary intention c. Tertiary intention d. Primary intention

ANS: B A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater. A clean surgical incision is an example of a wound with little loss of tissue that heals by primary intention. The skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repair is done on partial- thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed until the risk of infection is resolved.

A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, what is the next best step for the nurse to take? a. Inspect the wound for foreign bodies. b. Inspect the wound for bleeding. c. Determine the size of the wound. d. Determine the need for a tetanus antitoxin injection.

ANS: B After determining that a patient's condition is stable, inspect the wound for bleeding. An abrasion will have limited bleeding, a laceration can bleed more profusely, and a puncture wound bleeds in relation to the size and depth of the wound. Address any bleeding issues. Inspect the wound for foreign bodies; traumatic wounds are dirty and may need to be addressed. Determine the size of the wound. A large open wound may expose bone or tissue and be protected, or the wound may need suturing. When the wound is caused by a dirty penetrating object, determine the need for a tetanus vaccination.

The nurse is caring for a group of patients. Which task can the nurse delegate to the nursing assistive personnel? a. Assessing a surgical patient for risk of pressure ulcers b. Applying an elastic bandage to a medical-surgical patient c. Treating a pressure ulcer on the buttocks of a medical patient d. Implementing negative-pressure wound therapy on a stable patient

ANS: B Applying an elastic bandage to a medical-surgical patient can be delegated to the nursing assistive personnel (NAP). Assessing pressure ulcer risk, treating a pressure ulcer, and implementing negative- pressure wound therapy cannot be delegated to an NAP.

The nurse is caring for a patient with a healing Stage III pressure ulcer. The wound is clean and granulating. Which health care provider's order will the nurse question? a. Use a low-air-loss therapy unit. b. Irrigate with Dakin's solution. c. Apply a hydrogel dressing. d. Consult a dietitian.

ANS: B Clean pressure ulcers with noncytotoxic cleansers such as normal saline, which will not kill fibroblasts and healing tissue. Cytotoxic cleansers such as Dakin's solution, acetic acid, povidone- iodine, and hydrogen peroxide can hinder the healing process and should not be utilized on clean granulating wounds. Consulting a dietitian for the nutritional needs of the patient, utilizing a low-air- loss therapy unit to decrease pressure, and applying hydrogel dressings to provide a moist environment for healing are all orders that would be appropriate.

The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. Which action should the nurse take? a. Turn on the television. b. Explain the procedure. c. Tell the patient "Close your eyes." d. Ask the family to leave the room.

ANS: B Explaining the procedure educates the patient regarding the dressing change and involves him in the care, thereby allowing the patient some control in decreasing anxiety. Telling the patient to close the eyes and turning on the television are distractions that do not usually decrease a patient's anxiety. If the family is a support system, asking support systems to leave the room can actually increase a patient's anxiety.

The nurse is caring for a patient who has a Stage IV pressure ulcer with grafted surgical sites. Which specialty bed will the nurse use for this patient? a. Low-air-loss b. Air-fluidized c. Lateral rotation d. Standard mattress

ANS: B For a patient with newly flapped or grafted surgical sites, the air-fluidized bed will be the best choice; this uses air and fluid support to provide pressure redistribution via a fluid-like medium created by forcing air through beads as characterized by immersion and envelopment. A low-air-loss bed is utilized for prevention or treatment of skin breakdown by preventing buildup of moisture and skin breakdown through the use of airflow. A standard mattress is utilized for an individual whodoes not have actual or potential altered or impaired skin integrity. Lateral rotation is used for treatment and prevention of pulmonary, venous stasis and urinary complications associated with mobility.

A nurse is caring for a patient with a wound. Which assessment data will be most important for the nurse to gather with regard to wound healing? a. Muscular strength assessment b. Pulse oximetry assessment c. Sensation assessment d. Sleep assessment

ANS: B Oxygen fuels the cellular functions essential to the healing process; the ability to perfuse tissues with adequate amounts of oxygenated blood is critical in wound healing. Pulse oximetry measures the oxygen saturation of blood. Assessment of muscular strength and sensation, although useful for fitness and mobility testing, does not provide any data with regard to wound healing. Sleep, although important for rest and for integration of learning and restoration of cognitive function, does not provide any data with regard to wound healing.

The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. Which priority element will the nurseconsider when planning care to decrease the development of a decubitus ulcer? a. Resistance b. Pressure c. Weight d. Stress

ANS: B Pressure is the main element that causes pressure ulcers. Three pressure-related factors contribute to pressure ulcer development: pressure intensity, pressure duration, and tissue tolerance. When the intensity of the pressure exerted on the capillary exceeds 15 to 32 mm Hg, this occludes the vessel, causing ischemic injury to the tissues it normally feeds. High pressure over a short time and low pressure over a long time cause skin breakdown. Resistance, stress, and weight are not the priority causes of pressure ulcers.

The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient? a. Partial-thickness wound repair b. Full-thickness wound repair c. Primary intention d. Tertiary intention

ANS: B Stage IV pressure ulcers are full-thickness wounds that extend into the dermis and heal by scar formation because the deeper structures do not regenerate, hence the need for full-thickness repair. The full-thickness repair has four phases: hemostasis, inflammatory, proliferative, and maturation. A wound heals by primary intention when wounds such as surgical wounds have little tissue loss; the skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed until risk of infection is resolved

The nurse collects the following assessment data: right heel with reddened area that does not blanch. Which nursing diagnosis will the nurse assign to this patient? A) Imbalanced nutrition: less than body requirements B) Ineffective peripheral tissue perfusion C) Risk for infection D) Acute pain

ANS: B The area on the heel has experienced a decreased supply of blood and oxygen (tissue perfusion), which has resulted in tissue damage. The most appropriate nursing diagnosis with this information is Ineffective peripheral tissue perfusion. Risk for infection, Acute pain, and Imbalanced nutrition do not support the data in the question.

The nurse is performing a moist-to-dry dressing. The nurse has prepared the supplies, solution, and removed the old dressing. In which order will the nurse implement the steps, starting with the first one? 1. Apply sterile gloves. 2. Cover and secure topper dressing. 3. Assess wound and surrounding skin. 4. Moisten gauze with prescribed solution. 5. Gently wring out excess solution and unfold. 6. Loosely pack until all wound surfaces are in contact with gauze. a. 4, 3, 1, 5, 6, 2 b. 1, 3, 4, 5, 6, 2 c. 4, 1, 3, 5, 6, 2 d. 1, 4, 3, 5, 6, 2

ANS: B The steps for a moist-to-dry dressing are as follows: (1) Apply sterile gloves; (2) assess appearance of surrounding skin; (3) moisten gauze with prescribed solution. (4) Gently wring out excess solution and unfold; apply gauze as single layer directly onto wound surface. (5) If wound is deep, gently pack dressing into wound base by hand until all wound surfaces are in contact with gauze; (6) cover with sterile dry gauze and secure topper dressing.

The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer? a. Stage I b. Stage II c. Stage III d. Stage IV

ANS: B This would be a Stage II pressure ulcer because it presents as partial-thickness skin loss involving epidermis and dermis. The ulcer presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin with nonblanchable redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be visible, but bone, tendon, and muscles are not exposed. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle.

The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair? a. At least 3 hours b. Less than 2 hours c. No longer than 30 minutes d. As long as the patient remains comfortable

ANS: B When patients are able to sit up in a chair, make sure to limit the amount of time to 2 hours or less. The chair sitting time should be individualized. In the sitting position, pressure on the ischial tuberosities is greater than in a supine position. Utilize foam, gel, or an air cushion to distribute weight. Sitting for longer than 2 hours can increase the chance of ischemia.

The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. Which is the best method for repositioning the patient? a. Place the patient in a 30-degree supine position. b. Utilize a transfer device to lift the patient. c. Elevate the head of the bed 45 degrees. d. Slide the patient into the new position.

ANS: B When repositioning the patient, obtain assistance and utilize a transfer device to lift rather than drag the patient. Sliding the patient into the new position will increase friction. The patient should be placed in a 30-degree lateral position, not a supine position. The head of the bed should be elevated less than 30 degrees to prevent pressure ulcer development from shearing forces.

The nurse is caring for a patient with potential skin breakdown. Which components will the nurse include in the skin assessment? (Select all that apply.) a. Vision b. Hyperemia c. Induration d. Blanching e. Temperature of skin

ANS: B, C, D, E Assessment of the skin includes both visual and tactile inspection. Assess for hyperemia and palpate for blanching or nonblaching. Early signs of skin damage include induration, bogginess (less-than- normal stiffness), and increased warmth at the injury site compared to nearby areas. Changes in temperature can indicate changes in blood flow to that area of the skin. Vision is not included in the skin assessment.

The nurse is updating the plan of care for a patient with impaired skin integrity. Which findings indicate achievement of goals and outcomes? (Select all that apply.) a. The patient's expectations are not being met. b. Skin is intact with no redness or swelling. c. Nonblanchable erythema is absent. d. No injuries to the skin and tissues are evident. e. Granulation tissue is present.

ANS: B, C, D, E Optimal outcomes are to prevent injury to skin and tissues, reduce injury to skin, reduce injury to underlying tissues, and restore skin integrity. Skin intact, nonblanchable erythema absent, no injuries, and presence of granulation tissue are all findings indicating achievement of goals and outcomes. The patient's expectations not being met indicates no progression toward goals/outcomes.

The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis does the nurse add to the care plan? A. Readiness for enhanced nutrition B. Impaired physical mobility C. Impaired skin integrity D. Chronic pain

ANS: C After the assessment is completed and the information that the patient has a Stage IV pressure ulcer is gathered, a diagnosis of Impaired skin integrity is selected. Readiness forenhanced nutrition would be selected for an individual with an adequate diet that could be improved. Impaired physical mobility and Chronic pain do not support the current data in the question.

A patient's abdominal wound starts to separate, revealing the inner layers of muscle. This is called wound

Dehiscence

The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. Which statement by the patient indicates issues with self-concept? a. "I am so weak and tired. I want to feel better." b. "I am thinking I will be ready to go home early next week." c. "I am ready for my bath and linen change right now since this is awful." d. "I am hoping there will be something good for dinner tonight."

ANS: C Body image changes can influence self-concept. The wound is odorous, and a drain is in place. The patient who is asking for a bath and change in linens and states that this is awful gives you a clue that he or she may be concerned about the smell in the room. Factors that affect the patient's perception of the wound include the presence of scars, drains, odor from drainage, and temporary or permanent prosthetic devices. The patient's stating that he or she wants to feel better, talking about going home, and caring about what is for dinner could be interpreted as positive statements that indicate progress along the health journey.

The nurse is cleansing a wound site. As the nurse administers the procedure, which intervention should be included? a. Allow the solution to flow from the most contaminated to the least contaminated. b. Scrub vigorously when applying noncytotoxic solution to the skin. c. Cleanse in a direction from the least contaminated area. d. Utilize clean gauze and clean gloves to cleanse a site.

ANS: C Cleanse in a direction from the least contaminated area, such as from the wound or incision, to the surrounding skin. While cleansing surgical or traumatic wounds by applying noncytotoxic solution with sterile gauze or by irrigations is correct, vigorous scrubbing is inappropriate and can cause damage to the skin. Use gentle friction when applying solutions to the skin, and allow irrigation to flow from the least to the most contaminated area.

The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate? a. Monitor the wound. b. Document the wound. c. Debride the wound. d. Manage drainage from wound.

ANS: C Debridement is the removal of nonviable necrotic (black) tissue. Removal of necrotic tissue is necessary to rid the ulcer of a source of infection, to enable visualization of the wound bed, and to provide a clean base for healing. A wound will not move through the phases of healing if the wound is infected. Documentation occurs after completion of skill. When treating a pressure ulcer, it is important to monitor and reassess the wound at least every 8 hours. Management of drainage will help keep the wound clean, but that is not the next step.

The nurse is caring for a patient who is experiencing a full-thickness repair. Which type of tissue will the nurse expect to observe when the wound is healing? a. Eschar b. Slough c. Granulation d. Purulent drainage

ANS: C Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. Soft yellow or white tissue is characteristic of slough—a substance that needs to be removed for the wound to heal. Black or brown necrotic tissue is called eschar, which also needs to be removed for a wound to heal. Purulent drainage is indicative of an infection and will need to be resolved for the wound to heal.

A patient has developed a pressure ulcer. Which laboratory data will be important for the nurse to check? a. Vitamin E b. Potassium c. Albumin d. Sodium

ANS: C Normal wound healing requires proper nutrition. Serum proteins are biochemical indicators of malnutrition, and serum albumin is probably the most frequently measured of these parameters. The best measurement of nutritional status is prealbumin because it reflects not only what the patient has ingested but also what the body has absorbed, digested, and metabolized. Zinc and copper are the minerals important for wound healing, not potassium and sodium. Vitamins A and C are important for wound healing, not vitamin E.

A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence? a. Protrusion of visceral organs through a wound opening b. Chronic drainage of fluid through the incision site c. Report by patient that something has given way d. Drainage that is odorous and purulent

ANS: C Patients often report feeling as though something has given way with dehiscence. Dehiscence occurs when an incision fails to heal properly and the layers of skin and tissue separate. It involves abdominal surgical wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. Evisceration is seen when vital organs protrude through a wound opening. When there is an increase in serosanguineous drainage from a wound in the first few days after surgery, be alert for the potential for dehiscence. Infection is characterized by drainage that is odorous and purulent.

The nurse is caring for a patient who is immobile. The nurse wants to decrease the formation of pressure ulcers. Which action will the nurse take first? a. Offer favorite fluids. b. Turn the patient every 2 hours. c. Determine the patient's risk factors. d. Encourage increased quantities of carbohydrates and fats.

ANS: C The first step in prevention is to assess the patient's risk factors for pressure ulcer development. When a patient is immobile, the major risk to the skin is the formation of pressure ulcers. Nursing interventions focus on prevention. Offering favorite fluids, turning, and increasing carbohydrates and fats are not the first steps. Determining risk factors is first so interventions can be implemented to reduce or eliminate those risk factors.

The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan? a. Partial-thickness repair b. Secondary intention c. Tertiary intention d. Primary intention

ANS: D A clean surgical incision is an example of a wound with little loss of tissue that heals with primary intention. The skin edges are approximated or closed, and the risk for infection is low. Partial- thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed until the risk of infection is resolved. A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater.

What stage will you find bone is visible and undermining tunneling Full-thickness skin and tissue loss Full - thicken skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Depths varies by anatomical location. If slough or eschar obscures the extent of tissue loss is an Unstageable Pressure Injury.

Stage 4

The nurse is caring for a patient with a Stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. The nurse is completingthe plan of care and is writing goals for the patient. Which is the best goal for this patient? a. The patient will state what to look for with regard to an infection. b. The patient's family will demonstrate specific care of the wound site. c. The patient's family members will wash their hands when visiting the patient. d. The patient will remain free of odorous or purulent drainage from the wound.

ANS: D Because the patient has an open wound and the skin is no longer intact to protect the tissue, the patient is at increased risk for infection. The nurse will be assessing the patient for signs and symptoms of infection, including an increase in temperature, an increase in white count, and odorous and purulent drainage from the wound. The patient is unconscious and is unable to communicate the signs and symptoms of infection. It is important for the patient's family to be able to demonstrate how to care for the wound and wash their hands, but these statements are not goals or outcomes for this nursing diagnosis.

The nurse is caring for a postoperative medial meniscus repair of the right knee. Which action should the nurse take to assist with pain management? a. Monitor vital signs every 15 minutes. b. Check pulses in the right foot. c. Keep the leg dependent. d. Apply ice.

ANS: D Ice assists in preventing edema formation, controlling bleeding, and anesthetizing the body part. Elevation (not dependent) assists in preventing edema, which in turn can cause pain. Monitoring vital signs every 15 minutes is routine postoperative care and includes a pain assessment but in itself is not an intervention that decreases pain. Checking the pulses is important to monitor the circulation of the extremity but in itself is not a pain management intervention.

The nurse is caring for a surgical patient. Which intervention is most important for the nurse to complete to decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility? a. Explain the risks of immobility to the patient. b. Turn the patient every 3 hours while in bed. c. Encourage the patient to sit up in the chair. d. Provide analgesic medication as ordered.

ANS: D Maintaining adequate pain control (providing analgesic medications) and patient comfort increases the patient's willingness and ability to increase mobility, which in turn reduces pressure ulcer risks. Although sitting in the chair is beneficial, it does not increase mobility or provide pain control. Explaining the risk of immobility is important for the patient because it may impact the patient's willingness but not his or her ability. Turning the patient is important for decreasing pressure ulcers but needs to be done every 2 hours and, again, does not influence the patient's ability to increase mobility.

The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission.The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed? a. 12 b. 13 c. 20 d. 23

ANS: D The best sign is a perfect score of 23. The Braden Scale is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The total score ranges from 6 to 23, and a lower total score indicates a higher risk for pressure ulcer development. The cutoff score for onset of pressure ulcer risk with the Braden Scale in the general adult population is 18.

The nurse is caring for a patient after an open abdominal aortic aneurysm repair. The nurse requests an abdominal binder and carefully applies the binder. Which is the best explanation forthe nurse to use when teaching the patient the reason for the binder? a. It reduces edema at the surgical site. b. It secures the dressing in place. c. It immobilizes the abdomen. d. It supports the abdomen.

ANS: D The patient has a large abdominal incision. This incision will need support, and an abdominal binder will support this wound, especially during movement, as well as during deep breathing and coughing. A binder can be used to immobilize a body part (e.g., an elastic bandage applied around a sprained ankle). A binder can be used to prevent edema, for example, in an extremity but in this case is not used to reduce edema at a surgical site. A binder can be used to secure dressings such as elastic webbing applied around a leg after vein stripping.

The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which item should the nurse usefirst to assist in staging an ulcer on this patient? a. Disposable measuring tape b. Cotton-tipped applicator c. Sterile gloves d. Halogen light

ANS: D When assessing a patient with darkly pigmented skin, proper lighting is essential to accurately complete the first step in assessment—inspection—and the entire assessment process. Natural light or a halogen light is recommended. Fluorescent light sources can produce blue tones on darkly pigmented skin and can interfere with an accurate assessment. Other items that could possibly be used during the assessment include gloves for infection control, a disposable measuring device to measure the size of the wound, and a cotton-tipped applicator to measure the depth of the wound, but these items are not the first items used.

When a patient tries to lift a piano shortly after surgery, his abdominal incision separates, and his intestines protrude through it. This is called a(n)

Evisceration

Which part of Debridement is the : Necrotic tissue is removed down to the superficial fascia, usually reserved for very deep and severe burns.

Fascial

What stage would you find damage extends all the way down into muscle, bone, or tendon.

Stage 4 = 4 layers of damage

What sometimes may bleed more profusely (especially if the patient is taking anticoagulants or other blood thinners), depending on the depth and location of the wound. For example, minor scalp lacerations tend to bleed profusely because of the rich blood supply to the scalp.

Laceration

What are the most common areas for pressure sore injuries?

Lower back and buttock (sacrum and Coccyx) Heels and ankles Hip bones Should area and elbows

Which part of Debridement is Done during hydrotherapy, with washcloths or sponges to remove eschar. May include wet to dry dressing changes. Painful and may cause bleeding.

Mechanical

What stage will you find a wound involving loss of tissue such as a burn, pressure injury or, severe laceration heals by secondary intention Partial- thickness loss of skin with exposed dermis The wound bed is viable, pink or red, and moist and may also present as an intact or ruptured serum -filled blister Adipose (fat) is not visible and deeper tissue are are not visible.

Stage 2

What stage would you have an open wound: Affecting both the epidermis and dermis. Wound bed is red/pinky and shiny or dry.

Stage 2 = 2 Layers

What stage will you find Full - thickness skin loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present Slough and or eschar may be visible. Undermining and tunneling may occur.

Stage 3

The drainage from a patient's wound is pink. This drainage is described as

Serosanguineous

What stage will you find Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin?

Stage 1

What stage would you find red skin that is NON blanchable and NOT broken. Damage only to the epidermis.

Stage 1 = 1 Layer

What stage would you find Full thickness skin loss into the subcutaneous fat; wound may tunnel under the edges of the wounds bed. Damage to the epidermis, dermis, and subcutaneous layers

Stage 3 = 3 Layers

What stage will you find a Pressure Injury Obscured full-thickness and tissue loss Full _thickness skin and tissue loss in which the extent of tissue damage within ulcer cannot be confirmed because it is obscured by slough or eschar (fluctuate) do not soften or removed dry skin, adherent, intact without erythe

Unstable