intro module 2 exam--skin-wound care part one Downs/Julian

7.Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence? Keeping the buttocks exposed to air at all times Using a large absorbent diaper, changing when saturated Using an incontinence cleaner, followed by application of a moisture-barrier ointment Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel

Using an incontinence cleaner, followed by application of a moisture-barrier ointment Skin that is in contact with stool and urine can become moist and soft, allowing it to become damaged. The stool contains bacteria and in some cases enzymes that can harm the skin if in contact for a prolonged period of time. The use of an incontinence cleaner provides a gentle removal of stool and urine, and the use of the moisture-barrier ointment provides a protective layer between the skin and the next incontinence episode.

types of dressings

gauze sponges telfa gauze transparent film hydrocolloid hydrogel

pressure ulcers

is a localized injury to skin & other underlying tissue, usually over a bony prominence.

stage 1

nonblanchable redness of intact skin

friction

occurs when skin is dragged across a coarse surface (bed linens) usually affecting the top layer or epidermis of skin

stage 2

partial thickness skin loss or blister

heat applications

vasodilation decrease viscosity of blood reduce muscle tension increased capillary permeability

The nurse has collected the following assessment data: right heel with reddened area that does not blanch. What nursing diagnosis would the nurse assign? a. Ineffective tissue perfusion b. Risk for infection c. Imbalanced nutrition: less than body requirements d. Acute pain

ANS: A 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 tissue perfusion. Risk for infection, Acute pain, and Imbalanced nutrition may be part of this patient's nursing diagnosis, but the data provided do not support this nursing diagnosis.

Which of the following are primary risk factors for pressure ulcers? Select all that apply. 1. Low-protein diet 2. Insomnia 3. Lengthy surgical procedures 4. Fever 5. Sleeping on a waterbed

1, 3, & 4; Risk factors for pressure ulcers include a low-protein diet, lengthy surgical procedures, and fever. Protein is needed for adequate skin health and healing. During surgery, the client is on a hard surface and may not be well protected from pressure on bony prominences. Fever increases skin moisture, which can lead to skin breakdown, plus the stress on the body from the cause of the fever could impair circulation and skin integrity. Insomnia (option 2) would generally involve restless sleeping, which transfers pressure to different parts of the body and would reduce chances of skin breakdown. A waterbed (option 5) distributes pressure more evenly than a regular mattress and, thus, actually reduces the chance of skin breakdown.

Your client has a pressure ulcer over the sacral area that is believed to be due to shearing force. The client's family asks you to explain shearing force. You would be most accurate if you tell the family that shearing force involves: 1. A tearing of the muscle tissue due to a considerable downward force. 2. A sudden break in skin integrity due to being pulled against the bed linens. 3. A superficial skin fold getting pinched, and tissues irritated by the pressure. 4. Superficial skin surface relatively unmoving in relation to the bed surface.

3. A superficial skin fold getting pinched, and tissues irritated by the pressure; Shearing force is a combination of friction and pressure with skin surface unmoving in relation to the bed surface, while deeper tissue attached to the skeleton tends to move with the body.

The client at greatest risk for postoperative wound infection is: 1. A 3-month-old infant postoperative from pyloric stenosis repair 2. A 78-year-old postoperative from inguinal hernia repair 3. An 18-year-old drug user postoperative from removal of a bullet in the leg 4. A 32-year-old diabetic postoperative from an appendectomy

3. An 18-year-old drug user postoperative from removal of a bullet in the leg; All are at risk for infection. Answer 3 is at greatest risk, because the bullet is unclean, and a drug user is at great risk for immune deficiency.

Which statement, if made by the client or family member, would indicate the need for further teaching? 1. If a skin area gets red but then the red goes away after turning, I should report it to the nurse. 2. Putting foam pads under the heels or other bony areas can help decrease pressure. 3. If a person cannot turn himself in bed, someone should help them change position q4h. 4. The skin should be washed with only warm water (not hot) and lotion put on while it is still a little wet.

3. If a person cannot turn himself in bed, someone should help them change position q4h; Immobile and dependent persons should be repositioned at least every 2 hours, not every 4, so this client or family member requires additional teaching. Warm water and moisturizing damp skin are correct techniques for skin care. Red areas that do not return to normal skin color should be reported. It would also be correct to use a foam pad to help relieve pressure.

You find that your newly assigned client has very shiny skin on their legs, has little or no leg hair, and the client reports that their skin damages easily. You would suspect that these signs and symptoms are related to: 1. Overuse of caustic products to strip the leg hair. 2. Chronic neurological pathology. 3. Impaired peripheral arterial circulation. 4. Inherited reduction in sweat glands and hair follicles.

3. Impaired peripheral arterial circulation; Shiny skin on the legs, reduction in or absence of leg hair, and skin that damages easily is often related to impaired peripheral arterial circulation.

A client is admitted to the Emergency Department after a motorcycle accident that resulted in the client's skidding across a cement parking lot. Since the client was wearing shorts, there are large areas on the legs where the skin is ripped off. This wound is best described as: 1. Abrasion 2. Unapproximated 3. Laceration 4. Eschar

3. Laceration; Laceration best describes the wound, because skin is ripped off. An abrasion is a scrape. Unapproximated is a general term for a wound that is not closed. Eschar is a scab-like covering over a wound.

Thirty minutes after application is initiated, the client requests that the nurse leave the heating pad in place. The nurse explains to the client that: 1. Heat application for longer than thirty minutes can actually cause the opposite effect (constriction) of the one desired (dilation) 2. It will be acceptable to leave the pad in place for another thirty minutes

1. Heat application for longer than thirty minutes can actually cause the opposite effect (constriction) of the one desired (dilation); The heating pads need to be removed. After 30 minutes of heat application, the blood vessels in the area will begin to exhibit the rebound effect resulting in vasoconstriction. Lowering the temperature, but still delivering heat -dry or moist- will not prevent the rebound effect. The visual appearance of the site on inspection (option 3) does not indicate if rebound is occurring.

The nurse cares for a client with a wound in the late regeneration phase of tissue repair. The wound may be protected by applying a: 1. Transparent film 2. Hydrogel dressing 3. Collogenase dressing 4. Wet to dry dressing

1. Transparent film; Wounds in the regeneration phase of healing need to be protected as new tissue grows. Answers 2, 3, and 4 are dressings used to remove nonviable tissue.

When receiving a report at the beginning of your shift, you learn that your assigned client has a surgical incision that is healing by primary intention. You know that your client's incision is: 1. Well approximated, with minimal or no drainage. 2. Going to take a little longer than usual to heal. 3. Going to have more scarring than most incisions. 4. Draining some serosanguineous drainage.

1. Well approximated, with minimal or no drainage; Primary intention means that the wound edges are well approximated, with minimal or no tissue loss as well as formation of minimal granulation tissue and scarring.

complications of wound healing

1. hemorrhage-bleeding from wound 2. infection a. note: surgical wound infection usually does not develop until the 4th or 5th day post op 3.dehiscence-layers of skin and tissue separate 4.evisceration-protrusion of visceral organs through the wound opening

partial thickness wounds phases of healing

1. inflammatory response 2.epithelial proliferation & migration 3. reestablishment of epidermal layers

full thickness wounds phases of healing

1.hemostasis 2.inflammatory phase 3.proliferative phase 4.remodeling

care of wounds

1.hemostasis a.direct pressure b.elevate affected part c.allow puncture wound to bleed d.don't remove penetrating objects 2.clean wound a.gently clean to remove contaminants b.normal saline. preferred 3.protect the wound a.protect from injury b.prevent microorganisms from entering

wound healing

1.primary intention a.wound is closed b.wound that is sutured or stapled c.heals by epithelialization 2.secondary intention a.wound edges not approximated b.pressure ulcers & surgical wounds with tissue loss. c.heals by granulation tissue formation, wound contraction & epithelialization 3.tertiary intention a.closure of wound is delayed until risk of infection is resolved.

Which condition places the client at the greatest risk for developing an infection? 1. Implantation of a prosthetic device 2. Burns over more than 20% of the body 3. Presence of an indwelling urinary catheter 4. More than 2 puncture sites from laparoscopic surgery

2. Burns over more than 20% of the body, Burns more than 20% of the client's total body surface are generally considered major burn injuries. When the skin is damaged by a burn the underlying tissue is left unprotected and the individual is at risk for infection. The greater the extent and deeper the depth of the burn, the higher the risk is for infection. Prosthetic devices are surgically implanted under sterile conditions to minimize risk of infection. Indwelling urinary catheters are implanted under sterile conditions and are considered closed systems where sterile technique is maintained. Laparoscopic surgery is also performed using sterile technique.

A home health nurse visits a client who twisted an ankle in the morning. The client has an ice bag on the ankle. Which one of the client's chronic conditions contraindicates the use of ice? 1. Gastritis 2. Diabetes 3. Glaucoma 4. Osteoporosis

2. Diabetes; Diabetes contradicts the use for ice. Clients with neurological or circulatory impairment are at risk for injury with ice use.

An appropriate nursing diagnosis for a client with large areas of skin excoriation resulting from scratching an allergic rash is: 1. Risk for Impaired Skin Integrity 2. Impaired Skin Integrity 3. Impaired Tissue Integrity 4. Risk for Infection

2. Impaired Skin Integrity; The client has an actual impairment of the skin due to the rash and the scratching so is no longer "at risk". Because the damage is at the skin level, it is not impaired tissue integrity (option 3) since that would involve deeper tissues. Surface excoriation is also not prone to becoming infected.

Which of the following actions would place a client at the greatest risk for a shearing force injury to the skin? 1. Walking without shoes 2. Sitting in Fowler's position 3. Lying supine in bed 4. Using a heating pad

2. Sitting in Fowler's position; None of the other movements or situations creates the combination of friction and pressure with downward movement seen in bedridden clients positioned in Fowler's position.

You are caring for an assigned client and notice a superficial ulcer on the client's buttock that appears as a shallow crater involving the epidermis and the dermis. Which of the following stages would you say best describes this break in skin integrity? 1. Stage I 2. Stage II 3. Stage III 4. Stage IV

2. Stage II; Stage I pressure ulcer involves a nonblanchable erythema of intact skin, while a stage II involves a partial-thickness skin loss involving epidermis, dermis, or both, with the ulcer being superficial and presenting as an abrasion, blister, or shallow crater.

Name one intervention and the rationalization to use that intervention to reduce the likelihood of a shear injury to a patient.

A transfer device can pick up a patient and prevent his or her skin from sticking to the bed sheet as he is repositioned. A second intervention would be to position the patient with the head of the bed to be elevated at 30 degrees, which prevents him or her from sliding. A third intervention would be to educate the patient and his or her caregiver on the importance of not sliding on the sheets when repositioning.

Black wounds are treated with debridement. Which type of debridement is most selective and least damaging? 1. Debridement with scissors 2. Debridement with wet to dry dressings 3. Mechanical debridement 4. Chemical debridement

4. Chemical debridement; Chemical debridement is either done with enzyme agents or autolytic agents. Answer 1 is a type of sharp debridement. Answers 2 and 3 are mechanical and less precise than chemical.

You are at the scene of an accident and find the victim has a bleeding lower leg wound. After flushing the wound with water and covering it with a clean dressing, you find the dressing has been saturated with blood. Which of the following would be the best action to take in this case? 1. Lower the extremity while applying pressure to the wound. 2. Take off the first dressing and apply another clean or sterile dressing. 3. Encircle the client's ankle with your hands and apply pressure. 4. Reinforce the first layer of dressing with a second layer of dressing.

4. Reinforce the first layer of dressing with a second layer of dressing; To control severe bleeding, apply direct pressure to the wound and elevate the extremity. If the dressing becomes saturated, apply a second layer. Removing the first dressing may disturb blood clots and increase the bleeding.

The nurse is caring for a patient with a large abrasion from a motorcycle accident. The nurse recalls that if the wound is kept moist, it can resurface in _____ day(s). a. 4 b. 2 c. 1 d. 7

ANS: A A partial-thickness wound repair has three compartments: the inflammatory response, epithelial proliferation and migration, and re-establishment of the epidermal layers. Epithelial proliferation and migration start at all edges of the wound, allowing for quick resurfacing. Epithelial cells begin to migrate across the wound bed soon after the wound occurs. A wound left open to air resurfaces within 6 to 7 days, whereas a wound that is kept moist can resurface in 4 days. One or 2 days is too soon for this process to occur, moist or dry.

A patient has developed a decubitus ulcer. What laboratory data would be important to gather? a. Serum albumin b. Creatine kinase c. Vitamin E d. Potassium

ANS: A 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. Measurement of creatine kinase helps in the diagnosis of myocardial infarcts and has no known role in wound healing. Potassium is a major electrolyte that helps to regulate metabolic activities, cardiac muscle contraction, skeletal and smooth muscle contraction, and transmission and conduction of nerve impulses. Vitamin E is a fat-soluble vitamin that prevents the oxidation of unsaturated fatty acids. It is believed to reduce the risk of coronary artery disease and cancer. Vitamin E has no known role in wound healing.

The nurse is completing an assessment of the skin's integrity, which includes a. Pressure points. b. All pulses. c. Breath sounds. d. Bowel sounds.

ANS: A The nurse continually assesses the skin for signs of ulcer development. Assessment of tissue pressure damage includes visual and tactile inspection of the skin. Observe pressure points such as bony prominences and areas next to treatments such as a binasal cannula and the nares. 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 of a skin assessment.

1.When repositioning an immobile patient, the nurse notices redness over a bony prominence. 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 III pressure ulcer needing the appropriate dressing 4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.

Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode. When repositioning an immobile patient, it is important to assess all bony prominences for the presence of redness, which can be the first sign of impaired skin integrity. Pressing over the area compresses the blood vessels in the area; and, if the integrity of the vessels is good, the area turns lighter in color and then returns to the red color. However, if the area does not blanch when pressure is applied, tissue damage is likely.

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

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

The largest organ of the body

The skin

10.When is an application of a warm compress indicated? (Select all that apply.) To relieve edema For a patient who is shivering To improve blood flow to an injured part To protect bony prominences from pressure ulcers

To relieve edema To improve blood flow to an injured part Warm compresses can improve circulation by dilating blood vessels, and they reduce edema. The moisture of the compress conducts heat.

13.On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient's pressure ulcer? Stage II Stage IV Unstageable Suspected deep tissue damage

Unstageable To determine the stage of a pressure ulcer you examine the depth of the tissue involvement. Since the pressure ulcer assessed was covered with necrotic tissue, the depth could not be determined. Thus this pressure ulcer cannot be staged.

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

Stage I A stage I pressure ulcer does not have a break in the skin but has a redness that does not blanch. Depending on the skin color, there may be a discoloration; the area may feel warm because of the vasodilation or cool if blood is constricted in the area; and the tissue may feel firm if there is edema in the area or soft if the blood flow is compromised. The patient may report pain in the area.

Name three important dimensions to consistently measure to determine wound healing.

Width, length and depth. Consistent measurement of the wound using the dimensions of width, length, and depth provide information on the overall change in wound size that indicates if the wound is moving toward healing.

3.When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? Necrotic tissue Wound drainage Drainage on the dressing Wound after it has first been cleaned with normal saline

Wound after it has first been cleaned with normal saline Drainage that has been present on the wound surface can contain bacteria from the skin, and the culture may not contain the true causative organisms of a wound infection. By cleaning the area before obtaining the culture, the skin flora is removed.

laceration

a break or opening in the skin that may be smooth or jagged. bleed more depending on location and depth

collagen

a tough fibrous protein

9.Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? Collection of wound drainage Reduction of abdominal swelling Reduction of stress on the abdominal incision Stimulation of peristalsis (return of bowel function) from direct pressure

Reduction of stress on the abdominal incision A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreasing stress from coughing and movement.

5.Which description best fits that of serous drainage from a wound? Fresh bleeding Thick and yellow Clear, watery plasma Beige to brown and foul smelling

Clear, watery plasma Serous fluid generally is serum and presents as light red, almost clear fluid.

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

Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration If a patient has an opening in the surgical incision and a portion of the small bowel is noted, the small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist.

the skin: Two layers

EPIDERMIS-outerlayer-- prevents waterloss & injury prevents entry of pathogens generates new cells DERMIS-keeps skin moist contains bundles of collagen & elastic fibers

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

Ice bag An ice bag helps to constrict excess fluid in tissues, which prevents edema. The blood vessels become constricted, help to control bleeding, and can decrease pain where the ice bag is placed.

Which client information collected by the nurse reflects a systemic response to a wound infection? 1. Hyperthermia 2. Exudate 3. Edema 4. Pain

1. Hyperthermia; Hyperthermia is a common systemic response to infection. With hyperthermia, microorganisms or endotoxins stimulate phagocytotic cells that release pyrogens, which stimulate the hypothalamic thermoregulatory center, resulting in fever. Exudate, edema, and pain are all signs of infection but are considered local responses to infection or injury

eschar

black or brown necrotic tissue - has to be removed before healing can occur

hemorrhage

bleeding from a wound site

sanguineous

bright red which indicates active bleeding

sanguineous

bright red, indicates active bleeding

A client has a pressure ulcer with a shallow, partial skin thickness, eroded area but no necrotic areas. The nurse would treat the area with which dressing? 1. Alginate 2. Dry Gauze 3. Hydrocolloid 4. No dressing indicated.

3. Hydrocolloid; Hydrocolloid dressings protect shallow ulcers and maintain an appropriate healing environment. Alginates (option 1) are used for wounds with significant drainage; dry gauze (option 2) will stick to granulation tissue, causing more damage. A dressing is needed to protect the wound and enhance healing.

shearing force

force exerted parallel to skin resulting from both gravity pushing down on the body and resistance (friction) between the client and a surface. when the head of the bed is elevated and the sliding of the skeleton starts but the skin is fixed because of friction with the bed

stage 3

full thickness tissue loss ( fat visible)

stage 4

full thickness tissue loss ( muscle/bone visible)

adolescence

hormonal changes.... estrogen causes skin to be soft,smooth,thicker, w/increased vascularity male hormones cause increased thickness w/darkening.... sebaceous glands become more active & sweat glands become fully functional....

puncture

caused by an object piercing the skin and creating a hole. bleeding determined by depth and size. primary dangers are internal bleeding and infection.

serous

clear watery plasma

serous

clear, watery plasma

approximated

closed

cold therapies

cold moist and dry compresses cold soaks ice bags or collars

pressure ulcer

impaired skin integrity related to unrelieved prolonged pressure

hemostasis

injured blood vessels constrict and platelets gather to stop bleeding

skin is a sensory organ for....

pain, temperature, & touch

serosanguineous

pale, pink, watery:mixture of clear and red fluid

serosanguineous

pale, red, watery; mixture of clear and red fluid

dehiscence

partial or total separation of wound layers - this happens when wounds fail to heal properly - occurs before collagen formation

patients at risk for pressure ulcers

decreased mobility decreased sensory perception incontinence poor nutrition

Full thickness wounds

deeper wounds loss extends into the dermis ex. pressure ulcer heals by scar formation

dehiscence

dehiscence-layers of skin and tissue separate

older adults

epidermal cell replacement slows.... skins thins.... loses resiliency.... decreased moisture increased itching.... increased risk for bruising & injury

evisceration

evisceration-protrusion of visceral organs through the wound opening

evisceration

protrusion of visceral organs through a wound opening

granulation tissue

red moist tissue composed of new blood vessels which indicated progression toward healing

normal reactive hyperemia

redness-localized vasodilation; blanching w/ fingertip pressure; lasts less than 1 hour

Dressings:

reduce the exposure to microorgisma pressure dressings used for hemostasis absorb drainage from the wound provide debridement (wet to dry) provides a moist environment

toddler & child

reluctant to bathe.... use games... teach good habits....

debridement

removal of nonviable, necrotic tissue

sebum

sebum-has lower ph also softens & lubricates skin.... slows water loss, and has bactericidal properties

Partial thickness wounds

shallow wounds loss of epidermis & partial loss of dermis ex. clean surgical wound or abrasion heals by regeneration

neonate

skin immature, thin, and layers loosely bound together skin is almost transparent.... topicals absorb into skin to well don't use..... friction causes bruising & any break which result in infection....

darkly pigmented skin

skin that remains unchanged (does not blanch) when pressure is applied on a bony prominence - this doesn't have anything to do with a patient's race or ethnicity

slough

string substance attached to wound bed - has to be removed before wound can heal properly

abrasion

superficial wound with little bleeding, considered a partial-thickness wound. Often appears "weepy" because of plasma leakage from damaged capilliaries

epithelialization

the natural act of healing by secondary intention; the proliferation (rapid reproduction) of new epithelium into an area devoid of it but that naturally is covered by it

purulent

thick yellow green, tan or brown

purulent

thick, yellow, green, tan, or brown pus or drainage

pressure ulcers-depth unknown

unstageable or unclassified full thickness skin or tissue loss-depth unknown a. slough b.eschar suspected deep tissue injury-depth unknown-purple or maroon area of discolored intact skin a.blood filled blister

cold applications

vasoconstriction local anesthesia reduce cell metabolism increase blood viscosity decrease muscle tension

skin synthesizes

vitamin D

heat therapies

warm moist compresses warm soaks sitz baths hot packs

tissue ischemia

when living tissue is deprived of oxygen - depriving tissue of adequate blood flow is the same as depriving tissue of oxygen

blanching

when normal red tones of the light skinned patient are absent as when pressing a patient's fingertips to test capillary refill - blanching of the skin does not occur in darly pigmented skin

denuded skin

when the top layer is off, sore is very superficial and usual caused from a shearing force or friction "sheet burn"

Which of the following items are used to perform wound care irrigation? Select all that apply. 1. Clean gloves 2. Sterile gloves 3. Refrigerated irrigating solution 4. 60-mL syringe

wound care irrigation? Select all that apply. 1. Clean gloves 2. Sterile gloves 3. Refrigerated irrigating solution 4. 60-mL syringe 1, 2, and 4; To irrigate a wound, the nurse uses clean gloves to remove the old dressing and to hold the basin collecting the irrigating fluid plus sterile gloves to apply the new dressing. A 60-mL syringe is the correct size to hold the volume of irrigating solution plus deliver safe irrigating pressure. The irrigation fluid should be at room or body temperature-- certainly not refrigerated.

primary intention

wound healing with skin edges that are approximated, risk of infection is low, healing occurs quickly with minimal scar formation as long as infection and secondary breakdown is prevented (similar to a surgical wound)

A client has a diabetic stasis ulcer on the lower leg. The nurse uses a hydrocolloid dressing to cover it. The procedure for application includes: 1. Cleaning the skin and wound with betadine 2. Removing all traces of residues for the old dressing 3. Choosing a dressing no more than quarter-inch larger than the wound size 4. Holding in place for one minute to allow it to adhere

4. Holding in place for one minute to allow it to adhere; The skin is cleansed with normal saline or a mild cleanser. Residue of old dressings will dissolve. The dressing size is to be 3-4 cm (1.5 inches) larger than the size of the wound.

A client's wound is draining thick yellow material. The nurse correctly describes the drainage as: 1. Sanguineous 2. Serous-sanguineous 3. Serous 4. Purulent

4. Purulent; Drainage is described as purulent. Sanguineous and Serous-sanguineous contain blood. Serous is clear and watery.

.The nurse is caring for a patient with a healing stage III pressure ulcer. The wound is clean and granulating. Which of the following orders would the nurse question? a. Use a low-air-loss therapy unit. b. Consult a dietitian. c. Irrigate with hydrogen peroxide. d. Utilize hydrogel dressing.

ANS: C 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 who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair? 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.

The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a pressure ulcer takes time to heal and is an example of a. Primary intention. b. Partial-thickness wound repair. c. Full-thickness wound repair. d. Tertiary intention.

ANS: C 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 three phases: inflammatory, proliferative, and remodeling. 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 approximated. Wound closure is delayed until risk of infection is resolved. DIF: Remember REF: 1181-1183 OBJ: Discuss the normal process of wound healing.

The nurse is collaborating with the dietitian about a patient with a stage III pressure ulcer. After the collaboration, the nurse orders a meal plan that includes increased a. Fat. b. Carbohydrates. c. Protein. d. Vitamin E.

ANS: C 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. A balanced diet of fat and carbohydrates, along with protein, vitamins, and minerals, is needed in any diet. Wound healing does not require increased amounts of fats or carbohydrates. Vitamin E has no known role in wound healing.

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 would the nurse stage this ulcer? 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." Once an ulcer has been staged, the stage endures even as the ulcer heals. This ulcer was labeled a stage III, 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 III.

The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer would be staged as stage a. I. b. II. c. III. d. IV.

ANS: B This would be a stage II pressure ulcer because it presents as partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and 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 has experienced a laparoscopic appendectomy. The nurse recalls that this type of wound heals by A.Tertiary intention. B.Secondary intention. C.Partial-thickness repair. 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.

The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which of the following would be used first to assist in staging an ulcer on this patient? a. Cotton-tipped applicator b. Disposable measuring tape 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 whole 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 not the first item used.

What physiological conditions are contraindicated for using heat as a therapy? (Select all that apply.) 1. The first 24 hours of injury 2. Active hemorrhage 3. Noninflammatory edema 4. Localized malignant tumor

All of the above; Heat causes vasodilatation and increases blood flow to the affected area bringing oxygen, nutrients, antibodies, and leukocytes. A possible disadvantage of heat is that it increases capillary permeability, which allows extracellular fluid and substances to pass through the capillary walls and may result in edema or an increase in preexisting edema. Contraindications include: the first 24 hours of injury, active hemorrhage, noninflammatory edema, localized malignant tumor, and skin disorder that causes redness or blisters.

11.What is the removal of devitalized tissue from a wound called? Debridement Pressure reduction Negative pressure wound therapy Sanitization

Debridement Debridement is the removal of nonliving tissue, cleaning the wound to move toward healing.

abnormal reactive hyperemia

Excessive vasodilation and induration; skin is bright pink to red; NO blanching with fingertip pressure; can last 1 hour to 2 weeks; Stage I pressure ulcer

A nurse is caring for patients with a variety of wounds. Which would will most likely heal by primary intention? 1. Cut in the skin from a kitchen knife 2. Excoriated perineal area 3. Abrasion of the skin 4. Pressure ulcer

1. Cut in the skin from a kitchen knife; A cut in the skin by a sharp instrument with minimal tissue loss can heal by primary intention when the wound edges are lightly pulled together (approximated). Excoriations, abrasions, and pressure ulcers heal by secondary, not primary. Secondary intention healing occurs when wound edges are not approximated because of full-thickness tissue loss; the wound is left open until it fills with new tissue. Abrasions and excoriations are injuries to the surface of the skin.

8.Which of the following describes a hydrocolloid dressing? A seaweed derivative that is highly absorptive Premoistened gauze placed over a granulating wound A debriding enzyme that is used to remove necrotic tissue A dressing that forms a gel that interacts with the wound surface

A dressing that forms a gel that interacts with the wound surface A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing.

The client is only comfortable lying on the right side or left side (not on the back or stomach). List at least four potential sites of pressure ulcers the nurse must assess.

These are important areas to assess. Potential ulcer sites for side-lying clients include: 1. Ankles 2. Knees 3. Trochanters 4. Ilia 5. Shoulders 6. Ears