Module 14 Skin Integrity & Wound Care Questions

To prevent shearing do what?

Use draw sheet and keep HOB (Head Of Bed) below 30%!

What is the purpose of skin barrier lotion?

To protect the skin from moisture and break down.

Proteins

promote fibroplasia, angiogenesis, collagen formation, and immune function during wound healing.

Vitamin C

promotes collagen synthesis and capillary wall integrity, and provides antioxidant benefits to support wound healing.

Tissue ischemia

A decreased supply of oxygenated blood to a pody part.

Name and describe the three phases of wound healing.

(Page 1191 Potter) INFLAMMATION PHASE - 4-6 days. The onset. It's edematous. Huge phagocytosis occurring. Lots of wbc being directed to the area. PROLIFERATION PHASE OR GRANULATION STAGE - 14-21 days. This is where the epithelial cells are starting to grow; budding. This is where it should be nice and pink. It starts getting a protective layer ie scabbing. Then scarring occurs. MATURATION PHASE - 21 days - 2 years. Scar strengthens and starts to fade. Not bright pink anymore. Fades toward normal skin color.

Name and describe the 4 types of wound healing.

1) REGENERATION: New tissue grows. No scar. The REPAIR PHASES (BELOW) Usually result in a scar: 2) PRIMARY INTENTION: Simplest. Healing takes place when wound margins are neatly approximated (close together) either by the skin itself or by sutures or staples, as in a surgical incision or a paper cut. Wound surface heals with the epithelium and it heals quickly. 3) SECONDARY INTENTION: Granulation is 2nd step. Less open. Prolonged healing time. Wound edges are not approximated (not close together). Wound heals by granulation so it is healing from the inside out. 4) TERTIARY INTENTION: Wound is open, infected, left open for days. Think of abdominal wounds. Frequently irrigated so you are frequently cleaning. Later it is brought together through skin grafts. Literally takes awhile. Wound vacs help. THE PRIMARY, SECONDARY AND TERTIARY INTENTIONS ARE ALL STEPS IN THE **REPAIR** PHASE WHICH OCCURS AFTER THE INITIAL REGENERATION PHASE.

What quantity of vitamin C is recommended for wound healing? Record your answer using a whole number.

1,000 mg/day The amount of vitamin C recommended for wound healing is 1000 mg/day in order to promote collagen synthesis, maintain capillary wall integrity, help fibroblast function, promote immunity, and provide antioxidant benefits. p. 1196

Name and give examples of the types of debridement.

1- Mechanical - Wet to dry dressing. When taking it off you are mechanically removing the slough. When removed unfortunately removing the good granulation tissue. Now it is more moist to dry instead of wet to dry. 2- Enzymatic & Chemical - Topical agents that break down the skin and debride it. 3- Surgical - Surgeon physically going in and removing the dead skin/necrotic tissues. 4- Autolytic - Occlusive moisture retaining dressing. Think of a blessing with a tagaderm (clear dressing); you will see your body processing that wound. You will see the exudate etc. 5- Biological - "Clean" maggots from the pharmacy as well as leaches. 6- Pulsatile Lavage - Process of washing out an organ. 7- Ultrasound - Actually break it up. 8- Whirlpools - Not used so much. Due to infection.

Describe a Stage 4 Pressure Ulcer

A deep crater. Full thickness damage down to the muscle and bone etc. Extensive destruction. Stage 4's need debridement, multiple surgeries, wound vacs, lots of time and money, prolonged hospital stays and can end in death.

Name the 4 types of wound drainage.

A purulent wound has drainage, which is thick, yellow, green, tan, or brown. Serosanguineous drainage is pale, pink, and watery with a mixture of clear and red fluid. Serous wound drainage is clear and watery. Sanguineous drainage is bright red, indicating active bleeding.

Which type of ulcer can be dressed with a transparent or hydrocolloid dressing? 1 - Stage I 2 - Stage II 3 - Stage III 4 - Stage IV

A stage I pressure ulcer is an intact ulcer that can be dressed with a transparent or hydrocolloid dressing. Composite film, hydrocolloid, and hydrogel dressings are appropriate for stage II pressure ulcers. Hydrocolloid, hydrogen gel covered with foam, calcium alginate, and gauze dressings are appropriate for stage III pressure ulcers. Hydrogel covered with foam, calcium alginate, and gauze dressings are appropriate for stage IV pressure ulcers.

What size syringe is used for irrigating an open wound? Record your answer using whole number.

A 35-mL syringe is used for irrigating an open wound. p. 1216

Under the supervision of the registered nurse, a nursing student is providing negative-pressure wound therapy to a patient who has a wound near the knee joint. Which nursing action indicates the need for further learning? 1 - Drying the periwound thoroughly before dressing 2 - Covering the skin near the suction line with at hydrocolloid dressing 3 - Applying adhesive remover at the affected site before the dressing 4 - Dressing the wound with a hydrocolloid film 3 cm away from the wound

C Application of adhesive remover at the affected area may leave a residue that hinders dressing film adherence the remaining actions are correct. The periwound should be thoroughly dried before dressing, because it promotes wound healing. Hydrocolloid dressing may result in contact dermatitis, so it is necessary to cover the skin near and under the areas of suction. Dressing the wound with hydrocolloid film 3 to 5 cm away from the wound ensures proper wound care.

eschar

Black, brown, tan or necrotic which needs to be removed before healing can proceed.

Hyperemia

Bright red. Blood flow returns and the skin turns red. Also, excess of blood in part of the body, caused by increased blood flow ex. the inflammatory response.

Describe (causes and implications) of: " Chronic" of wound classifications.

CHRONIC: Description: Wound that FAILS to proceed through an orderly and timely process to produce anatomical & functional integrity. Causes: Vascular compromie, chronic inflammation, or repetitive insults to tissue. Implications for healing: Continued exposure to insult impedes wound healing.

Calcium alginate steps

Calcium alginate Alginate dressings absorb serous fluid or exudate, forming a nonadhesive hydrophilic gel, which conforms to the shape of the wound (Rolstad et al., 2016). (1) Pack wound with alginate using applicator or gloved hand. Provides maintenance of wound moisture while absorbing excess drainage. (2) Apply dry gauze or foam over alginate. Tape in place. Holds alginate against wound surface. 6. Reposition patient comfortably off pressure area and other pressure points. Reduces pressure on existing wound and decreases pressure on at-risk areas. p. 1225

Name the most commonly evidence based practice scale for predicting pressure ulcer score risk.

The most used EBP scare is the: Brayden scale (1193 Potter) Sensory Perception Moisture Activity Mobility Nutrition Friction and shear THIS IS SUBJECTIVE BUT its the most accurate and the best we have.

What is Repair?

Repair is healing as a result of lost cells being replaced by connective tissue. Repair is a more common type of healing and USUALLY LEAVES A SCAR. More complex process than regeneration. Most injuries heal by connective tissue repair. REPAIR HEALING OCCURS BY: PRIMARY INTENTIONS SECONDARY INTENTIONS AND TERTIARY INTENTIONS.

Name each suture type and describe each.

Retention sutures, which are placed more deeply than skin sutures. Continuous sutures have a series of stitches, but they are not individually knotted. Intermittent sutures, each individual suture is made in the skin. A blanket suture is a continuous self-locking stitch. p. 1217

Pressure Ulcer Prevention for Decreased activity/mobility

Risk Factor: Decreased activity/mobility Nursing Intervention: Establish and post individualized turning schedule. p. 1203

Pressure Ulcer Prevention for Friction and Shear

Risk Factor: Friction and Shear Nursing Interventions: Reposition patient using drawsheet or a transfer board surface. Provide trapeze to facilitate movement in bed. Position patient at a 30-degree lateral turn and limit head elevation to 30 degrees (see Figure 48-15). p. 1203

Pressure Ulcer Prevention for Moisture

Risk Factor: Moisture Nursing Interventions: Following each incontinent episode, clean area with no-rinse perineal cleaner and protect skin with moisture-barrier ointment (Rolstad et al., 2016). Keep skin dry and free of maceration (Gray et al., 2011; Colwell et al., 2011). Turn patient off of at-risk areas often. Friction and shear p. 1203

Pressure Ulcer Prevention for Poor Nutrition

Risk Factor: Poor nutrition Nursing Interventions: Provide adequate nutritional and fluid intake; help with intake as necessary. Consult dietitian for nutritional assessment and recommended nutrients. p. 1203

Pressure Ulcer Prevention for Decreased sensory perception

Risk Factor: Decreased sensory perception Nursing Interventions: Provide pressure-redistribution surface. Be sure to include protection for pressure points from medical devices such as oxygen tubing, feeding tubes, and casts. p. 1203

Describe (causes and implications) of: "Secondary Intention" of wound classifications.

SECONDARY INTENTION: Description: Wound edges not approximated. Causes: Pressure ulcers, surgical wounds that have tissue loss or contamination. Implications for healing: Wound heals by granulation tissue formation, wound contraction, and epithelialization.

When cleaning a wound, which action is incorrect? 1 - Using two separate swabs to clean the affected site 2 - Irrigating from the least to most contaminated area 3 - Applying noncytotoxic solutions using gentle friction 4 - Cleaning from the surrounding skin to the site of incision

The nurse should clean away from the wound to prevent contamination. Two separate swabs are to be used: one to clean from the top of the incision toward the draining site and another to clean from the bottom of the incision toward the draining site. Irrigation fluid should flow from the least to most contaminated area to prevent transmission of bacteria. Application of pressure while cleaning the wound should be avoided, but gentle friction may be applied while cleaning the traumatic wound with the noncytotoxic solution.

What does the nurse teach a pt. with a Stage II Pressure Ulcer?

The nurse would teach about healing via reepithelialization, p. 1213

What does the nurse teach a pt. with an Unstageable Pressure Ulcer?

The nurse would teach about softening the eschar with debridement. p. 1213

periwound

The skin area around the wound. Be sure to access it for redness, warmth, and signs of maceration and palpate the area for signs of pain or induration. Presence of any of these factors on the periwound skin indicates wound deterioration.

Skin in moisture.... "friction"

Top skin looks normal, underside gets wrinkled and torn underneath. It can look like a bruise. It can be a deep tissue injury. Eventually it can come to the surface.

What should be included in description of drainage?

Type. Is it dry or moist? Ex. dry gangrene or wet gangrene. Even if it is dry it is still drainage etc. it's debris, sloughing of the skin like crusties. Serous, Purulent, Serosanguineous, Sanguineous, slough. Odor? Amount? How many ABD pads are soaked? Wound vac? Is there a drain attached to it? You need to measure the amount of drainage. Color?

The absence of adequate amounts of which nutrient in the diet may impair inflammatory response in wound healing? Zinc Proteins Vitamin A Vitamin C

Vitamin A Vitamin A plays a major role in the inflammatory response in wound healing, so a lack of it can impair the inflammatory response. Zinc plays a role in collagen formation and protein synthesis during wound healing. Proteins promote fibroplasia, angiogenesis, collagen formation, and immune function during wound healing. Vitamin C promotes collagen synthesis and capillary wall integrity, and provides antioxidant benefits to support wound healing. p. 1196

Vitamin A

Vitamin A's role in healing: Epithelialization, wound closure, inflammatory response, angiogenesis, collagen formation. ALSO: Can reverse steroid effects on skin and delayed healing Recommended: 1600-2000 retinol equivalents per day Food source: Green leafy vegetables (spinach), broccoli, carrots, sweet potatoes, liver

Vitamin C

Vitamin C (ascorbic acid) role in healing: Collagen synthesis, capillary wall integrity, fibroblast function, immunological function, antioxidant Recommended: 1000 mg/day Food source: Citrus fruits, tomatoes, potatoes, fortified fruit juices

Physicians sometimes go ahead and order ____________ to be given to the pt post surgery.

Vitamin C and Zinc to help with wound healing

How do you avoid contaminating topical medications?

Wear gloves! Use an applicator. Discard first bit of med bc it is potentially contaminated. Be sure to recap. Do not touch tip to the skin, finger tip...etc. Don't share. Don't double dip. Don't put top on the counter.

Name pros and cons of each type of debridement (if applicable).

Wet to dry dressings are not used because it takes the good pink tissue off when it is removed. Takes the scab off, makes it bleed again and you are literally starting the healing process all over again.

What should be included in a wound assessment?

Size/depth/length/width Age of wound/how long ago did this start Dry wound or wet wound Eschar (black - un-stagable skin/it is necrotic but DO NOT CUT IT OFF) it is there for a reason. Tunneling and Undermining (Use the clock method) Any drainage or exudate and specific type of drainage Necrotic tissue Color/Pain/Odor/Location/Temperature Integrity of skin surrounding the wound (called wound margin) Is it blanching? Non-blanching? It is intact? Is it macerated? It is painful? What stage it is. If it is a pressure ulcer If bone is present Type.... laceration verses puncture Level of contamination, in growing area... How was it acquired? Stepped on nail? Surgical incision? How far along it is in the healing process or getting worse Any previous dressing? Did they have a wound vac previously and now at wet to dry? Or vise versa. Crepitus? Noisy discharge. Air around the tissue. Seen often in chest tubes improperly. Can be seen in big wounds. Feels like bubble wrap under the skin. Some bacteria can cause it depending on if it is aerobic or anaerobic depending on where it is at.

Factors that delay wound healing.

Smoking Infection (localized and systemic infection) Poor hygiene Diabetes Sugar Increased glucose Stress When body is stressed the cortisol goes up when it goes up so does your sugar. This is why insulin is given in the hospital. To maintain blood sugar levels. Even given to nondiabetic patients. Poor Nutrition Dehydration Age Decreased circulation Immunocompromised Immobility Decreased hemoglobin/Anemia Wound care Dirty or contaminated wounds A decrease inflammatory response due to meds or autoimmune processes. Location Reinjury

Hydrogel dressings

Some are creams. Keeps wounds moist. Autolytic debridement. Gauze or sheet dressings w/water or glycerin-based amorphous gel. Absorbs small amounts of exudate. For partial-thickness/full-thickness wounds, deep wounds with some exudate; necrotic wounds, burns and radiation damaged skin. Very soothing to a pt and don't adhere to the wound bed. Soothing & can reduce wound pain. Debrides necrotic tissue (by softening the necrotic tissue). Doesn't adhere to the wound base/easy to remove.

Hydrocolloid dressings

Some are creams. Keeps wounds moist. Helps with autolytic debridement. Useful for on shallow to moderately deep dermal ulcers. They cannot absorb the amount of drainage from heavily draining wounds and some are contraindicated for use in full-thickness and infected wounds. They will leave a residue in the wound bed that is easy to confuse with purulent drainage.

Pressure Ulcer Prevention INTERVENTION for WOUND CARE

Wound Care: Irrigate wound with saline solution twice per day per wound-care provider's order. Cleanse wound and surrounding area of wound debris and exudate. **************** Apply dressing (i.e., gauze moistened with solution twice a day after irrigation) according to wound-care provider's order. Provides appropriate topical therapy to wound, placing wound in best environment for healing. ************** At frequent intervals evaluate patient's pain level and offer pain medication as indicated by assessment. Provides patient with pain reduction/relief, allowing for greater mobility and comfort p. 1202

Describe Tertiary Intention

Wound is open for several days, infected, left open. Think of abdominal wounds. Frequently irrigated so you are frequently cleaning. Later it is brought together through skin grafts. Literally takes awhile. Wound vacs help.

Name factors in bed making that contribute to skin breakdown.

Wrinkles in linen Tuck feet tightly in the sheet Seams facing the patient Draw sheet (pulling on the sheet) Moist and soiled sheets Too many pillows/blankets Lying on the call light or remote Head of bed elevated too high (if it is elevated too high they can get sacral) REMEMBER NOT EVERYONE NEEDS A CHUCK PAD - it protects the linen not the patient.

An air-fluidized bed support surface

a support surface that prevents skin breakdown and may also be used to protect newly flapped or grafted surgical sites.

Pressure Ulcer Prevention INTERVENTION for PRESSURE MANAGEMENT

Order and place on pt.'s bed a pressure redistribution surface. Repositioning every 90 minutes as her condition allows. Use a drawsheet when helping to reposition. Repositioning is still required for pressure redistribution and comfort when a support surface is in use. Use a lift or transfer sheet to minimize friction and/or shear when repositioning, keeping bed linens smooth and unwrinkled. ***** Elevate head of bed no more than 30 degrees. Hip patient may not be allowed to turn in to 30-degree lateral position. If sitting in bed is necessary, avoid head-of-bed elevation or a slouched position that places pressure and shear on the sacrum and coccyx *** Keep skin dry and clean; avoid rubbing or massaging around the open area. The presence of skin damage from moisture increases the risk of pressure ulceration. Rubbing or massaging areas of nonblanching erythema causes further tissue damage ******* Use moisture barrier ointment over the ulcer at least 3 times a day to decrease friction and provide moisture to the open tissue. An ointment covers the area, providing base of ulcer with moisture, which encourages healing. Ointment prevents sheets from rubbing on area, thus decreasing the friction p. 1202

Describe a Category/Stage II Classification of Pressure Ulcers

Partial thickness loss of dermis presents as a shallow, open ulcer with a red-pink wound bed without slough. It may also present as an intact or open/ruptured serum-filled or serosanguineous-filled blister. It presents as a shiny or dry shallow ulcer without slough or bruising (see Figure 48-4, B). The presence of bruising indicates deep tissue injury. This category should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration, or excoriation. p. 87

Factors essential to effective wound healing.

Proper wound care. Are they doing it? Circulation at the wound site. Can their body transport the materials it needs? The nutrients? The blood? The oxygen? If there is no blood circulating at the wound site then it is not going to heal right. Needs to look like it is healing with granulation tissue. It should look like dark red hamburger meat, not pale pink. Moist wound bed? Positive blood flow? See if there is any granulation tissue. What is their overall health status? Good general health? Someone with diabetes will heal slower and someone with HIV/AIDS will heal slower than someone with diabetes. Proper nutrition... ex. protein, vit c. etc Hydration Hygiene.... are they keeping it clean? Proper medication being prescribed Medications and dressings being used properly? Their lifestyle Age Dressing change

Antibiotic cream, lotion or ointment

Prophylactic for infection prevention or can be used for an active infection.

Protein

Protein's role in healing: Fibroplasia, angiogenesis, collagen formation and wound remodeling, immune function Recommended: 1.25-1.5 g protein/kg body weight Food Source: Poultry, fish, eggs, beef

evisceration

Protrustion of visceral organs through a wond opening. The process whereby tissue or organs that usually reside within a body cavity are displaced outside that cavity, usually through a traumatic disruption of the wall of the cavity; evisceration of bowel. Removal of the contents of the eyeball, leaving the sclera and sometimes the cornea.

Name nursing considerations when administering topical medications

REMEMBER 6 RIGHTS! MOST IMPORTANT CHECK DR.'S ORDERS! Look up the med, make sure pt does not have any allergies to it. WEAR GLOVES protect yourself (the nurse)! warm before applying. some can be warmed, some cannot. Some NEED a DR's orders! Apply to clean, dry skin Note if it should be applied liberally or sparingly surface area temperature of skin skin breakdown age bc of absorption Making sure skin's not irritated/ has a rash before Applying Make sure pt has no allergies to the topical med. Hair in the area

Skin assessment on pt with dark pgmented skin:

The NPUAP, EPUAP, PPPIA guidelines suggest that, when conducting a skin assessment on an individual with darkly pigmented skin, prioritize assessment of skin temperature, edema, and change in tissue consistency in relation to surrounding tissue. Additional aspects of assessing dark skin are in Box 48-3. p. 1189

Heat therapy is used for:

Rectal surgery Painful hemorrhoids Vaginal inflammation

Describe color-based wound classification and what each color means r/t nursing assessment and intervention

Red: Yellow Black:

Describe the following wound classifications

Red: Healthy & Healing: INFLAMMATORY/PROLIFERATIVE/MATURATION PHASES It is healing. THINK RED BLOOD. Blood is getting to that wound. It brings nutrients and oxygen. Yellow: Slough. INFECTED. NASTY. Yellow/green. Black: Necrotic. Eschar. Not ready to heal. Cellular death. It may never heal. Think of Black and death. The necrotic tissue part in a wound will not come back and it impairs the ability of the tissue underneath to heal properly. So that tissue could possibly die.

Calories

Calories are fuel for cell energy "Protein protection" Recommended: 30-35 kcal/kg/day (Individuals who are underweight or have significant unintentional weight loss may need additional calories.)

Name and define 5 complications of wound healing.

DEHISCENSE - Edges of the wound separate. Pt probably moved wrong and it opened back up. Partial or total separation of wound layers. Surgical separation of a surgical incision or rupture of a wound closure, typically an abdominal incision. HEMORRHAGING - Bleeding (If it is an abdominal wound the blood can pool under them). Turn your patients! INFECTION - EVISCERATION - Bowels come out through the open wound. More of an abdominal wound issue. DO NOT PUT THINGS BACK IN! Requires surgical repair. Organs come out. FISTULA - an abnormal passage from an internal organ tot he body surface or between two internal organs.

Gauze to fit around the drain or the wound

DO NOT cut the gauze to fit around the drain or the wound, because the cut edges may fray and enter the wound, causing irritation at the wound site.

Debriding enzymes steps

Debriding enzymes (1) Apply thin, even layer of ointment over necrotic areas of ulcer only. Do not apply enzyme to surrounding skin. Check manufacturer directions for frequency of application. Thin layer absorbs and acts more effectively than thick layer. Excess medication irritates surrounding skin (Rolstad et al., 2016). Some enzymes cause burning, paresthesia, and dermatitis to surrounding skin. (2) Apply gauze dressing directly over ulcer. Protects wound and keeps enzymes in place. Prevents bacteria from entering wound. (3) Tape securely in place. Keeps dressing in place. p. 1225

Other methods for wound healing.

Electric stimulation Maggot therapy High voltage pulse currents Phototherapy UV lights (not old fashioned heat lamps) Negative pressure aka: wound vacs Hyperbaric wound therapy: hyperbaric chambers where the oxygen levels are higher. Ex. the bends with divers.

State the purpose of a transparent film dressing.

For protection. It's for autolytic debridement. Ideal for Stage 1 Pressure ulcers or a partial-thickness wound. It traps moisture over a wound, providing a moist environment. You can see through it and it's for protection.

Alginate dressings

For wounds with large excessive amounts of exudate and those that need packing. Works like a sponge and absorbs ALL the moisture. DO NOT USE IN DRY WOUNDS.

Describe a Stage 3 Pressure Ulcer

Full thickness involving subcutaneous tissues down to but not through the fascia (the last layer/area before you get down to the bone)

Describe a Category/Stage III Classification of Pressure Ulcers

Full-Thickness Skin Loss. In full-thickness tissue loss subcutaneous fat may be visible; but bone, tendon, and muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. It may include undermining and tunneling. The depth of a category/stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue; and category/stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep category/stage III pressure ulcers. Bone/tendon is not visible or directly palpable (see Figure 48-4, C). p. 1187

Describe a Unstageable/Unclassified Classification of Pressure Ulcers

Full-Thickness Skin or Tissue Loss—Depth Unknown. Full-thickness tissue loss in which actual depth of an ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed is unstageable. Until enough slough and/or eschar are removed to expose the base of a wound, the true depth cannot be determined; but it will be either a category/stage III or IV. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the natural (biological) cover of the body" and should not be removed (see Figure 48-4, E). p. 1187

Describe a Category/Stage IV Classification of Pressure Ulcers

Full-Thickness Tissue Loss. In full-thickness tissue loss with exposed bone, tendon, or muscle, subcutaneous fat may be visible; but bone, tendon, and muscle are exposed. Slough or eschar may be present. It often includes undermining and tunneling. The depth of a category/stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue; and these ulcers can be shallow. Category/stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule), making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable (see Figure 48-4, D). p. 1187

Expected change in size of a healing wound.

Gets smaller. Decreases by pproximately 25-30% smaller in surface size by week 4 of a treatment plan.

Describe (causes and implications) of: "Healing Process - Primary Intention" of wound classifications.

HEALING PROCESS - PRIMARY INTENTION: Description: Wound that is closed. Causes: Surgical incision Wound that is sutured or stapled. Implications for healing: Healing occurs by epithelialization; heals quickly with minimal scar formation.

Describe the inflammation phase.

INFLAMMATION PHASE - 4-6 days. The onset. It's edematous. Huge phagocytosis occurring. Lots of wbc being directed to the area.

Name the one exception to debriding slough/eschar.

If it is on the heal of a foot.

Emollient lotion

Keeps the skin moist, flexible and healthy.

Support surfaces help in preventing and treating skin breakdown.

Low-air-loss and nonpowered

What does the nurse need to know about using transdermal patches?

MUST wear gloves! Is it time released? Some may not start working right away. Is it ok to cut? Normally not but some you can so ask HCP or pharmacy. Name and dosage of medication Rotate the application sites Place on non-hairy skin. Temperature of the patient. Remove if pt has a fever. They take it quicker if they have a temp due to vasodilation. Severe neurological impairment after wearing a fentanyl patch, having a temp and sitting in hot weather. Sensitivity to drug allergies Proper disposal. DO NOT put in sharps container. Fold it and put it in a napkin and trash it. Don't put it back in it's actual packet. Pt's go looking for these things. Remove after specific amount of hours (ck orders!)

Which blood cells are known as garbage cells? 1 - Neutrophils 2 - Erythrocytes 3 - Macrophages 4 - T-lymphocytes

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.

eschar

black, brown, tan or nectrotic tissue that needs to be removed before healing can proceed.

sclerosis

abnormal hardening of body tissue. excessive resistance to change.

induration

an increase in the fibrous elements in tissue commonly associated with inflammation and marked by loss of elasticity and pliability, sclerosis. a hardened mass or formation.

Hydrocolloid dressings are used

for burns with minor exudate.

Transparent film dressings are used

for superficial wounds.

surgical incisions

heal by primary intention. The skin edges are approximated (meaning closed) and the risk of infection is low. Healing occurs quickly, with minimal scar forming as long as infection and secondary breakdown are prevented.

secondary intention

healing for a wound that involves loss of tissues such as a burn, pressure ulcer, or severe laceration. The wound is left open until it becomes filled by scar tissue. Takes longer to heal this way, therefore the chances of infection are greater. If scarring from secondary intention is severe, loss of tissue function is often permananent.

granulation tissue

is red, moist tissue composed of new blood vesssels, the presence of which indidcates progression toward healing.

periwound

is the tissue surrounding the wound itself. This tissue ideally provides a barrier to the wound, which protects it and confines the area of healing, ideally, so that the wound does not spread.

A lateral rotation support surface

is useful in treating and preventing pulmonary, venous stasis, and urinary complications associated with immobility.

Vitamin A

plays a major role in the inflammatory response in wound healing, so a lack of it can impair the inflammatory response.

Zinc

plays a role in collagen formation and protein synthesis during wound healing.

exudate

describes the amount, color, consistency and odor of wound drainage and is part of the wound assessment. Excessive exudate indicates the presence of infection. The skin around the wound (periwound) should be assessed. Examine the periwound for redness, warmth, and signs of maceration and palpate the area for signs of pain or induration. Presence of any of these factors on the periwound skin indicates wound deterioration.

serous

drainage is clear, watery plasma

sanguineous

drainage that is bright red, indicating active pleeding.

serosanguineous

drainage that is pale pink and watery

purulent

drainage that is thick and yellow, green, tan, or brown.

Black foam is used for

dressing a granulating wound, because it provides wound contraction, but it is not used for a draining wound.

Induration

early signs of skin damage. bogginess (less than normal stiffness) and warmth at the injury site compared to nearby areas. Over time, as tissues become more damaged, the area becomes cooler to the touch.

Barrier film helps to

provide an airtight seal needed for negative-pressure wound therapy (NPWT) and protects the periwound from maceration.

6 stages of the braden scale

sensory perception moisture activity mobility nutrition friction and shear

shear

shear force is the sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary. Ex.: 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. Also, occurs when transferring a patient from the bed to the stretcher and the patients skin is pulled across the bed.

A wound with drainage

should be dressed with precut split gauze to provide absorption of the drainage from the wound.

slough

soft yellow or white tissue. Stringy substance attached to wound bed. It must be removed by a skilled clinician or with the use of an appropriate wound dressing before the wound is able to heal.

friction

the force of two surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens.

Fibroplasia definition

the process of forming fibrous tissue (as in wound healing). Protein assists in this to quicken fibrous tissue growth.

Foam dressings are used

to absorb the drainages around drainage tubes.

Calcium alginate is used for

wounds with excessive drainage; therefore, this patient should receive a calcium alginate dressing because the alginate forms a gel when it comes in contact with the wound fluid.

What factors put an elderly client to impaired skin integrity?

Moisture Poor nutrition/nutritional deficiency (meaning proper vitamins ex: Vit. A etc) (not necessarily anorexia or obese) Edema Obesity (specifically bc of skin folds) Age Illness and infections Incontinence Immobility Hygiene Poor circulation Medications/corticosteroids Not turning Cognitive decreased circulation Lifestyle/exercise/smoking etc Loss of subcutaneous fat Diminished sensation (ex diabetics) padding bony prominences

Which of the following requires a Dr.'s orders?

Moisturizing lotion - no Antifungal (includes nystatin) - yes Skin barrier - no Hydrocortisone - yes Neosporin or another antibiotic cream - yes

Identify essentials of nursing skin assessment.

NOT COMPLETE...... NEED MORE!! Include: Hair Nails

Blanching

Normal skin blanches! The beginning of pressure problems does not turn white! Turns lighter in color then the color (normal red tones) comes back almost immediately. In dark-skinned pts, dark skin may not show the blanch response. Instead, after applying light pressure, lk for an area darker than the surrounding skin or one that is taut, shiny or indurated (hardened). Look for localized changes in skin texture and temperature.

Describe (causes and implications) of: " Onset & Duration Acute" of wound classifications.

ONSET & DURATION ACUTE: Description: Wound that proceeds through an orderly & timely reparative process that results in sustained restoration of anatomical & functional integrity. Causes: Trauma. Surgical incision. Implications for healing: Wound edges are clean and intact.

Name the 5 types of wound classifications.

Onset & Duration Acute Chronic Healing Process/Primary Intention Secondary Intention Tertiary Intention

What must be determined before initiating moist wound healing?

Adequate blood circulation at the wound site. With moist wound healing you are keeping the body moist so the body can debride (removal of nonviable, necrotic tissue)itself. But you have to have adequate blood circulation for the phagocytosis to occur for the toxins to be pulled away.

skin disntegration

An ulcer, a lesion or sore on the skin or mucous membrane resulting from the gradual disintegration of surface epithelial tissue.

Which nutrient is an antioxidant that promotes wound healing? 1 - Zinc 2 - Protein 3 - Vitamin C 4 - Vitamin A

Answer 3 Vitamin C is an antioxidant that is useful in wound healing by promoting collagen synthesis, capillary wall integrity, fibroblast function, and immunity. Zinc is an essential nutrient that promotes collagen formation, protein synthesis, and cell membrane and host defenses. Proteins support healing with fibroplasia, angiogenesis, collagen formation, and wound remodeling while boosting immunity. Vitamin A supports healing with epithelialization, wound closure, inflammatory response, angiogenesis, and collagen formation. p. 1196

How is the nursing care for a patient who has a stage IV pressure ulcer different from that for a patient who has a stage I pressure ulcer? 1 - Stage IV requires keeping the patient out of a have slouched position. 2 - Stage IV requires the use of a low-air-loss, alternating pressure, or air-fluidized support surface. 3 - Stage IV requires keeping the patient out of a prolonged head-of-bed elevation position. 4 - Stage IV requires consulting a seating specialist for the appropriate seating surface for the patient.

Answer is #2: Stage IV requires the use of a low-air-loss, alternating pressure, or air-fluidized support surface. For patients who have stage IV pressure ulcers, special support surfaces such as low-air-loss (mattress overlays which alternate/redistribute pressure), and air-fluidized support surfaces (surfaces that change load distribution using air and fluid support to provide pressure redistribution). ************************************** Patients with stage I ulcers, they would use higher-specification foam or a similar nonpowered redistribution support surface. Both stages require: **Keeping the patient out of a slouched position **Keeping the pt. out of prolonged head-of-bed elevation position **Both stages REQUIRE consulting a seating specialist for the appropriate seating surface for the patient. p. 1209

The registered nurse is overseeing a nursing student who is collecting samples of wound drainage for culture. Which nursing action indicates a need for further learning? 1 - Cleaning a wound with normal saline 2 - Using a different method of specimen collection for each type of organism 3 - Collecting wound culture samples from old drainage 4 - Using a 10-mL disposable syringe with a 22-gauge needle

Answer is 3. The nursing student should never collect a wound culture sample from old drainage, because these organisms may not be the organisms that caused the infection. The other actions are correct. Cleaning a wound with normal saline helps to remove skin flora. The nursing student should use a different method of specimen collection for each type of organism. The nursing student should use a 10-mL disposable syringe with a 22-gauge needle to aspirate the wound drainage for culture.

What should the nurse consider when developing a nursing plan for an immobile patient whose skin is intact but is at a high risk for impaired skin integrity? 1 - Consider either a low-air-loss, alternating pressure, or air-fluidized support surface. 2 - Use a pillow under the calves so that the heels are elevated to reduce the risk of heel breakdown. 3 - Consider the use of a wheelchair cushion. 4 - Use an active support surface, such as an overlay or mattress, when frequent manual repositioning is difficult. 5 - Avoid prolonged head-of-bed elevation and a slouched position that places pressure and shear on the sacrum and coccyx.

Answers: 2, 4, and 5 For an immobile patient whose skin is intact but is at high risk for impaired skin integrity, the nurse should plan to use a pillow under the calves so that the heels are elevated to reduce the risk of heel breakdown. The nurse should also use an active support surface, such as an overlay or mattress, when frequent manual repositioning is difficult. Avoiding should also be part of the nursing plan prolonged head-of-bed elevation and a slouched position that places pressure and shear on the sacrum and coccyx. The nurse should consider using either low-air-loss, alternating pressure, or air-fluidized support surface for patients who already have pressure ulcers. The nurse will also consider using a wheelchair cushion for a patient who has a sacral or coccyx pressure ulcer. p. 1209

Which piece of knowledge does a nurse not require for assessing a patient's risk for developing pressure ulcers? Pathogenesis of pressure ulcers Factors contributing to pressure ulcer formation Factors contributing to wound healing Factors contributing to inflammation and infection

Answers: Factors contributing to inflammation and infection. While the nurse will need to be aware of factors contributing to inflammation and infection, this is a separate assessment from that for the risk of pressure ulcer development. However, to assess a patient's risk for pressure ulcer development, the nurse must understand the pathogenesis of pressure ulcers, factors contributing to pressure ulcer formation, and factors contributing to wound healing. p. 1197

For which pressure ulcers would the nurse include education related to both granulation and reepithelialization? Stage I Stage II Stage III Stage IV Unstageable

Answers: Stage III & Stage IV Stage III and Stage IV pressure ulcers are expected to heal through granulation and reepithelialization, so the nurse would educate the patients on these expected changes. The nurse would teach a patient with a stage I ulcer about healing over 7 to 14 days, a patient with a stage II ulcer about healing via reepithelialization, and a patient with an unstageable ulcer about softening the eschar with debridement. p. 1213

What does the nurse teach a pt. with a Stage I Pressure Ulcer?

Answer: The nurse would teach a patient with a stage I ulcer about healing over 7 to 14 days, p. 1213

Under the supervision of the registered nurse, the nursing student is repositioning a patient to reduce the risk of pressure ulcers. Which nursing action indicates a need for further learning? 1 Teaching the patient to shift his or her weight every 15 mins 2 Encouraging the patient to sleep in a supine position 3 Encouraging the patient to sit on a donut-shaped cushion 4 Encouraging the patient to place the ischial areas on an air-filled pillow

Answer: Rigid and donut-shaped cushions reduce blood supply to the vulnerable areas, resulting in wider areas of ischemia. Therefore, the patient who is at risk of pressure ulcers should avoid such cushions. The remaining actions are correct. If the patient can shift his or her weight every 15 minutes, this can help prevent pressure ulcers. The pressure on the ischial tuberosities, areas at risk for ulcers, can be reduced to a certain extent by allowing the patient to rest in a supine position. Using a foam, gel, or air cushion can help redistribute weight away from the ischial areas. p. 1207

Which patient statement indicates understanding of the disadvantages of using moist applications for wound therapy? "It increases body fluid loss." "It causes maceration of the skin." "It causes increased drying of the skin." "It does not penetrate deep into tissues."

Answer: "It causes maceration of the skin." A disadvantage of using moist applications for wound therapy is that it can cause maceration of the skin. Increased loss of body fluid, increased drying of the skin, and lack of penetration to deep tissues are disadvantages of dry, not moist, applications for wound therapy. p. 1221

The nursing instructor is discussing the Braden Scale for pressure ulcer development risk with a nursing student. Which of the student's statements is incorrect? 1 "The Braden Scale has shown sufficient predictive validity and accuracy for all patients." 2 "The Braden Scale was developed based on risk factors in a nursing home population." 3 "The Braden Scale contains six subscales, and the total score ranges from 6 to 23." 4 "The Braden Scale is the most widely used risk assessment tool for pressure ulcers."

Answer: 1 The Braden Scale for pressure ulcer development risk has shown insufficient predictive validity and poor accuracy in determining risk for pressure ulcers. It was developed based on risk factors in a nursing home population. The Braden Scale contains six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The total score ranges from 6 to 23. It is the most widely used risk assessment tool for pressure ulcers. p. 1194

What step is a component of the planning phase for a patient who has impaired skin integrity? 1 - Involve the patient and family in choosing interventions. 2 - Apply standards of practice outlining expected outcomes. 3 - Examine the patient's skin for impairment of skin integrity. 4 - Ask the patient for his or her perception of skin integrity after the intervention.

Answer: 1 Involving the patient who has impaired skin integrity and his or her family in choosing interventions is part of the planning phase. Applying the standards of practice outlining the expected outcomes is part of the evaluation phase. Examining the patient's skin for impairment of skin integrity is part of the assessment phase. Asking the patient for his or her perception of skin integrity after the intervention is part of the evaluation phase. p. 1203

The registered nurse is overseeing a nursing student who is providing a dressing change to a patient who had a cesarean section. Which nursing action indicates a need for further learning? 1 - Choosing a dressing that keeps the periwound moist 2 - Applying a dressing that controls exudates from the wound 3 - Cleaning the periwound and wound without applying pressure 4 - Using sterile normal saline and a sterile gauze to clean the surgical wound

Answer: 1 The nurse providing wound care should choose a dressing that keeps the periwound skin dry and the surgical wound bed moist to promote healing. The dressing used for wound care should control exudate from the wound, but it should not desiccate the wound bed. Application of pressure while cleaning the periwound and wound may deepen the wound bed. Using sterile normal saline and a sterile gauze to clean the surgical wound reduces the incidences of infection. p. 1211

Which condition warrants the use of cold therapy? 1 Direct trauma 2 Rectal surgery 3 Painful hemorrhoids 4 Vaginal inflammation

Answer: 1 The nurse should apply cold therapy in instances of direct trauma to diminish swelling and pain. Heat therapy rather than cold therapy is used for patients recovering from rectal surgery or experiencing hemorrhoids and vaginal inflammation. p. 1221

Which task can be delegated to nursing assistive personnel (NAP) in caring for a patient who has pressure ulcers? 1 - Applying an elastic bandage 2 - Performing wound irrigation 3 - Implementing negative-pressure wound therapy 4 - Assessing the patient for the risk of additional pressure ulcers

Answer: 1 1 - Applying an elastic bandage The task of applying an elastic bandage can be delegated to nursing assistive personnel (NAP). The task of performing wound irrigation cannot be delegated to NAP, because it requires a sterile technique for wound care. The task of implementing negative-pressure wound therapy cannot be delegated to NAP. NAP are not allowed to assess patients for the risk of pressure ulcers; only health care providers can perform this assessment. p. 1238

What is the advantage of a moist application in wound healing? 1 - Does not promote sweating 2 - Does not cause skin maceration 3 - Retains temperature longer 4 - Less risk for burns to the skin than dry applications

Answer: 1 - Does not promote sweating A warm, moist application does not promote sweating, so it limits unnecessary fluid loss. A dry, not moist, application does not cause skin maceration. Dry, not moist, heat retains temperature longer, because evaporation does not occur. Dry heat carries less risk for burns skin than does moist heat. p. 1221

The nurse performs the skin and risk assessment on a patient who has diabetes and limited mobility due to a fractured left hip and finds that the skin is intact without any skin disintegration. Which nursing intervention should the nurse provide to the patient? 1 - Place a pillow under the patient's calves. 2 - Position the patient at a 30-degree medial turn. 3 - Use standard hospital foam mattresses for the patient. 4 - Recommend alternating pressure support surfaces for the patient.

Answer: 1 - Place a pillow under the pt.'s calves. ***************************************** Although the patient's skin is currently healthy, the patient's diabetes and limited mobility put this patient at a high risk for developing pressure ulcers. As a preventive measure, the nurse should place a pillow under the calves of the patient to elevate the heels to reduce the risk of heel breakdown. Such patients should be positioned at a 30-degree lateral, not medial, turn position to avoid typical at-risk pressure points. The nurse should use higher-specification foam mattresses rather than standard hospital foam mattresses. Alternating pressure support surfaces are needed for patients who already have ulcers. These are not necessary for this patient. p. 1209

What is the most important nursing intervention that the nurse should provide to a patient who has impaired physical mobility related to incisional pain? 1 - Reposition the patient at least once every 90 minutes. 2 - Apply a dressing to the area to support moist wound healing. 3 - Apply a moisture barrier to the incisional area at least three times daily. 4 - Pack open areas of the wound with gauze moistened with antibiotic solution.

Answer: 1 - Reposition pt. @ least once every 90 mins. A patient who is diagnosed with impaired physical mobility related to incisional pain should be repositioned at least once every 90 minutes. This helps redistribute the pressure on the skin. Applying dressings and moisture barriers to the wound promote healing but do not address the risks caused by impaired mobility. Applying antibiotics to the wound helps prevent infection but does not address the risks caused by impaired physical mobility. p. 1205

Which advantages should the nurse include in a teaching session on the benefits of using moist applications for treating a wound? 1 - Softens wound exudate 2 - Decreases the risk for burns 3 - Conforms well to most body areas 4 - Penetrates deeply into tissue layers 5 - Retains temperature longer because evaporation does not occur

Answer: 1, 3, and 4: 1 - Softens wound exudate; 2 - Conforms well to most body areas and 3 - Penetrates deeply into tissue layers. The benefits of using moist applications when treating wounds include softening the exudate, conforming well to most body areas, and penetrating deeply into the tissue layers. Decreased risk for burns and retaining temperature longer because evaporation does not occur are both benefits of using dry, not moist, applications. p. 1221

What purpose does the dry gauze dressing serve in wound healing? 1 - Aids in hemostasis 2 - Keeps the wound dry 3 - Provides debridement 4 - Keeps the periwound skin moist 5 - Prevents microbial contamination

Answer: 1, 3, and 5 1 - Aids in hemostasis 3 - Provides debridement 5 - Prevents microbial contamination Wound dressing maintains hemostasis, a series of events designed to control blood loss, establish bacterial control, and seal the defect that occurs when there is an injury. The dry gauze dressings help to remove the dead and contaminated tissues from the wound, debridement, thus promoting wound healing. The dressings also help to prevent microorganism contamination. The dressings keep the wound moist, not dry, and the periwound area dry, not moist. p. 1211

What amount of protein per kilogram of body weight a day should the nurse recommend a patient consume to support wound healing? 1.25 to 1.5 g 2 to 3.5 g 3.5 to 4.5 g 5.15 to 6.5 g

Answer: 1.25 to 1.5 g The nurse should recommend that the patient consume 1.25 to 1.5 g of protein per kilogram of body weight a day to support wound healing. p. 1196

When an injury is a result of trauma from a dirty penetrating object, a tetanus antitoxin injection is necessary unless the patient's last shot was administered within the past years. Record you answer using whole number.

Answer: 10 years When an injury is a result of trauma from a dirty penetrating object, a tetanus antitoxin injection is necessary if the patient has not had one within 10 years. p. 1200

What amount of zinc is recommended for wound healing? 15-30 mg 30-50 mg 25-60 mg 50-70 mg

Answer: 15 - 30 mg The amount of zinc recommended for wound healing is 15 to 30 mg. The amounts of 30 to 50 mg, 25 to 60 mg, and 50 to 70 mg are more than is necessary. p. 1196

A patient who has a stage III pressure ulcer develops a body temperature of 103° F. While changing the wound dressing, the nurse finds purulent discharge with an odor coming from the wound. What will the nurse suspect is occurring in the patient? 1 Bruising 2 Infection 3 Internal bleeding 4 Blanchable erythema

Answer: 2 A patient who has a stage III pressure ulcer has full-thickness skin loss. Purulent drainage with a characteristic odor and a fever are indications of wound infection. Skin discoloration to bluish and purplish color are manifestations of bruising. Internal bleeding manifests as swelling and bluish discoloration at the affected part. Blanchable erythema is visible skin redness that becomes white when pressure is applied and reddens when pressure is relieved, but it does not come with fever and purulent discharge. p. 1197

What is characteristic of stage III pressure ulcers? 1 Underlying muscle is exposed 2 Slough may be present with slough, but it does not obscure the depth of tissue loss. 3 Discoloration of the skin, warmth, edema, hardness, and/or pain may be present. 4 It presents as a shallow, open ulcer with a red-pink wound bed without slough.

Answer: 2 In a stage III pressure ulcer, there is full-thickness skin loss. Slough may be present, but it does not obscure the depth of tissue loss. In a stage IV pressure ulcer, there is full-thickness tissue loss, exposing bone, tendon, or muscle. In a stage I pressure ulcer, there may be discoloration of the skin, warmth, edema, hardness, or pain. In a stage II pressure ulcer, partial-thickness loss of dermis presents as a shallow, open ulcer with a red-pink wound bed without slough. p. 1189

Which statement regarding the skin is true? 1 The stratum corneum prevents entrance of topical medications. 2 The dermis, the inner layer of the skin provides tensile strength. 3 The basal layer of the epidermis is responsible for collagen formation. 4 The three layers of the skin are the epidermis, dermis, and endodermis.

Answer: 2 The dermis (which is the inner layer of the skin) provides tensile strength and mechanical support to the muscles, bones, and inner organs. The top layer the epidermis (has several layers to it). The thin, outermost layer of the epidermis is the stratum corneum The stratum corneum promotes, absorption of topical medications. Fibroblasts, not the basal layer of the epidermis, are responsible for collagen formation. The skin has two layers only: the top layer called the epidermis and the lower layer called the dermis. p. 1187

Which pressure ulcer site is found immediately distal to the buttock? 1 - Sole 2 - Ischium 3 - Sacrum 4 - Scapula

Answer: 2 The ischium pressure ulcer site is just below the buttock on the upper thigh. The sole pressure ulcer site is found on the bottom of the foot. The sacrum pressure ulcer site is on the tailbone, or just above the gluteal area. The scapula pressure ulcer site is found on the shoulder blade. pg. 1199

A patient with an abdominal wound from a motor vehicle accident comes into the emergency room with evisceration. The nurse immediately places sterile gauze soaked in sterile saline over the extruding tissues. What is the rationale for this nursing action? 1 - To reduce pain 2 - To prevent infection 3 - To prevent pressure ulcers 4 - To prevent periwound edema

Answer: 2 To prevent bacterial invasion and drying of the extruding tissues. Evisceration is a medical emergency in which the visceral organs protrude through a wound opening. Immediate application of sterile gauzed soaked in sterile saline over the extruding tissues helps to prevent bacterial invasion, infection, and drying of the tissues. Analgesics will be used to reduce pain. Pressure ulcer prevention will not be a primary concern in an emergency situation such as this. Saline-soaked gauze will not prevent edema.

What does the nonblanchable erythema indicate about the skin? 1 The tissue is infected. 2 The tissue is damaged. 3 The tissue is under hypoxia. 4 The tissue is under pressure.

Answer: 2 2 - The tissue is damaged The nonblanchable erythema indicates that the tissue was under pressure and caused inflammation, leading to tissue damage. The tissue is infected when there is drainage from the wound or sutures at the surgical site. The tissue appears mottled or exhibits pallor when it is under hypoxia. The tissue with erythema is an early indication of pressure to the tissue. p. 1225

The nurse is assisting the primary health care provider in applying moist dressing for a patient who has pressure ulcers. The nurse reviews the orders for the dressing change procedure. What is the rationale behind this nursing action? 1 - To prevent adverse reactions 2 - To learn the type of dressing that is to be used 3 - To determine the specific areas that will be included during patient teaching 4 - To plan for the proper type of supplies required for dressing

Answer: 2 2 - To learn the type of dressing that is to be used Reviewing the orders for the dressing change procedure indicates to the nurse the type of dressing or applications needed for dressing the wound. The nurse should assess the patient for any allergies to wound cleansing agents or any other agents used while dressing, to prevent adverse reactions. The nurse assesses the patient's and the family's knowledge of wound dressing to determine what will need to be included while teaching them. Reviewing the patient's medical record to learn about the size and location of the wound helps the nurse to plan for the proper type and amount of supplies required for dressing the wound. p. 1228

Which advantages should the nurse include in a teaching session on using dry applications when treating a wound? 1 - Softens wound exudate 2 - Decreases the risk for burns 3 - Conforms well to most body areas 4 - Penetrates deeply into tissue layers 5 - Retains temperature longer because evaporation does not occur

Answer: 2 & 5 Decreases the risk for burns; and Retains temperature longer because evaporation does not occur The benefits of using dry applications when treating wounds include a decreased risk for burns and retaining the temperature longer because evaporation does not occur. The benefits of moist, not dry, applications include softening the exudate, conforming well to most body areas, and penetrating deeply into the tissue layers. p. 1221

Which patient statement indicates understanding of the advantages of using dry applications for wound therapy? 1 - "It softens wound exudate." 2 - "It reduces the risk of burns." 3 - "It conforms well to most body areas." 4 - "It allows heat to penetrate deeply into tissue layers."

Answer: 2 - "It reduces the risk of burns." Dry heat applications for wound therapy decrease the risk for burns. This patient statement indicates understanding of the advantages of using dry applications for wound therapy. Moist, not dry, applications soften wound exudate, conform well to most body areas, and allow heat to penetrate deeply into the tissue layers.

Which action is inappropriate for maintaining an airtight seal in negative-pressure wound therapy? 1 - Avoiding adhesive removers 2 - Moistening the periwound area thoroughly 3 - Framing the periwound area with skin sealant 4 - Filling uneven skin surfaces with a skin-barrier product

Answer: 2 - Moistening the periwound area thoroughly To maintain an airtight seal, the periwound area should be dried thoroughly, not moistened. The remaining actions are appropriate. Adhesive removers should be avoided because they leave a residue that hinders film adherence. The periwound area should be framed with skin sealant. Uneven skin surfaces should be filled with skin-barrier products. p. 1215

What is characteristic of stage III pressure ulcers? 1 - Underlying muscle is exposed 2 - Slough may be present with slough, but it does not obscure the depth of tissue loss. 3 - Discoloration of the skin, warmth, edema, hardness, and/or pain may be present. 4 - It presents as a shallow, open ulcer with a red-pink wound bed without slough.

Answer: 2 - Slough may be present w/ slough, but it does not obscure the depth of tissue loss. In a stage III pressure ulcer, there is full-thickness skin loss. Slough may be present, but it does not obscure the depth of tissue loss. In a stage IV pressure ulcer, there is full-thickness tissue loss, exposing bone, tendon, or muscle. In a stage I pressure ulcer, there may be discoloration of the skin, warmth, edema, hardness, or pain. In a stage II pressure ulcer, partial-thickness loss of dermis presents as a shallow, open ulcer with a red-pink wound bed without slough. p. 1189

While applying gauze dressing to a wound, the patient complains of severe pain. What could be the reason for the pain? 1 The nurse did not use gloves to clean the wound site. 2 The nurse did not remove the gauze dressings one at a time. 3 The nurse did not perform hand hygiene before wearing gloves. 4 The nurse did not use sodium hypochlorite for irrigating the wound.

Answer: 2 - The nurse did not remove the gauze dressings one at a time. If the nurse removes the dressings all at the same time from a patient, dislocation occurs and may cause pain. The gauze dressings should be removed one layer at a time to prevent the dislocation of underlying drains and tubing. The nurse uses gloves to prevent infection when cleaning the wound site; not wearing them would not cause pain for the patient. Hand hygiene is performed to provide the dressing in a sterile environment and prevent the transmission of microorganisms. If a nurse does not perform hand hygiene, it may pose a risk of infection, but not pain. Not using sodium hypochlorite for irrigating the wound should not cause pain to the patient. p. 1229

What might the nurse anticipate for a patient with new-onset bowel incontinence that is causing compromised skin integrity? 1 - A new prescription for a diuretic. 2 - A change in dietary prescription. 3 - The implementation of timed voiding. 4 - The implementation of physical therapy.

Answer: 2 A change in dietary prescription. ********************************** New onset bowel incontinence is often treated with a change in diet. A nurse would expect a new prescription for a diuretic if the patient needed increased urine output, but this would not improve bowel incontinence. The implementation of timed voiding is more appropriate for urinary, not bowel, incontinence. The implementation of physical therapy would be appropriate for a patient with impaired mobility, but not bowel incontinence.

Which support surface is useful for treating and preventing pulmonary, venous stasis, and urinary complications associated with immobility? 1 - Low-air-loss surface 2 - Nonpoweredsurface 3 - Lateral rotation surface 4 - Air-fluidized bed

Answer: 3 A lateral rotation support surface is useful in treating and preventing pulmonary, venous stasis, and urinary complications associated with immobility. Low-air-loss and nonpowered support surfaces help in preventing and treating skin breakdown. An air-fluidized bed support surface prevents skin breakdown and may also be used to protect newly flapped or grafted surgical sites. p. 120

A patient who has an acute wound due to trauma is admitted to the emergency unit. Which nursing action for wound care is the priority in this situation? 1 - Educating the patient about wound care 2 - Positioning the patient in different angles 3 - Encouraging the patient to drink 6 to 8 L of water 4 - Applying a sterile dressing as per the health care provider's order

Answer: 3 An acute wound due to trauma needs an immediate intervention, such as the application of a sterile dressing to reduce bleeding and prevent sepsis. The nurse may educate the patient about hygiene and wound care, have the patient change positions to prevent pressure ulcers, and encourage the patient to drink 6 to 8 L of water to promote cell function, but these are all secondary to stopping the bleeding.

Which sign is an early indication of pressure that resolves without tissue loss if the pressure is eliminated? 1 - Pallor or molting 2 - Dark red or purple discoloration 3 - Blanchable erythema 4 - Nonblanchable erythema

Answer: 3 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 I pressure ulcer. p. 1225

According to the Braden Scale for predicting pressure ulcer risk, which factor most puts the patient at risk for developing a pressure ulcer? 1 Dry skin 2 Walks occasionally 3 Poor nutrition 4 Slightly limited sensory perception

Answer: 3 Of these factors, the patient's poor nutrition carries the highest risk for the patient developing a pressure ulcer. The better the nutrition, the lower the risk. Moist, not dry, skin puts a patient at a greater risk for developing a pressure ulcer. Although frequent, rather than occasional, activity is ideal for reducing the risk for developing a pressure ulcer, the more immobile the patient is, the greater the chance of pressure ulcer development. Slightly limited sensory perception puts a patient at less of a risk than does very limited or completely limited sensory perception.

The registered nurse is overseeing a nursing student who is collecting samples of wound drainage for culture. Which nursing action indicates a need for further learning? 1 Cleaning a wound with normal saline 2 Using a different method of specimen collection for each type of organism 3 Collecting wound culture samples from old drainage 4 Using a 10-mL disposable syringe with a 22-gauge needle

Answer: 3 The nursing student should never collect a wound culture sample from old drainage, because these organisms may not be the organisms that caused the infection. The other actions are correct. Cleaning a wound with normal saline helps to remove skin flora. The nursing student should use a different method of specimen collection for each type of organism. The nursing student should use a 10-mL disposable syringe with a 22-gauge needle to aspirate the wound drainage for culture. p. 1201

What is the role of vitamin A in wound healing? 1 Quickens fibroplasia 2 Acts as an antioxidant 3 Promotes wound closure 4 Acts as immune function

Answer: 3 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. p. 1196

What is the role of vitamin A in wound healing? 1 - Quickens fibroplasia 2 - Acts as an antioxidant 3 - Promotes wound closure 4 - Acts as immune function

Answer: 3 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. p. 1196

A nurse is educating a patient about the role of nutrients in wound healing. Which statement will the nurse include? 1 - "Zinc facilitates angiogenesis, and the recommended quantity is 10 to 15 mg." 2 - "Vitamin C promotes collagen synthesis, and the recommended quantity is 2000 mg/day." 3 - "Protein facilitates collagen formation, and the recommended quantity is 1.25 to 1.5 g protein per kilogram of body weight." 4 - "Vitamin A promotes wound closure, and the recommended quantity is 1100 to 1400 retinol equivalents per day."

Answer: 3 - "Protein facilitates collagen formation, and the recommended quantity is 1.25 to 1.5g protein per kilogram of body weight." Protein helps in collagen formation, and the recommended quantity for wound healing is 1.25 to 1.5 g protein per kilogram of body weight. Protein also helps in fibroplasia, angiogenesis, and immune function. Zinc is needed for collagen formation, not angiogenesis, and the recommended quantity is 15 to 30 mg. Vitamin C promotes collagen synthesis, but the recommended quantity is 1000 mg/day, not 2000 mg/day. Vitamin A promotes wound closure, but the recommended quantity is 1600 to 2000, not 1100 to 1400 retinol equivalents per day. p. 1196

Which statement is true regarding cold application? 1 - It causes vasodilation. 2 - It reduces blood viscosity. 3 - It decreases muscle tension. 4 - It increases tissue metabolism.

Answer: 3 - It decreases muscle tension. Cold application decreases muscle tension and helps relieve pain. Heat, not cold, application causes vasodilation, reduced blood viscosity, and increased tissue metabolism due to increase in blood flow. p. 1221

Which nursing interventions are appropriate when a patient complains of sensation under the dressing? 1 Apply pressure over the wound 2 Instruct the patient to walk for some time 3 Observe the wound for increased drainage 4 Report to the primary health care provider immediately 5 Cover the wound with a sterile moist dressing if underlying organs protrude

Answer: 3, 4, and 5 When a patient reports of sensation under the dressing, then the nurse should immediately observe the wound for increased drainage. The nurse should also inform the primary health care provider immediately, because sensation under the wound is a serious complication. If the nurse observes protrusion of underlying organs, then the nurse should protect them by covering the wound with a sterile moist dressing. The nurse should not apply pressure on the wound in this condition, because sensation under the wound is a serious complication; pressure should be applied when the nurse observes bleeding in the wound while dressing. The nurse should instruct the patient to lie still and not move around, to manage the condition. p. 1232

The nurse is preparing a care plan for a patient who has a pressure ulcer on the coccyx. Which part of the plan is included to provide comfort to the patient? 1 Repositioning the patient every 90 minutes 2 Cleaning and massaging around the affected area 3 Elevating the head of the patient's bed to 30 degrees 4 Applying a moisture barrier ointment over the ulcer

Answer: 4 Ointments may decrease friction with the sheets and cover the affected area, encouraging healing and moisture in open ulcers and minimizing patient discomfort. The patient should be repositioned every 90 minutes to reduce pressure over vulnerable areas of the body, but this does not necessarily relieve the patient's discomfort. Elevation of the patient's head of the bed is avoided to minimize further pressure on the sacrum and coccyx. Rubbing or massaging the affected areas may cause tissue damage, so this is avoided. p. 1204

While caring for a patient in the postsurgical unit, the nurse palpates the area around the surgical wound and asks the patient if there is tenderness. What is the rationale behind this nursing action? 1 - To assess for the risk of abrasion 2 - To assess for the risk of hematoma 3 - To assess for the risk of evisceration 4 - To assess for the risk of periwound edema

Answer: 4 The nurse may assess the patient for periwound edema and pain by palpating the affected area for tenderness. An abrasion is a small superficial wound with little damage to the capillaries. Swelling, bluish discoloration, sensation, and warmth are signs of a hematoma. Evisceration is an emergency condition in which visceral organs protrude out through the wound opening. Abrasion, hematoma, and evisceration can be observed with visual inspection; palpation is not necessary.

Which is characteristic of abnormal healing in a secondary-intention wound? 1 - Increase in inflammation in the first 3 to 5 days after injury 2 - Absence of epithelialization of wound edges by day 4 3 - Presence of drainage for more than three days after closure 4 - Presence of necrotic or slough tissue at the base of the wound

Answer: 4 The presence of necrotic or slough tissue at the base of the wound indicates abnormal healing in a secondary-intention wound. An increase in inflammation in the first 3 to 5 days after injury, an absence of epithelialization of the wound edges by day 4, and the presence of drainage for more than 3 days after wound closure are characteristic of abnormal healing of a primary-intention wound, not a secondary-intention wound. p. 1200

The nurse observes the development of a pressure ulcer in a patient while providing care after hip replacement surgery. Which nursing intervention would have prevented the pressure ulcer? 1 - Assessing sensory perception 2 - Using foam wedges for positioning 3 - Frequently turning the patient on the bed 4 - Monitoring the surgical area for drainage

Answer: 4 4 - Monitoring the surgical area for drainage ************************************ The drainages from the surgical site can make the skin more sensitive and render skin breakdown if not corrected; therefore, the nurse should assess the surgical site for drainages to prevent pressure ulcer development. A patient who has no sensory perception can be at risk for developing pressure ulcers; therefore, a nurse should provide pressure-redistribution surface. Assessing sensory perception in the patient with hip replacement surgery may not be helpful to prevent pressure ulcer development. A patient who has undergone hip replacement surgery should not be moved on the bed; therefore, using foam wedges for positioning and frequently turning this patient will not prevent pressure ulcer development. p. 1224

When cleaning a wound, which action is incorrect? 1 - Using two separate swabs to clean the affected site 2 - Irrigating from the least to most contaminated area 3 - Applying noncytotoxic solutions using gentle friction 4 - Cleaning from the surrounding skin to the site of incision

Answer: 4 The nurse should clean away from the wound to prevent contamination. Two separate swabs are to be used: one to clean from the top of the incision toward the draining site and another to clean from the bottom of the incision toward the draining site. Irrigation fluid should flow from the least to most contaminated area to prevent transmission of bacteria. Application of pressure while cleaning the wound should be avoided, but gentle friction may be applied while cleaning the traumatic wound with the noncytotoxic solution. p. 1215

A nurse discusses the purposes of wound dressings with a nursing student. Which of the nursing student's statements indicates the need for further learning? 1 - "Dressings absorb drainage to promote wound healing." 2 - "Dressings promote hemostasis and thermal insulation." 3 - "Dressings help reduce exposure to microorganisms, and they support the wound site." 4 - "Dressings provide a dry environment to facilitate healing."

Answer: 4 - "Dressings provide a dry environment to facilitate healing." ********************************** A dressing supports a moist wound environment, not a dry one. The remaining statements indicate understanding. Dressings absorb drainage to promote wound healing, promote hemostasis and thermal insulation, help reduce exposure to microorganisms, and support the wound site. p. 1211

What intervention should the nurse plan for a patient who has a sacral pressure ulcer? 1 - Apply a moisture barrier to the wound at least twice daily. 2 - Administer an analgesic 15 minutes before repositioning and wound care. 3 - When the patient is lying down, position him or her in a 45-degree lateral position. 4 - Pack open areas of the wound with gauze moistened with an antibiotic solution.

Answer: 4 - Pack open areas of the wound with gauze moistened w/ an antibiotic solution. For a patient who has a sacral pressure ulcer, the nurse will plan to pack the open areas of the wound with gauze moistened with an antibiotic solution. The nurse should apply a moisture barrier to the area at least three times daily; twice a day is not enough. Administering analgesics 15 minutes before repositioning and wound care does not allow enough time for pain relief; they should be provided 30 minutes ahead of time. When the patient is lying down, he or she should be positioned in a 30-degree, not 45-degree, lateral position. p. 1205

Which nursing intervention is appropriate for a patient who is at risk for skin breakdown due to friction and shear? 1 Keep the skin dry and free of maceration 2 Provide pressure-redistribution surface 3 Consult a dietician for nutritional assessment 4 Provide a trapeze to facilitate movement in bed

Answer: 4 - Provide a trapeze to facilitate movement in bed Whereas all of these interventions are appropriate for a patient who is at risk for skin breakdown, the one specific to a patient at risk for skin breakdown due to friction and sheer is to provide a trapeze to facilitate movement in the bed. Keeping the skin dry and free of maceration is appropriate for a patient who is at risk for skin breakdown due to moisture. Providing a pressure-redistribution surface is appropriate for a patient who is at risk for skin breakdown due to decreased sensory perception. Consulting a dietician for a nutritional assessment is appropriate for a patient who is at risk for skin breakdown due to poor nutrition. p. 1206

When performing any wound care procedure, which nursing action is appropriate for addressing the patient's pain and discomfort? Administering pain medication after the procedure Administering pain medication at the beginning of the procedure Administering pain medication 10 to 20 minutes before the procedure Administering pain medication 30 to 60 minutes before the procedure

Answer: Administering pain medication 30 to 60 minutes before the procedure. To address the patient's pain and discomfort during a wound care procedure, the nurse administers pain medication 30 to 60 minutes before the procedure, depending on the time of peak action for the prescribed drug. Administering pain medication after the procedure will not provide analgesia during the procedure. Administering pain medication at the beginning of the procedure or 10 to 20 minutes before the procedure will not provide relief quickly enough. p. 1215

The nurse reviews the primary health care provider's orders for the amount of negative pressure to be applied while providing negative-pressure wound therapy (NPWT) to a patient. Which step of the nursing process is involved in this situation? Planning Evaluation Assessment Implementation

Answer: Assessment Assessment is the first step of the nursing process in which the nursing actions include reviewing the health care provider's orders for the frequency of dressing change, type of foam to be used, and the amount of negative pressure to be applied. Planning is the next step of the nursing process in which the nurse administers analgesics before changing the dressing. Evaluation is the last step of the nursing process in which the nurse evaluates the outcome of the interventions by inspecting the wound. Implementation comes after planning; this is the main step in which the treatment is provided. p. 1234

Which stage of the pressure ulcer involves partial-thickness loss of the dermis and manifests as a red-pink, open ulcer without slough? A - Stage I B - Stage II C - Stage III D - Stage IV

Answer: B A stage II pressure ulcer involves partial-thickness loss of the dermis and manifests as a red-pink, open ulcer without slough. A stage I pressure ulcer presents as intact, nonblanchable, red skin, often over a bony prominence. A stage III pressure ulcer involves full-thickness tissue loss so that subcutaneous fat is visible. A stage IV pressure ulcer involves full-thickness tissue loss extending to and exposing bone, tendon, and/or muscle. pp. 1187-1190

A patient who has a burn injury is experiencing moderate drainage from the site. Which type of dressing should be provided to the patient? Foam Hydrocolloid Calcium alginate Transparent film

Answer: Calcium alginate Calcium alginate is used for wounds with excessive drainage; therefore, this patient should receive a calcium alginate dressing because the alginate forms a gel when it comes in contact with the wound fluid. Foam dressings are used to absorb the drainages around drainage tubes. Hydrocolloid dressings are used for burns with minor exudate. Transparent film dressings are used for superficial wounds. p. 1212

Which dressing will the nurse use for a patient with a clean stage III pressure ulcer? None Adherent film Composite film Calcium alginate

Answer: Calcium alginate The nurse would use a calcium alginate dressing for a patient with a clean stage III pressure ulcer. No dressing is only appropriate for an intact stage I pressure ulcer. An adherent film dressing is appropriate for an unstageable pressure ulcer. A composite film dressing is appropriate for a clean stage II pressure ulcer. p. 1213

The nurse observes increased wound drainage in a patient provided with a moist-to-dry dressing for pressure ulcers. What should be the immediate nursing intervention? Change the dressing Obtain wound culture Apply pressure on the wound Monitor the patient's white blood cell count

Answer: Change the dressing. When the wound drainage increases, the nurse should immediately change the dressing first to prevent infection. When the wound appears inflamed or tender, then the nurse can obtain wound culture to determine the risk of infection. Pressure should be applied when the wound bleeds during dressing change. The patient's white blood cell count and temperature should be monitored when the wound appears tender and inflamed, and without drainage to determine the risk of infection. p. 1232

Which action is involved in safely removing retention sutures? Cut the suture at the end nearest to the knot. Cut the suture as farthest to the skin edge as possible. Pull the visible part of the suture above the skin through underlying tissue. Clip suture materials nearest to the skin edge on one side, and pull from the other side.

Answer: Clip suture materials nearest to the skin edge on one side and pull from the other side. The nurse should clip the suture material nearest to the skin edge on one side and pull from the other side. Sutures should be cut away from the knot and nearest to the skin edge, not the knot, as possible. Sutures should never be pulled through the visible part of the suture through the underlying tissue, because this can lead to infection. p. 1217

What amount of retinol equivalents for vitamin A per day should the nurse recommend a patient to consume to support proper wound healing? A - 1200-1400 B - 1400-1500 C - 1500-1600 D - 1600-2000

Answer: D To consume enough vitamin A to support proper wound healing, the nurse should recommend 1600 to 2000 retinol equivalents per day. The amounts of 1200 to 1400, 1400 to 1500, and 1500 to 1600 are not enough. p. 1196

While assessing a patient who has a pressure ulcer, the nurse finds black wound tissue. In which stage is this pressure ulcer? A - Stage I B - Stage II C - Stage III D - Unstageable

Answer: D - Unstageable Black tissue is characteristic of an eschar. Because the eschar obscures the depth of the wound, this ulcer is unstageable. Stage I ulcers manifest as localized nonblanchable redness over intact skin. Stage II ulcers are characterized by partial-thickness dermis loss. Stage III ulcers are characterized by full-thickness skin loss to the extent that subcutaneous fat may be visible. pp. 1189-1190

Which type of gauze should a nurse use when a patient has a necrotic ulcer? Dry gauze Moist gauze Hydrocolloid Transparent film dressing

Answer: Dry gauze APPLY DRY GAUZE TO HYDROGEL AND CALCIUM ALGINATE P. 1225 The patient who has a necrotic ulcer requires dressing that causes debriding of the necrotic tissue. When debriding enzymes are used, a moist contact dressing should be placed directly over the wound. Dry gauze should be placed over the contact dressing which dries the wound and thus, facilitates removal of the dead tissues. Moist gauze is used for providing moisture to the wound for healing. Hydrocolloid and transparent film dressing are used when moisture is required for wound healing. p. 1211

A 76-year-old female patient who has osteoarthritis and mild hypertension develops redness and oozing of foul-smelling tan-colored drainage from her hip incision on postoperative day 4. Because of the pain at the incision site, she needs assistance in turning and transferring herself from her bed to the chair. What intervention will the nurse avoid? Elevating the head of the bed to 45 degrees Irrigating the wound with saline solution twice a day Helping the patient with repositioning every 90 minutes Checking the patient's pain level and offering analgesics at frequent intervals

Answer: Elevating the head of the bed to 45 degrees For a patient who has undergone hip surgery, the head of the bed should not be elevated to more than 30 degrees. The wound and surrounding area needs to be irrigated with saline solution twice a day. Helping the patient with repositioning is necessary for pressure redistribution and comfort. Checking the patient's pain level and offering analgesics at frequent intervals provides relief to the patient and allows for greater mobility. p. 1204

Which nursing action is appropriate when framing the periwound area with skin sealant? Extending the sealant 1 to 2 cm (0.4 to 0.8 in) beyond the wound edges Extending the sealant 2 to 4 cm (0.8 to 1.6 in) beyond the wound edges Extending the sealant 3 to 5 cm (1.2 to 2 in) beyond the wound edges Extending the sealant 4 to 6 cm (1.6 to 2.4 in) beyond the wound edges

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

Which type of dressing is preferred for dry wounds? Hydrogel Hydrocolloid Calcium alginate Debriding enzymes

Answer: Hydrogel Hydrogel dressings hydrate the wounds and provide a moist environment. Therefore, these dressings are preferred for dry wounds. Hydrocolloid dressings help in the healing of clean granulating wounds and autolytically debride necrotic wounds. Calcium alginate dressings should not be used in dry wounds, because they require secondary dressing. Debriding enzymes should be applied only over the necrotic areas of the wounds; they are not used specifically for dry wounds. p. 1229

Which dressing should the nurse use to protect and absorb moisture when providing care to a patient with a pressure ulcer? Gauze Adherent film Calcium alginate Hydrogel covered with foam

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

Which intervention is part of the nursing intervention classification (NIC) for wound care? Repositioning the patient every 90 minutes Irrigating the wound with a saline solution two times per day Avoiding the use of massage around the open area Elevating the head of the patient's bed to no more than 30 degrees

Answer: Irrigating the wound with a saline solution two times per day Irrigating the wound with a saline solution two times per day is an intervention that supports the wound care nursing intervention classification (NIC). Repositioning the patient every 90 minutes, avoiding the use of massage around the open area, and elevating the head of the patient's bed to no more than 30 degrees are interventions that are part of the pressure management NIC. p. 1204

Which statement is true regarding cold application? It causes vasodilation. It reduces blood viscosity. It decreases muscle tension. It increases tissue metabolism.

Answer: It decreases muscle tension Cold application decreases muscle tension and helps relieve pain. Heat, not cold, application causes vasodilation, reduced blood viscosity, and increased tissue metabolism due to increase in blood flow. p. 1221

Which type of support surface should the nurse plan to use to treat and prevent pulmonary, venous stasis, and urinary complications associated with immobility? Low-air-loss Nonpowered Lateral rotation Air-fluidized beds

Answer: Lateral rotation Lateral rotation support surfaces may be used to treat and prevent pulmonary, venous stasis, and urinary complications associated with immobility. Low-air-loss and nonpowered and support surfaces are indicated for prevention or treatment of skin breakdown. Air-fluidized beds may also be used to prevent or treat skin breakdown and to protect newly flapped or grafted surgical sites. p. 1208

The nurse is caring for a patient who is diagnosed with venous stasis ulcers. Which support surface should the nurse anticipate for this patient? Low-air-loss bed Nonpowered bed Lateral rotation Air-fluidized bed

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

Which is the priority nursing action for any wound care procedure? Carefully removing tape Gently cleaning the wound edges Turning and repositioning the patient carefully Managing pain prior to initiating care

Answer: Managing pain prior to initiating care The priority nursing action for a wound care procedure is to administer an analgesic 30 to 60 minutes prior to initiating care; this will relieve the patient's pain and discomfort. Removing tape, gently cleaning the wound edges, and turning and repositioning the patient carefully are important parts of wound care procedures, but they can be done after the patient's pain has been proactively addressed. p. 1215

Which nursing action is appropriate when providing care to a patient who has intact skin but is at high risk for impaired skin integrity of the heels? Avoid prolonged elevation of the head of the bed Order a standard hospital foam mattress Consider an alternating pressure support surface Place a pillow under the calves

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

Which is the most effective intervention for compromised skin integrity? Preventing breakdown Administering medication Implementing wound care Monitoring wound healing

Answer: Preventing breakdown The most effective intervention for compromised skin integrity and wound care is prevention of skin breakdown. Whereas administering medication, implementing wound care, and monitoring wound healing are all important nursing actions, prevention is the first step. p. 1205

Which nursing intervention is appropriate for a patient who is at risk for skin breakdown due to decreased sensory perception? Keep the skin dry and free of maceration Provide a pressure-redistribution surface Consult a dietician for nutritional assessment Provide a trapeze to facilitate movement in bed

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

A patient's wound drainage appears thick and yellow. Which type of drainage is this considered? Serous Purulent Sanguineous Serosanguineous

Answer: Purulent ********************** Purulent drainage is thick and yellow, green, tan, or brown. Serous drainage is clear, watery plasma. Sanguineous drainage is bright red, indicating active bleeding. Serosanguineous drainage is pale pink and watery. p. 1194

Upon assessing a patient's surgical incision on the left hip, the nurse observes reddened periwound tissue, foul drainage, and open areas between the staples. What is the likely nursing diagnosis? Risk for infection Risk for inflammation Impaired skin integrity related to limited mobility Impaired physical mobility related to incisional pain

Answer: Risk for inflammation The nurse's observations of reddened tissue, drainage, and open areas between the staples are characteristic of infection. The reddened periwound tissue may also indicate inflammation, but the drainage and open areas do not. Impaired skin integrity related to limited mobility would be characterized by pressure ulcers and reactive hyperemia. Impaired physical mobility related to incisional pain would be indicated by the patient reporting pain, resisting assisted movement, and not moving in bed. p. 1205

Which adjuvant treatments are only considered for patients diagnosed with clean stage IV or unstageable pressure ulcers? Support hydration Nutritional support Surgical consultation for closure Surgical consultation for debridement Evaluation of pressure-redistribution needs

Answer: Surgical consultation for closure Surgical consultation for debridement Whereas all patients diagnosed with pressure ulcers could potentially benefit from support hydration, nutritional support, and the evaluation of pressure-redistribution needs, only patients diagnosed with clean stage IV and unstageable pressure ulcers would need surgical consultation for closure (stage IV) or surgical consultation for debridement (unstageable). Support hydration, nutritional support, and evaluation of pressure-redistribution needs are interventions more appropriate for pressure ulcers in stages I-III. p. 1213

Why is maintaining an airtight seal when providing care to a patient who is receiving negative-pressure wound therapy important? To avoid a wound infection To avoid wound desiccation To avoid accelerated wound healing To avoid discomfort with wound dressing changes

Answer: To avoid wound desiccation The rationale for maintaining an airtight seal when providing care to a patient who is prescribed negative-pressure wound therapy is to avoid wound desiccation. An airtight seal in negative-pressure wound therapy will not necessarily avoid wound infection, accelerated healing, or discomfort during dressing changes. p. 1215

While dressing a patient's wound, the nurse irrigates the wound until there is a clear flow of the solution. What is the rationale behind this nursing action? To reduce the chance of skin damage To remove the debris from the wound To provide a moist environment to the wound To prevent contamination of the previously cleaned area

Answer: To remove the debris from the wound The nurse irrigates the wound until there is a clear flow of solution to remove any debris from the wound. Skin damage can be reduced by pushing the skin away from the tape while pulling the adhesive from the skin. The moist environment that heals the wound is provided by dressing the wound with moist gauze. To prevent contamination of the previously cleaned area, the wound should be cleaned from its center to its surrounding skin. p. 1230

The registered nurse is teaching a nursing student about home care considerations to prevent the risk of pressure ulcers. Which statements made by the nursing student indicate effective learning? 1 - "I should educate the patient about the signs of wound infection." 2 - "I should discuss reactive surfaces that may increase pressure to the wound." 3 - "I should instruct the patient to dispose of the soiled dressings by incineration." 4 - "I should instruct the patient to evaluate the healing by using the pressure ulcer staging system." 5 - "I should instruct the patient to approach the registered nurse if the wound does not heal within 2 weeks."

Answers: 1 & 2 1 - "I should educate the patient about the signs of wound infection." 2 - "I should discuss reactive surfaces that may increase pressure to the wound." ********************************************* The nurse should educate the patient and the family caregiver about the signs of wound infection, so that early detection of the wound can be made and appropriate intervention provided. The nurse should discuss the home associated pressure and the methods of pressure redistribution to prevent ulcer development. The soiled dressings at home should be disposed in a manner consistent with the local regulations for contaminated wastes and not by incineration. The healing process should not be evaluated by the use of a pressure ulcer staging system; this is a system to determine the depth of the wound. Healing takes 2 to 4 weeks. If the patient does not observe any healing beyond 4 weeks, then the patient should be advised to report to the health care provider or the registered nurse. pp. 1227-1228

During assessment, the nurse notes a foul-smelling drainage from the wound with deep tunneling. Which actions of the nurse indicate the need for further teaching? 1 - Covering the entire wound with the gauze 2 - Placing the dripping wet gauze into the tunnel 3 - Using the gauze only to clean the wound 4 - Using the Montgomery ties to secure the dressing 5 - Using dry dressing and topper dressing over inner gauze

Answers: 1 & 2 1 - Covering the entire wound with the gauze 2 - Placing the dripping wet gauze into the tunnel ************************************************* A nurse who is treating a deep incision wound should place the gauze into the wound incision without touching the wound area. The wound should be packed loosely to provide wicking of the drainage into the absorbent outer layer of the dressing. The nurse should wet the gauze to provide moisture to encourage wound healing, but the gauze should not be dripping. Excessively moist dressings may damage the periwound skin, and can cause a foul smell and drainage. Gauze should be used only one time for cleaning the wound; using the same gauze a second time may cause contamination of the wound. Montgomery ties are used to secure the wound in place and to prevent maceration of the periwound skin; they may not be a cause for infection. Dressing for a deep incision requires dry and topper gauze to drain out the moisture from the wound and prevent strike-through of the wound drainage respectively. p. 1231

The registered nurse is teaching a nursing student about the instructions to be followed while dressing any type of wound. Which statement made by the nurse indicates effective learning? 1 - Select the dressing that controls the exudate 2 - Choose the dressing that keeps the periwound area moist 3 - Use the same type of dressing throughout the wound care 4 - Use the dressing that provides a moist environment to the ulcer bed 5 - Clean the wound and periwound area while dressing for the first time

Answers: 1 & 4 1 - Select the dressing that controls the exudate 4 - Use the dressing that provides a moist environment to the ulcer bed. **************************************** The dressings should control the exudates, but should not desiccate the ulcer bed. Dressings that provide a moist environment to the ulcer bed should be selected for effective wound healing. The dressings should keep the periwound area dry, not moist, to prevent dermatitis and a burning sensation. The dressings should be changed regularly as the pressure ulcer heals or deteriorates. The wound and periwound areas should be cleaned every time while changing the dressing, not just during the first time. p. 1211

Which nursing interventions minimize the risk for pressure ulcer development? 1 - Repositioning the patient every two hours 2 - Using a draw sheet to assist with repositioning 3 - Conducting a nutritional assessment every 8 hours 4 - Applying barrier creams for patients who are incontinent 5 - Providing education related to preventing skin breakdown

Answers: 1, 2, 4, and 5 Three major areas of nursing interventions for prevention of pressure ulcers are: (1) skin care and management of incontinence, such as applying barrier creams for patients who are incontinent; (2) mechanical loading and support devices, which include proper positioning and the use of therapeutic surfaces, such as repositioning the patient every 2 hours and using a draw sheet during repositioning; and (3) education, such as information related to preventing skin breakdown. Conducting a nutritional assessment is important; however, this is a part of assessment and is not necessary every 8 hours. p. 1205

A patient has a stage II pressure ulcer. Which dressings might the nurse plan to use for the patient? 1 - Hydrogel 2 - Hydrocolloid 3 - Adherent film 4 - Composite film 5 - Transparent

Answers: 1, 2, and 4. Hydrogel, Hydrocolloid, & a Composite Film ****************************************** If a patient has a stage II pressure ulcer, the nurse may plan to use hydrogel, hydrocolloid, and composite film dressings. Adherent film dressings should be used for unstageable pressure ulcers. Transparent dressings should be used for stage I pressure ulcers. p. 1213

What are the implications for healing of a surgical incision? 1 Heals by epithelialization 2 Lacks wound contraction 3 Clean and intact wound edges 4 Lacks granulation tissue formation 5 Heals quickly with minimal scar formation

Answers: 1, 3, 5 In the case of a wound caused by a surgical incision, healing occurs by epithelialization, the edges are clean and intact, and healing is quick with minimal scar formation. Wound contraction is present, not absent. Granulation tissue forms. p. 1191

Which interventions are part of the nursing intervention classification (NIC) of pressure management? 1 Repositioning the patient every 90 minutes 2 Irrigating the wound with a saline solution two times per day 3 Avoiding the use of massage around the open area 4 Dressing the area two times per day per provider prescription 5 Elevating the head of the patient's bed to no more than 30 degrees

Answers: 1, 3, and 5 If possible order and place pts bed on a pressure redistribution surface. Reposition the patient every 90 minutes as her condition allows. Avoiding the use of massage around the open area Elevate the head of the bed to no more than 30 degrees. Hip pts may not be able to turn in to a 30 degree lateral position). Use moisture barrier ointment over the ulcer at least 3 times a day to decrease friction and provide moisture to the open tissue. Keep skin dry and clean. Do not rub or massage around the open area. Irrigating a wound with a saline solution and dressing the area twice a day are interventions that are parts of the NIC of wound care.

Which interventions are part of the nursing intervention classification (NIC) of pressure management? 1 - Repositioning the patient every 90 minutes 2 - Irrigating the wound with a saline solution two times per day 3 - Avoiding the use of massage around the open area 4 - Dressing the area two times per day per provider prescription 5 - Elevating the head of the patient's bed to no more than 30 degrees

Answers: 1, 3, and 5 - Repositioning the pt. every 90 mins. Avoiding the use of massage around the open area. And elevating the head of the pt.'s bed to no more than 30 degrees. Repositioning the patient every 90 minutes, avoiding the use of massage around the open area, and elevating the head of the bed to no more than 30 degrees are parts of the nursing intervention classification (NIC) of pressure management. Irrigating a wound with a saline solution and dressing the area twice a day are interventions that are parts of the NIC of wound care. p. 1204

A patient with limited mobility develops a sacral pressure ulcer. Which nursing interventionS are appropriate for reducing the risk for infection? 1 - Obtaining a wound culture as needed 2 - Irrigating and cleansing the wound with saline twice a day 3 - Repositioning the patient at least every 90 minutes 4 - Packing the open wound with antibiotic solution-moistened gauze

Answers: 2 & 4 Cleansing the wound and packing it with medicated gauze will reduce the risk for infection. Repositioning the patient at least every 90 minutes is appropriate for this patient, but it is done to improve mobility and prevent the risk for other ulcers developing. Obtaining a wound culture as needed will assess for infection but will not prevent it. p. 1205

A patient with limited mobility develops a sacral pressure ulcer. Which nursing interventions are appropriate for reducing the risk for infection? 1 Obtaining a wound culture as needed 2 Irrigating and cleansing the wound with saline twice a day 3 Repositioning the patient at least every 90 minutes 4 Packing the open wound with antibiotic solution-moistened gauze

Answers: 2 and 4 Cleansing the wound and packing it with medicated gauze will reduce the risk for infection. Repositioning the patient at least every 90 minutes is appropriate for this patient, but it is done to improve mobility and prevent the risk for other ulcers developing. Obtaining a wound culture as needed will assess for infection but will not prevent it. p. 1205

Which interventions should the nurse implement when providing care to a patient at risk for skin breakdown due to urinary incontinence? 1 - Provide adequate fluid intake 2 - Reposition the patient off at-risk areas often 3 - Apply a moisture-barrier ointment 4 - Cleanse perineal area with no-rinse cleaner 5 - Protect pressure points from medical devices

Answers: 2, 3, and 4 2 - Reposition the patient off at-risk areas 3- Apply a moisture barrier ointment 4 - Cleanse perineal area with no-rinse cleaner For a patient at risk for skin breakdown due to urinary incontinence, the nurse should reposition the patient off at-risk areas often, apply a moisture-barrier cream, and cleanse the perineal area with an on-rinse cleaner. Whereas providing adequate fluid intake and protecting pressure points from medical devices are appropriate interventions for a patient who is at risk for skin breakdown, these do not address the risk for skin breakdown due to urinary incontinence. p. 1206

Which nursing actions will help maintain an airtight seal for a patient who is prescribed negative-pressure wound therapy? 1 - Retaining hair around the wound 2 - Using a skin barrier around the wound 3 - Drying around the wound thoroughly 4 - Applying adhesive remover to the wound edges 5 - Filling uneven wound surfaces with a hydrocolloid product

Answers: 2, 3, and 5 To maintain an airtight seal for a patient who is prescribed negative-pressure wound therapy, the nurse would use a skin barrier around the wound, dry the wound thoroughly, and fill uneven wound surfaces with a hydrocolloid product. The nurse would clip, not retain, the hair around the wound to maintain an airtight seal. Adhesive remover should be avoided around the wound edges, because this can interfere with obtaining an airtight seal. p. 1215

Under the supervision of the registered nurse, a nursing student is providing negative-pressure wound therapy to a patient who has a wound near the knee joint. Which nursing action indicates the need for further learning? 1 Drying the periwound thoroughly before dressing 2 Covering the skin near the suction line with at hydrocolloid dressing 3 Applying adhesive remover at the affected site before the dressing 4 Dressing the wound with a hydrocolloid film 3 cm away from the wound

Answer 3 Application of adhesive remover at the affected area may leave a residue that hinders dressing film adherence the remaining actions are correct. The periwound should be thoroughly dried before dressing, because it promotes wound healing. Hydrocolloid dressing may result in contact dermatitis, so it is necessary to cover the skin near and under the areas of suction. Dressing the wound with hydrocolloid film 3 to 5 cm away from the wound ensures proper wound care. p. 1215

Which of a novice nurse's actions would necessitate intervention when providing care for a patient who is prescribed negative-pressure wound therapy? 1 - Retaining hair around the wound 2 -Using a skin barrier around the wound 3 -Drying around the wound thoroughly 4 - Filling uneven wound surfaces with a hydrocolloid product

Answer: 1 - Retaining hair around the wound Retaining hair around the wound edges can cause an air leak, so this action requires correction. Using a skin barrier, drying around the wound thoroughly, and filling uneven wound surfaces with a hydrocolloid product are all appropriate and will help maintain an airtight seal. p. 1215

A nursing instructor discusses with a nursing student the changes that occur in the skin with aging. Which of the student's statements indicates the need for further teaching? 1 - "The elasticity of the skin decreases with age." 2 - "The collagen content of the skin increases with age." 3 - "The underlying muscle and tissues become thinner with age." 4 - "The older adult's skin can be easily torn in response to mechanical trauma."

Answer: 2 The collagen content of the skin decreases, not increases, with age. The remaining statements indicate understanding. The elasticity of the skin decreases with aging, and the underlying muscle and tissues thin. Because of these changes, the older adult's skin can be easily torn in response to mechanical trauma. p. 1187

In a supine position, which site is not at risk for a pressure ulcer? 1 Ischium 2 Elbow 3 Occipital bone 4 Medial knee

Answer: 4 The medial knee may be at risk for a pressure ulcer in a patient who is in a side-lying position, but not in a supine position. The ischium, elbow, and occipital bone are all sites at risk for pressure ulcers in an immobilized supine patient. p. 1199

Which factor does not put a patient at risk for burns during heat therapy? Very young age Areas of edema Abscessed tooth Peripheral vascular disease

Answer: Abscessed tooth Applying heat to an abscessed tooth may increase a patient's risk for infection due to the possibility of rupture, but it will not necessarily increase the risk for burns. Because very young patients have thin skin, they are at an increased risk for burns during heat therapy. Because areas of edema and peripheral vascular disease both cause a patient to have decreased sensory perception, patients with these conditions are also at an increased risk for burns during heat therapy. p. 1208

What type of wound drainage is considered sanguineous? Clear, watery plasma Bright red, active bleeding Thick and yellow, green, tan, or brown Pale pink, watery mixture of clear and red fluid

Answer: Bright red, active bleeding Bright red fluid indicative of active bleeding is considered sanguineous wound drainage. Clear, watery plasma is considered serous wound drainage. Thick and yellow, green, tan, or brown fluid is considered purulent wound drainage. A pale pink, watery mixture of clear and red fluid is considered serosanguineous wound drainage. p. 1194

Which is characteristic of abnormal healing of a primary wound? 1 - Slough tissue in the wound base 2 - A fruity, earthy, or putrid odor 3 - A dry or moist granulation tissue bed 4 - Drainage for more than 3 days after closure

Answer: D If a primary-intention wound has drainage for more than 3 days after closure, this is a sign of abnormal healing. Slough tissue in the wound base, a fruity, earthy, or putrid odor, and a dry or moist granulation tissue bed are signs of abnormal healing of a secondary-intention wound.

How many calories per kilogram per day should the nurse suggest a patient consume to promote proper wound healing? A - 15-20 kcal B - 20-25 kcal C - 25-30 kcal D - 30-35 kcal

Answer: D The nurse should recommend the patient consume 30 to 35 kcal per kilogram per day to promote wound healing. The amounts of 15 to 20 kcal, 20 to 25 kcal, and 25 to 30 kcal are not enough. p. 1196

What intervention is not necessary for a patient who has impaired skin integrity related to limited mobility? Demonstrate correct repositioning techniques. Apply dressings to support moist wound healing. Perform an ongoing wound and risk assessment. Apply a moisture barrier to the area at least three times daily.

Answer: Demonstrate correct repositioning techniques. Demonstrating correct repositioning techniques is an intervention for a patient who has impaired physical mobility related to incisional pain, not a patient who has impaired skin integrity. Applying dressings to support moist wound healing, performing an ongoing wound and risk assessment, and applying a moisture barrier to the area at least three times daily are appropriate interventions for a patient who has impaired skin integrity related to limited mobility. p. 1205

While changing the wet-to-dry dressing, the nurse notes a dime-sized ulcer under the adhesive tape. What should be applied to secure the wound? Elastic net Rolled gauze Topper dressing Solid skin barrier Montgomery ties

Answer: Solid skin barrier and Montgomery ties A chronic wound may require several dressings to heal completely. In such dressings, the removal of tape may cause the skin to stretch and may also induce tension, which leads to skin damage and, thus, pressure ulcers. Solid skin barriers protect the skin from increasing the tension of the adhesive tape. Montgomery ties are used for repeated dressing changes. Elastic net and rolled gauze aid in supporting the dressings, but do not prevent pressure ulcer development. Topper dressing is a thicker dressing that prevents strike-through of wound drainage and provides a surface to tape the dressing in place; it does not prevent ulcer development. p. 1231

What stages of Pressure Ulcers are expected to heal through granulation and reepithelialization?

Answer: Stage III and Stage IV These stages require pt. education from the nurse. p. 1213

During a follow-up visit, the patient complains of irritation in the periwound tissue where the wound is dressed. Which nursing action could have caused this patient condition? The nurse used black foam for dressing. The nurse cut the gauze to fit the wound. The nurse used precut split gauze at the wound. The nurse applied barrier film over the periwound skin.

Answer: The nurse cut the gauze to fit the wound. The nurse should not cut the gauze to fit around the drain or the wound, because the cut edges may fray and enter the wound, causing irritation at the wound site. Black foam is used for dressing a granulating wound, because it provides wound contraction, but it is not used for a draining wound. A wound with drainage should be dressed with precut split gauze to provide absorption of the drainage from the wound. Barrier film helps to provide an airtight seal needed for negative-pressure wound therapy (NPWT) and protects the periwound from maceration. p. 1230

Which nutrient helps healing by promoting epithelialization, wound closure, inflammatory response, and angiogenesis? Zinc Protein Vitamin C Vitamin A

Answer: Vitamin A Vitamin A helps healing by promoting epithelialization, wound closure, inflammatory response, and angiogenesis. Zinc promotes collagen formation, protein synthesis, cell membrane, and host defenses. Protein promotes fibroplasia, angiogenesis, collagen formation, and wound remodeling. Vitamin C promotes collagen synthesis, capillary wall integrity, and immunologic function. p. 1196

Describe a Suspected Deep-Tissue Injury Classification of Pressure Ulcers

Depth Unknown. Suspected deep-tissue injury is a purple or maroon localized area of discolored intact skin or a blood-filled blister caused by damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler compared 1188to adjacent tissue. Deep-tissue injury may be difficult to detect in individuals with dark skin tones. It may begin as a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment (see Figure 48-4, F). p. 1187

Describe what is included in the nursing assessment of a wound.

Don't forget Documentation!

Hydrocortisone or any other steroidal cream

Hydrocortisone is specifically(Primarily) for reducing inflammation. and helps stop itching or reaction.

Describe Secondary Intention

Granulation is 2nd step. Less open. Prolonged healing time. Wound edges are not approximated (not close together). Wound heals by granulation so it is healing from the inside out.

What types of wounds are considered "un-stageable"

NEEDS MORE INFO HERE**** INCOMPLETE Eschar prevents you to see the bottom of the wound.

If evisceration occurs do what?

If evisceration occurs immediately lie the patient back. Cover them with sterile normal saline dressing Immediately call the doctor and house supervisor. Because an OR is needed immediately.

Non-blanching erythremia

If you're red (hyperemia) and you push down and it stays red and does not blanch (does not turn white); deep tissue damage is probable.

Parts of the NIC nursing intervention classification of wound care

Irrigating a wound with a saline solution Dressing the area twice a day and At frequent intervals evaluate pt's pain level and offer pain med as indicated by assessment

Describe the maturation phase.

MATURATION PHASE - 21 days - 2 years. Scar strengthens and starts to fade. Not bright pink anymore. Fades toward normal skin color.

What is Regeneration?

Regeneration is the replacement of lost cells and tissues with cells of the same type. Ability of cells to regenerate depends on the cell type. New tissue grows. NO SCARS.

Pressure Ulcers

PRESSURE - INTENSITY (Light, Moderate, Severe) - DURATION Underlying tissue gets damage due to constant pressure forces on the body; reduced circulation means there is no oxygen or nutrients reaching that tissue to provide what it needs to maintain a healthy balance. Intensity: amount of pressure; light pressure, moderate pressure, severe pressure; and duration. Once you have intensity you have capillary collapse. The duration also causes the capillaries to collapse even if intensity does not change. Capillary collapse means no oxygen being taken to the skin, no nutrients, no blood... cell death.

Describe the proliferation phase.

PROLIFERATION PHASE OR GRANULATION STAGE - 14-21 days. This is where the epithelial cells are starting to grow; budding. This is where it should be nice and pink. It starts getting a protective layer ie scabbing. Then scarring occurs.

Types of wound drainage

Page 1192 Potter Serous Purulent Serosanguineous Sanguineous Slough

Describe a Stage 2 Pressure Ulcer

Partial thickness loss involving the epidermis and dermis. It appears as an abrasion, a blister or a small crater. So it is as if the first layer is gone.

Nursing interventions to prevent pressure ulcers.

Rotate the patient every 2 hours/in wheelchair rotate every 15 minutes. Avoid friction and shearing; HOB (head of bed) less than 30% Keep the skin dry Nutrition and hydration Proper wound care Barrier creams/lotions and ointments ROM Padding bony prominences/do NOT massage bony prominences. Changing soiled sheets Hygiene/Cleanse skin immediately if wet or soiled/avoid hot bath water... increases risks of cracks in skin Use mild cleansing agents. Provide humidity....lips and skin can crack without humidity Encourage mobility Use assistive devices/trapezes, specialty bed, and mattresses Assessment

Describe Primary Intention

Primary Intention: Simplest. Healing takes place when wound margins are neatly approximated (close together) either by the skin itself or by sutures or staples, as in a surgical incision or a paper cut. There are three phases in Primary Intention: Initial phase Granulation Phase Maturation Phase & Scar Contraction

Describe (causes and implications) of: " Tertiary Intention" of wound classifications.

TERTIARY INTENTION: Description: Wound that is left open for several days, then wound edges are approximated (meaning closed and risk of infection is low.) Causes: Wounds that are contaminated and require observation for signs of inflammation. Implications for healing: Closure of wound is delayed until risk of infection is resolved.

Describe a Stage 1 Pressure Ulcer

No open skin Change in temperature and color Non-blanchable erythemia so it is continuously RED Black or darker skin may look maroon

Which nutrient supports healing by promoting wound closure? 1 - Protein 2 - Vitamin A 3 - Vitamin C 4 - Zinc

One role of vitamin A in healing is to promote wound closure. Protein promotes collagen formation and immunity, vitamin C promotes collagen synthesis and immunity, and zinc promotes collagen formation and protein synthesis.

'Decreased risk for burns' and 'retaining temperature longer because of evaporation' are benefits of what?

They are both benefits of using DRY applications, NOT moist, applications. p. 1221

Name, describe, and give examples of Discolorations and possible causes

Cyanosis

Hydrogel steps

Hydrogel (1) Cover surface of ulcer with hydrogel using applicator or gloved hand. Hydrogel dressings are designed to hydrate and donate moisture to wound, thus facilitating moist wound healing (Rolstad et al., 2016). (2) Apply dry gauze, hydrocolloid, or transparent film dressing over wound and adhere to intact skin. Covers wound base, maintaining hydrogel wound interface. p. 1225

Nursing Assessment Questions for Skin Integrity & Wound Care.

Nursing Assessment Questions (p. 1196 Box 48-4): 4 Questions Total: Sensation: • Do you have tingling, decreased feeling, or absent feeling in your extremities or any other region? • Is your skin sensitive to heat or cold? Mobility • Do you have any physical limitations, injury, or paralysis that limits your ability to move on your own? • Can you change your position easily? • Is movement painful? Continence: • Do you have any problems or accidents leaking urine or stool? • What help do you need when using the toilet? In what way? • How often do you need to use the toilet? During the day? At night? Presence of Wound: • What caused the wound? • When did the wound occur? Where is it located? • When did you receive a tetanus shot? • What has happened to this wound since it occurred? What were the changes and what caused them? • Which treatments, activities, or care have slowed or helped the wound to heal? Are there special needs for this wound to heal? • Do you have any pain, itching, or other symptoms with the wound? How are you managing the itching, and what works best for you? • Who helps you care for your wound?