NSG 371 Chapter 32: Skin Integrity and Wounds

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage? -serosanguineous -purulent -sanguineous -serous

serosanguineous This describes serosanguineous wound drainage. Drainage that is pale yellow, watery, and like the fluid from a blister is called serous. Drainage that is bloody is called sanguineous. Drainage that contains white cells and microorganisms is called purulent.

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. True or False

True A Penrose drain is an open drainage system that exits the skin through a stab wound. The purpose a Penrose drain is to provide a sinus tract for drainage.

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? -corticosteroids -antihypertensive drugs -potassium supplements -laxatives

corticosteroids Clients who are taking corticosteroids or require postoperative radiation therapy are at high risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing. Antihypertensive drugs, potassium supplements, and laxatives do not delay wound healing.

When assessing a wound that a client sustained as a result of surgery, the nurse notes well-approximated edges and no signs of infection. How will the nurse document this assessment finding? -abrasion -laceration -avulsion -incision

incision An incision is a clean separation of skin and tissue with smooth, even edges. Therefore the nurse documents the finding as an incision. In an avulsion, large areas of skin and underlying tissue have been stripped away. An abrasion involves the stripping of the surface layers of skin. A laceration is a separation of skin and tissue with torn, irregular edges. Therefore the nurse does not document the finding as an avulsion, abrasion, or laceration.

Which activity should the nurse implement to decrease shearing force on a client's stage II pressure injury? -preventing the client from sliding in bed -pulling the client up from under the arms -lubricating the area with skin oil -improving the client's hydration

preventing the client from sliding in bed Shearing force occurs when tissue layers move on one another, causing vessels to stretch as they pass through the subcutaneous tissue.

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question? -"Have you had any recent illnesses?" -"How many meals a day do you eat?" -"Do you experience incontinence?" -"Do you use any lotions on your skin?"

"Do you experience incontinence?" The client's health history is an essential component in assessing the client's integumentary status and identification of risk factors for problems with the skin. The priority question addresses a source of moisture on the skin. Moisture makes the skin more susceptible to injury because it can create an environment in which microorganisms can multiply, and the skin is more likely to blister, suffer abrasions, and become macerated (softening or disintegration of the skin in response to moisture). Sound nutrition is important in the prevention and treatment of pressure injuries. The number of meals eaten per day does not give a clear assessment of nutritional status. The nurse should question the client about the skin care regimen, such as the use of lotions, but this would not be the priority in determining the risk for pressure injury development. Asking the client about any recent illnesses is not a priority in determining the risk for pressure injury development.

The registered nurse (RN) observes the licensed practical nurse (LPN) preforming this action when applying a topical gel to a client's surigical wound during a dressing change. What instructions should the RN provide the LPN regarding this action? -"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." -"Be sure to apply a thin layer of gel to both the wound and to the surrounding unaffected skin for at least 1 inch (2.5 centimeters)." -"Be sure to initially apply the gel to the center of the wound working outward toward the unaffected skin." -"This procedure can be safely preformed using clean technique if care is taken not to touch the wound."

"To best avoid further traumatizing the wound bed, apply the gel with a sterile cotton tip applicator." The nurse should apply any topical medications, foams, gels, and/or gauze to the wound as prescribed; ensuring that the product stays confined to the wound and does not impact on intact surrounding tissue/skin. Applying the medicated gel with an applicator allows for better control over the application, thus minimizing any additional trauma to wound. The procedure should be preformed using sterile technique, but clean technique can be used when proving care to chronic or pressure injury wounds. To manage contamination risk, cleansing of a wound should be done from top to center to outside.

What type of dressing has the advantage of remaining in place for three to seven days, resulting in less interference with wound healing? transparent film hydrocolloid dressing alginate hydrogel

hydrocolloid dressing Hydrocolloids are occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment, provide minimal to moderate absorption of drainage, maintain a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing. Hydrogels maintain a moist wound environment and are best for partial or full-thickness wounds. Alginates absorb exudate and maintain a moist wound environment. They are best for wounds with heavy exudate. Transparent films allow exchange of oxygen between wound and environment. They are best for small partial-thickness wounds with minimal drainage.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury? stage II stage I stage III stage IV

stage IV Stage IV pressure injuries are characterized as exposing muscle and bone and may have slough and a foul odor. Stage I pressure injuries are characterized by intact but reddened skin that is unblanchable. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage.

The nurse is teaching a client about wound care at home following a cesarean birth of her baby. Which client statement requires further nursing teaching? -"After delivery, I will have sutures in place." -"I will not remove the staples myself." -"Reinforced adhesive skin closures will hold my wound together until it heals." -"I may have staples in place for a number of days."

"Reinforced adhesive skin closures will hold my wound together until it heals." After a cesarean birth, a client will be sutured and have staples put in place for a number of days. The health care provider or nurse will remove staples. Reinforced adhesive skin closures are not strong enough to hold this type of wound together.

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include? -"The surgeon will leave your wound open intentionally for a period of time." -"This is a complex reparative process." -"The margins of your wound are not in direct contact." -"Very little scar tissue will form."

"Very little scar tissue will form." Very little scar tissue is expected to form in a minor surgical wound. Second-intention healing involves a complex reparative process in which the margins of the wound are not in direct contact. Third-intention healing takes place when the wound edges are intentionally left widely separated and later brought together for closure.

A nurse is caring for a 78-year-old client who was admitted after a femur fracture. The primary care provider placed the client on bed rest. Which action should the nurse perform to prevent a pressure injury? -use pillows to maintain a side-lying position as needed -provide incontinent care every 4 hours as needed -elevate the head of the bed 90 degrees -place a foot board on the bed

use pillows to maintain a side-lying position as needed Using pillows to maintain a side-lying position allows the nursing staff to change position to alleviate and alternate pressure on client's bony prominences. The client's position should be changed a minimum of every 2 hours. In addition, incontinent care should be performed a minimum of every 2 hours and as needed to decrease moisture and irritation of the skin. A foot board prevents foot drop but does not decrease the risk for pressure injury.

The nurse is educating an older adult client about skin care. Which recommendation will assist the client in maintaining skin integrity? -"Do not apply skin moisturizers after bathing, as this creates a reservoir for skin infection." -"Be sure to take at least two showers daily to remove all microorganisms from the skin." -"Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer." -"Drink 8 ounces of water three times daily and once at bedtime to remain hydrated."

"Avoid soaps with artificial ingredients or fragrances, as milder soaps are safer." Wrinkling and poor skin turgor results from loss of elastic fibers and collagen changes in the dermal connective tissue. As such, clients should be taught to avoid soaps with artificial ingredients or fragrances, as these may be harsher on the skin. It is good to be clean; however, advice of taking at least two showers per day is excessive and may dry the skin. Moisturizer should be applied to the skin following bathing to prevent dryness of the skin. Drinking water is important to remain hydrated; however, the nurse should recommend drinking 1,500 to 2,000 mL of water daily. Drinking 8 ounces three times a day is 720 mL.

The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective? -"I must wait 15 minutes between applications of cold therapy." -"I can let this stay on my ankle an hour at a time." -"I should keep this on my ankle until it is numb." -"I will put a layer of cloth between my skin and the ice pack."

"I will put a layer of cloth between my skin and the ice pack."

A client who had a knee replacement asks the nurse, "Why do I need this little bulb coming out of my knee?" What is the appropriate nursing response? -"The drain works by suctioning out blood and drainage from the wound and will be removed when there is minimal or no drainage." -"The drain has measurement marks on it so that nurses can measure the amount of drainage and report it the health care provider." -"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." -"This drain is called a Jackson-Pratt or bulb drain and is compressed and closed shut to create a gentle suction

"The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound." The bulb-like drain allows removal of blood and drainage from the surgical wound. All the statements are factual and true; however, the name of the drain, how it works, when it will be removed, and measurement of the exudate are drain management skills and knowledge. Only, "the drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound" answers the clients question about why the drain is present.

The acute care nurse is caring for a client whose large surgical wound is healing by secondary intention. The client asks, "Why is my wound still open? Will it ever heal?" Which response by the nurse is most appropriate? -"Your surgeon may not have been skilled enough to close such a large wound, but it will eventually heal." -"If less scar tissue is essential, wounds are allowed to heal slowly through a process called secondary intention." -"As soon as the infection clears, your surgeon will staple the wound closed." -"Your wound will heal slowly as granulation tissue forms and fills the wound."

"Your wound will heal slowly as granulation tissue forms and fills the wound." This statement is correct, because it provides education to the client: "Your wound will heal slowly as granulation tissue forms and fills the wound." Large wounds with extensive tissue loss may not be able to be closed by primary intention, which is surgical intervention. Secondary intention, in which the wound is left open and closes naturally, is not done if less of a scar is necessary. Third intention is when a wound is left open for a few days and then, if there is no indication of infection, closed by a surgeon.

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true? -A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. -A Penrose drain has a round collection chamber with a spring that is kept under negative pressure. -A Penrose drain promotes passive drainage into a dressing. -A Penrose drain is a closed drainage system that is connected to an electronic suction device.

A Penrose drain promotes passive drainage into a dressing. The Jackson-Pratt drain has a small bulblike collection chamber that is kept under negative pressure. A Hemovac is a round collection chamber with a spring inside that also must be kept under negative pressure.

The wound care nurse is performing dressing changes for several clients on the unit. Which situation reinforces the nurse's competence in providing wound care? Select all that apply . -A nurse applies Telfa to a wound to keep drainage from passing through to a secondary dressing. -A nurse places a transparent dressing over a central venous access device insertion site. -A nurse places a transparent dressing over an ABD pad to help keep the wound dry. -A nurse uses aseptic techniques when changing a dressing. -A nurse places a drainage dressing around a drain insertion site. -A nurse places a Surgipad directly over an incision.

A nurse places a transparent dressing over a central venous access device insertion site. A nurse uses aseptic techniques when changing a dressing. A nurse places a drainage dressing around a drain insertion site. The nurse would place an OpSite over a central venous access device insertion site. An OpSite helps to secure the device and is appropriate for a site with little drainage. The nurse would use appropriate aseptic techniques when changing a dressing. The nurse would place a drainage dressing around a drain insertion site. The dressing absorbs drainage and protects the wound from contamination or injury. The nurse would not place a transparent dressing over an ABD pad. The nurse would use tape on the ABD pad. Drainage could be marked on the tape to determine any changes in drainage. The purpose of a Telfa is to not adhere to the wound, and allows drainage to pass through to a secondary dressing.

A pediatric nurse is familiar with specific characteristics of children's skin. Which statement describes the common skin characteristics in a child? -In children younger than 2 years, the skin is thicker and stronger than in adults. -An individual's skin changes little over the life span. -A child's skin becomes less resistant to injury and infection as the child grows. -An infant's skin and mucous membranes are easily injured and at risk for infection.

An infant's skin and mucous membranes are easily injured and at risk for infection. In children younger than 2 years, the skin is thinner and weaker than in adults. The structure of the skin changes as a person ages. A child's skin becomes more resistant to injury and infection as the child grows.

A client reports acute pain while negative pressure wound therapy is in place. What should the nurse do first? -Assess the client's wound and vital signs. -Administer the prescribed analgesic. -Notify the health care provider of the pain. -Document the pain and vital signs.

Assess the client's wound and vital signs. First, the nurse should assess the client. The nurse needs to assess the wound, assess if the therapy is working properly, assess the client's vital signs, and assess the pain. The other options might be appropriate but only after the client has been assessed.

A client comes to the emergency department reporting a painful left ankle, headache, and dizziness, after falling off a skateboard and sliding on the sidewalk. For what type of injuries would the nurse be alert? Select all that apply. Concussion Dehydration Abrasions Bruising Broken left ankle Soft tissue damage

Broken left ankle Bruising Soft tissue damage Concussion Abrasions Skateboard related injuries that the nurse needs to assess for are a concussion and other brain injuries, broken bones, soft tissue injuries, and skin abrasions, cuts, and bruises. Symptoms of a concussion are dizziness, headaches, visual changes, loss of memory, slowed speech, and sensitivity to noise. An abrasion involves stripping of layers on the skin's surface. Soft tissue injuries include damage to the muscles, tendons, and ligaments. Dehydration can cause headaches and dizziness; however, since the client injured oneslf while skateboarding a concussion should be suspected and assessed for. Because the client reported sliding on the sidewalk, the client should also be assessed for skin abrasions. Elevated thrombocytes would not be expected in a skateboard related injury.

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? -Once the wound is cleaned, gently dry the wound bed with an absorbent cloth. -Clean the wound in a circular pattern, beginning on the perimeter of the wound. -Clean the wound from the top to the bottom and from the center to outside. -Use clean technique to clean the wound.

Clean the wound from the top to the bottom and from the center to outside. Using sterile technique, clean the wound from the top to the bottom and from the center to the outside. Dry the area with a gauze sponge, not an absorbent cloth.

Which is not considered a skin appendage? -Connective tissue -Sebaceous gland -Eccrine sweat glands -Hair

Connective tissue Hair, the sebaceous gland, and eccrine sweat glands are skin appendages that are formed with the enfolding of the epidermis into the dermis. The dermis is composed of connective tissue.

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? -Desiccation -Maceration -Evisceration -Necrosis

Desiccation Desiccation is localized wound dehydration. Maceration is localized wound overhydration or excessive moisture. Necrosis is death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area.

A child is brought to the clinic by a parent. The parent states that the child has been at camp. The child has a rash on the face, arms, and legs. The child states it itches severely. How will the nurse describe the assessment findings? -Superficial abscess accompanied by pruritus -Superficial contusion accompanied by pruritus -Diffuse dermatitis accompanied by pruritus -Diffuse fungal infection accompanied by pruritus

Diffuse dermatitis accompanied by pruritus The external or internal irritants can cause skin reactions. The irritants may be chemical, such as poison ivy. Dermatitis, an inflammation of the skin, most often produces epidermal and dermal damage or irritation, possibly accompanied by pain, itching, redness, and blisters; pruritus is itching. A contusion is a closed wound with bleeding in underlying tissues from a blunt blow. Fungal infections do not cause a rash or itching. An abscess is a localized collection of white blood cells and cellular debris (pus) that appears swollen and inflamed.

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the best action by the nurse at this time? -Discontinue the therapy and assess the client. -Document the findings in the client's medical record. -Gently rub and massage the area to warm it up. -Notify the health care provider of the findings.

Discontinue the therapy and assess the client. The best action by the nurse at this time is to discontinue the therapy and assess the client; this should be done before notifying the health care provider or documenting the event. Gently rubbing the area or massaging it would not be appropriate at this time.

The nurse is helping a confused client with a large leg wound order dinner. Which food item is most appropriate for the nurse to select to promote wound healing? -Banana -Pasta salad -Fish -Green beans

Fish To promote wound healing, the nurse should ensure that the client's diet is high in protein, vitamin A, and vitamin C. The fish is high in protein and is therefore the most appropriate choice to promote wound healing. Pasta salad has a high carbohydrate amount with no protein. Banana has a high amount of vitamin C but no protein. Green beans have some protein but not as much as fish.

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture? -Utilize the culture swab to obtain cultures from multiple sites. -Stroke the culture swab on surrounding skin first. -Cleanse the wound after obtaining the wound culture. -Keep the swab and the inside of the culture tube sterile.

Keep the swab and the inside of the culture tube sterile. The swab and the inside of the culture tube should be kept sterile. The wound should be cleansed prior to obtaining the culture. The culture swab should not touch the skin surrounding the wound site. In addition, if multiple sites have to be cultured then separate culture swabs should be used.

A nurse removing sutures from a client's traumatic wound notices that the sutures are encrusted with blood and difficult to remove. What would be the nurse's most appropriate action? -Carefully pick the crusts off the sutures with the forceps before removing them. -Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. -Do not attempt to remove the sutures because the wound needs more time to heal. -Wash the sutures with warm, sterile water and an antimicrobial soap before removing them.

Moisten sterile gauze with sterile saline to gently loosen crusts before removing sutures. If sutures are crusted with dried blood or secretions, making them difficult to remove, the nurse should moisten sterile gauze with sterile saline and gently loosen crusts before removing the sutures; soap is not used for this purpose. Picking at the sutures could cause pain and bleeding. Crusting does not necessarily indicate inadequate wound healing.

A nurse is caring for a client who has an avulsion of her left thumb. Which description should the nurse understand as being the definition of avulsion? -Puncture of the skin -Cutting with a sharp instrument with wound edges in close approximation with correct alignment -Tearing of the skin and tissue with some type of instrument; tissue not aligned -Tearing of a structure from its normal position

Tearing of a structure from its normal position An avulsion involves tearing of a structure from its normal position on the body. Tearing of the skin and tissue with some type of instrument with the tissue not aligned is a laceration. Cutting with a sharp instrument with wound edges in close approximation and correct alignment is an incision. A puncture of the skin is simply a puncture.

A client who was injured when stepping on a rusted nail visits the health care facility. What is the most important assessment information the nurse needs to obtain? -The event leading up to the trauma -Staging the wound for assessment -The status of the client's tetanus immunization -If there is contamination of dirt and debris

The status of the client's tetanus immunization Staging the wound is only done with pressure injuries. The presence of dirt or debris is something that will need to be addressed, but not the most important assessment. Understanding how the client stepped on the nail will need to be noted and is a possible educational opportunity for prevention, but it is not the most important assessment concern. Tetanus is caused by the Clostridium bacteria that can enter the body through a deep injury like stepping on a nail. The tetanus vaccine booster should be given every 10 years and is the best defence against developing the tetanus illness. Tetanus is a concern because it is a painful medical emergency that could lead to death. So, finding out the status of the client's tetanus immunization is the most important assessment information the nurse can collect from the client.

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn? -May vary from brown or black to cherry red or pearly white; bullae may be present -A superficial partial-thickness burn, which can appear dry and leathery -Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown -Superficial, which may be pinkish or red with no blistering

Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown Second-degree burns are moderate to deep partial-thickness burns that may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. First-degree burns are superficial and may be pinkish or red with no blistering. Third-degree burns are full-thickness burns and may vary from brown or black to cherry-red or pearly-white; bullae may be present; can appear dry and leathery.

An older adult client has been admitted to the hospital with dehydration, and the nurse has inserted a peripheral intravenous line into the client's forearm in order to facilitate rehydration. What type of dressing should the nurse apply over the client's venous access site? -a gauze dressing precut halfway to fit around the IV line -a dressing with a nonadherent coating -a gauze dressing premedicated with antibiotics -a transparent film

a transparent film Transparent film dressings are semipermeable, waterproof, and adhesive, allowing visualization of the access site to aid assessment and protecting the site from microorganisms. Gauze dressings--precut, with an adherent coating, premedicated with antibiotics--do not allow the nurse to visualize the site without partially or completely removing the dressing.

The nurse would recognize which client as being particularly susceptible to impaired wound healing? -an obese woman with a history of type 1 diabetes -a man with a sedentary lifestyle and a long history of cigarette smoking -A client who is NPO (nothing by mouth) following bowel surgery -a client whose breast reconstruction surgery required numerous incisions

an obese woman with a history of type 1 diabetes Obese people tend to be more vulnerable to skin irritation and injury. More significant, however, is the role of diabetes in creating both susceptibility to skin breakdown and impairment of the healing process. This is a greater risk factor for impaired healing than are smoking and sedentary lifestyle. Large incisions in and of themselves do not necessarily complicate the healing process. Short-term lack of food intake is not as significant as longer-term lack of nutrition.

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention? -contacting the surgeon -assessing for impaired blood flow to the area of evisceration. -applying sterile dressings with normal saline over the protruding organs and tissue -monitoring for pallor and mottled appearance of the wound

applying sterile dressings with normal saline over the protruding organs and tissue The nurse will immediately apply sterile dressing moistened with normal saline over the protruding organs and tissue and call out for someone to contact the surgeon. While waiting for the surgeon, the nurse will continue to assess the area of evisceration and monitor the client's status.

A teacher brings a student to the school nurse and explains that the student fell onto both knees while running in the hallway. The knees have since turned shades of blue and purple. Which type of injury does the nurse anticipate assessing? -avulsion -contusion -incision -puncture

contusion A contusion is an injury to soft tissue, so this is what the nurse expects to see on the basis of the teacher's description of the incident. A puncture involves an opening in the skin caused by a narrow, sharp, pointed object such as a nail. An incision involves a clean separation of skin and tissue with smooth, even edges. An abrasion involves stripping of the surface layers of skin. In an avulsion injury, large areas of skin and underlying tissues have been stripped away.

A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for: evisceration. herniation. infection. dehiscence.

dehiscence. Dehiscence is a total or partial disruption of wound edges. Clients often report feeling that the incision has given way. Manifestations of infection include redness, warmth, swelling, and fever. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents.

A nurse is caring for a client in a wound care clinic. The client has a wound on the left forearm from a roofing accident. During wound care, the nurse notes that the wound base is beefy red and bleeds easily during wound cleansing. Which stage of wound healing should the nurse recognize in this client's wound? -proliferation phase -hemostasis -inflammatory phase -maturation phase

proliferation phase The wound description reveals a beefy red wound bed that bleeds easily. This is the proliferation stage and describes granulation tissue. Hemostasis is the initial phase, involving activation of platelets. In the inflammatory phase, white blood cells and macrophages enter the wound to remove debris. The maturation phase involves collagen remodeling and scar formation.

A nurse is documenting on a client who has had an appendectomy. During a dressing change of the surgical site, the nurse observed a watery pink drainage on the dressing. Which drainage type should the nurse document? -serous -sanguineous -purulent -serosanguineous

serosanguineous Serosanguineous drainage is a mixture of serum and red blood cells. It is usually pink. Serous drainage is a clear drainage consisting of the serous portion of the blood. Sanguineous drainage consists of red blood cells and looks like blood. Purulent drainage has various colors, such as green or yellow; this drainage indicates infection.

The nurse just completed a dressing change and returned the client to a comfortable position. What should the nurse do next? -Determine the extent of wound undermining. -Massage the healthy tissue surrounding the wound. -Measure length, width, and depth of the wound. -Document the color, odor, amount, and type of wound drainage.

Document the color, odor, amount, and type of wound drainage. After completing a dressing change and retuning the client to a comfortable position, it is important to document color, odor, amount, and the type of wound drainage. Early documentation helps to assure the most accurate information can be recorded. Determining the extent of wound undermining and measuring length, width, and depth of the wound should be performed during the dressing change, while the wound is still exposed. The healthy tissue surrounding the wound should never be massaged because it could cause further breakdown of healthy tissue.

A client's pressure injury is superficial and presents clinically as an abrasion, blister, or shallow crater. How would the nurse document this pressure injury? Stage III Stage I Stage II Stage IV

Stage II A stage II pressure injury involves partial thickness loss of dermis and presents as a shallow, open ulcer. A stage II injury could present as a blister, abrasion, or shallow crater. A stage I pressure injury is a defined area of intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding skin. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. A stage III injury presents with full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough that may be present does not obscure the depth of tissue loss. Injuries at this stage may include undermining and tunneling. Stage IV injuries involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some part of the wound bed and often include undermining and tunneling.

The nurse considers the impact of shearing forces in the development of pressure injuries in clients. Which client would be most likely to develop a pressure injury from shearing forces? -a client who lifts himself up on his elbows -a client who must remain on his back for long periods of time -a client who lies on wrinkled sheets -a client sitting in a chair who slides down

a client sitting in a chair who slides down Shear results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Clients who are pulled, rather than lifted, when being moved up in bed (or from bed to chair or stretcher) are at risk for injury from shearing forces. A client who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a client who sits in a chair but slides down. The client that is most likely to develop a pressure ulcer from shearing forces would be a client sitting in a chair who slides down.

The nurse is preparing to apply a roller bandage to the stump of a client who had a below-the-knee amputation. What is the nurse's first action? -wrapping distally to proximally -keeping the bandage free of gaps between turn -exerting equal, but not excessive, tension with each turn of the bandage -elevating and supporting the stump

elevating and supporting the stump The nurse will first elevate and support the stump, then begin the process of bandaging. The bandage will be applied distally to proximally with equal tension at each turn; the nurse will monitor throughout the application to keep the bandage free from gaps between turns.

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use? -spica turn -figure-of-eight turn -spiral-reverse turn -circular turn

figure-of-eight turn A figure-of-eight turn is used for joints like the elbows and knees.

A postoperative client is being transferred from the bed to a gurney and states, "I feel like something has just given away." What should the nurse assess in the client? -Infection of the wound -Dehiscence of the wound -Evisceration of the viscera -Herniation of the wound

Dehiscence of the wound Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that "something has suddenly given way." If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician. Once dehiscence occurs, the wound is managed like any open wound. Manifestations of infection include redness, warmth, swelling, and heat. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents.

The nurse is caring for a client with an irregular-shaped traumatic wound. What principles should the nurse use when gathering information about the wound to chart? Select all that apply. -Draw the shape of the wound with a description. -Use a dry sterile applicator at a 90-degree angle to measure depth. -Assess color, drainage, presence of pain, or complications. -Chart tunneling by using a quadrant approach to describe the location. -Measure the wound's length and width.

Draw the shape of the wound with a description. Measure the wound's length and width. Assess color, drainage, presence of pain, or complications. When charting the findings, draw an irregular-shaped wound, as in this question, and provide a description including its length and width. A sterile applicator moistened with saline should be used to measure the depth of a wound and to determine the presence of tunneling. A dry applicator could damage the wound by sticking to it. The nurse would use the imaginary face of a clock when describing where on the wound the locations of tunneling exist. The nurse would assess the color of the wound, and presence of drainage, pain or discomfort, and any complications, and include these in the charting.

After 30 minutes, the nurse is preparing to remove the cold therapy application when the client asks if it can be left on a little longer. What is the best action by the nurse? -Explain to the client that this is not possible because of the health care provider's prescription. -Leave the therapy on for 10 more minutes and return to remove it after that time. -Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis. -Assist the client to get out of bed and sit up in a chair for a short while.

Explain that leaving cold therapy on for longer than 30 minutes can cause tissue necrosis. The best response by the nurse is to explain the possible complications of leaving cold therapy in place for too long, including cell death and tissue necrosis. This response not only answers the client's question but teaches at the same time the rationale and reason for limiting the cold therapy. Leaving the therapy on for 10 more minutes places the client at increased risk of tissue injury. Assisting the client out of bed ignores the client's request. Using the health care provider's prescription as the reason displays lack of understanding by the nurse and does not aid the client in understanding the rationale for the time limit.

A nurse has applied a bandage to a client's arm from just above the wrist to just below the elbow. What finding(s) would suggest to the nurse that there are no circulatory complications? Select all that apply. -Decreased radial pulse -Fingers with quick capillary refill -Cyanosis -No finger numbness or tingling -Warm hand

Fingers with quick capillary refill Warm hand No finger numbness or tingling The nurse should monitor, observe, and document for quick capillary refill of fingers, normal radial pulse, normal skin color, no swelling, numbness, and tingling of the hand and fingers. Cyanosis, pallor, coolness, numbness, tingling, swelling, or absent or diminished pulse are signs that circulation may be decreased or that nerve function is impaired.

A 77-year-old client has experienced an ischemic stroke and is now dependent for all activities of daily living. What components of nursing care will the nurse initiate to prevent skin breakdown? -Perform passive range-of-motion exercises -Frequently orient client to place and situation -Massage skin surfaces daily, especially areas under pressure and bony prominences -Implement a 2-hour repositioning schedule

Implement a 2-hour repositioning schedule The nurse must regularly turn and reposition the client who is immobile to prevent ischemia and consequent skin breakdown. Other skin integrity interventions include monitoring skin for changes, monitor client's continence status and prevent or minimize exposure to urine and feces, evaluate need for positioning devices and specialty mattresses, nutritional status assessment, and individualize skin care plan. Range-of-motion exercises are good to combat problems related to immobility. Frequent orientation is helpful for clients with dementia. Massage may promote circulation, but it is less important than turning the client on a scheduled basis, and massaging areas over bony prominences could harm the skin's integrity.

The nurse is caring for a client on the unit. During change of shift, another nurse is observed doing what is pictured in the image (blowing on the wound). What is the most important reason this technique does not adhere to the standards of care for dressing changes? -Promotes coolness to the site, which further constricts blood flow -Increases the risk of infection by contaminating the wound -Causes an uncomfortable sensation to the client's skin -Reduces itching to the wound as it is healing

Increases the risk of infection by contaminating the wound Using the mouth to blow air into a wound bed or to dry the wound edges does not adhere to the standards of care or of ethics for nurses. This action will increase the risk of wound contamination and the wound is more likely to become infected as our mouths and the air we blow out harbors many kinds of bacteria that can adhere to the wound and increase the risk for infection and contamination. Every effort should be taken into consideration to use sterile equipment, solutions and medical aseptic, or clean technique to remove old dressings. Coolness to a site decreases blood flow and to heal a wound more blood flow to the site assists with healting and reducing the risk of infection. Blowing on a wound bed may cause a uncomfortable sensation to the skin or funny sensation but it will not reduce the risk of the infection. The effect of the blowing sensation and contaminants in to the wound bed demonstrates non-adherence to the standards of safe and effective wound care and management.

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors? -The volume of circulating blood must be sufficient. -Arteries and veins must be patent and functioning well. -Local capillary pressure must be lower than external pressure. -The heart must be able to pump adequately.

Local capillary pressure must be lower than external pressure. Local capillary pressure must be higher than external pressure for adequate skin perfusion.

Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take? -Apply a small amount of normal saline to the swab after collection to prevent drying and contamination of the specimen. -Remove the swab from the client's room immediately after collection and insert it in the culture tube at the nurse's station. -Apply a topical anesthetic to the wound bed 30 minutes before collecting the specimen to prevent pain. -Rotate the swab several times over the wound surface to obtain an adequate specimen.

Rotate the swab several times over the wound surface to obtain an adequate specimen. The nurse should press and rotate the swab several times over the wound surface. The swab should be inserted into the culture tube at the bedside, immediately after collection. Saline or any other fluid is not added to the tube and anesthetics are not applied prior to collection.

A student nurse is preparing to perform a dressing change for a pressure injury on a client's sacrum area. The chart states that the pressure injury is staged as "unstageable." Which wound description should the student nurse expect to assess? -The wound is 3 × 5 cm, with 60 percent tan tissue and 40 percent granulation tissue, with a tendon showing. -The wound is 3 × 5 cm, with 50 percent gray tissue and 50 percent red tissue, with subcutaneous tissue visible. -The wound is a 3 × 5-cm blood-filled blister. -The wound is 3 × 5 cm, with yellow tissue covering the entire wound.

The wound is 3 × 5 cm, with yellow tissue covering the entire wound. The wound with yellow tissue covering the entire wound is unstageable. The depth of the wound cannot be determined, because it is covered entirely with slough. A stage III wound will have subcutaneous tissue visible. A stage IV wound will have tendon, muscle, or bone exposed. A suspected deep tissue injury presents as a maroon or purple lesion or blood-filled blister.

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? -a wound left open for several days to allow edema to subside -a surgical incision with sutured approximated edges -a wound healing naturally that becomes infected. -a large wound with considerable tissue loss allowed to heal naturally

a surgical incision with sutured approximated edges Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention. Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention. If a wound that is healing by primary intention becomes infected, it will heal by secondary intention. Wounds that heal by secondary intention take longer to heal and form more scar tissue. Connective tissue healing and repair follow the same phases in healing. However, differences occur in the length of time required for each phase and in the extent of new tissue formed. Wounds healed by tertiary intention, or delayed primary closure, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed.

A medical-surgical nurse is assisting a wound care nurse with the debridement of a client's coccyx wound. What is the primary goal of this action? -removing purulent drainage from the wound bed in order to accurately assess it -removing dead or infected tissue to promote wound healing -removing excess drainage and wet tissue to prevent maceration of surrounding skin -stimulating the wound bed to promote the growth of granulation tissue

removing dead or infected tissue to promote wound healing Debridement is the act of removing debris and devitalized tissue in order to promote healing and reduce the risk of infection. Debridement does not directly stimulate the wound bed, and the goal is neither assessment nor the prevention of maceration.

A nurse is treating a client who has a wound with full-thickness tissue loss and edges that do not readily approximate. The nurse knows that the open wound will gradually fill with granulation tissue. Which type of wound healing is this? primary intention maturation tertiary intention secondary intention

secondary intention Healing by secondary intention occurs in wounds with edges that do not readily approximate. The wound gradually fills with granulation tissue, and eventually epithelial cells migrate across the granulation base. Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the wound are approximated and the risk of infection is lower when a wound heals in this manner. Maturation is the final stage of full-thickness wound healing. Tertiary intention occurs when there is a delay between injury and wound closure. The delay may occur when a deep wound is not sutured immediately or is left open until no sign of infection is evident.