Skin Integrity & Wound Care

Primary Prevention

health promotion, disease prevention

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

A. Pressure points

full thickness wound

-Damage extends into the lower layers of the dermis and underlying subcutaneous tissue. -Removal of the damaged tissue results in a defect that must be filled with granulation tissue to heal

Antecedents of tissue integrity?

-Good nutrition (calories and PROTEIN needed to rebuild cells/tissue. Assesses serum ALBUMIN) -Lack of external trauma -Adequate perfusion -Limited pressure on site

Clients at Risk for pressure ulcers

-Immobilized -Protein deficiency -Vitamin C Deficiency -Prolonged moisture on skin (incontinence) -Mental Status (confused/coma) -Age (Older Adults)

Populations at greatest risk for skin integrity?

-Infants -Children -Older adults

Partial thickness wound

-Involve damage to the epidermis and upper layers of the dermis -Heal by re-epithelialization within 5 to 7 days -Skin injury immediately followed by local inflammation

Physical and psychological clinical manifestations

-Itching -Burning -Pain -Excessively dry skin, peeling skin -Draining wound -Stage I to IV pressure ulcer -Tear in skin, abrasion, laceration -Depression, low self-esteem -Changes in skin color, skin temperature -Fluid and electrolyte imbalance

Prevention of Impetigo

-Keeping skin clean and dry -Cleaning minor cuts and scrapes with soap and water -If infection avoid sharing personal care items with family members -After touching infected skin wash hands with soap and water

Three types of wound healing processes

-Primary intention -Secondary intention -Tertiary intention

Secondary Prevention

-Providing pain management -Repositioning -Using barrier creams -Checking incontinent patients frequently to keep skin clean and dry -Manage hygiene -Provide appropriate nutrients to promote healthy skin or for wound healing -Administer medications, -Prevent spread of infections or infestations -Use lotions and oatmeal baths to relieve pruritus.

Tertiary Prevention

-Teach patient and care giver about home care concerning pressure relief, wound care, hygiene and incontinence care -Pruritus relief with oatmeal bath products or bath oil(such as Keri oil) and lotion -Nutrition -Safety behaviors to prevent trauma, general skin care

Psoriasis

•Autoimmune disorder with over production of skin cells, exacerbations and remissions do occur. •Scaling disorder with underlying dermal inflammation •Psoriasis vulgaris most often seen •Exfoliative psoriasis—an explosively eruptive and inflammatory form of the disease

Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence? a. Complaint by patient that something has given way b. Protrusion of visceral organs through a wound opening c. Chronic drainage of fluid through the incision site d. Drainage that is odorous and purulent

A. Complaint by patient that something has given way Rationale: occurs is when a wound fails to heal properly and the layers of skin and tissue separate. It involves abdominal surgical wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. Patients often report feeling as though something has given way. Evisceration is seen when vital organs protrude through a wound opening. A fistula is an abnormal passage between two organs or between an organ and the outside of the body that can be characterized by chronic drainage of fluid. Infection is characterized by drainage that is odorous and purulent.

In a non-infected wound, how often will the nurse change the dressing for a client with negative pressure wound therapy?

48-72hrs

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

A. Complete the head-to-toe assessment, and include current treatment, vital signs, and laboratory results. Rationale: The patient is showing signs and symptoms associated with infection in the wound. It is serious and needs treatment but is not a life-threatening emergency, where care is needed immediately or the patient will suffer long-term consequences. The nurse should complete the assessment; gather all data such as current treatment modalities, medications, vital signs including temperature, and laboratory results such as the most recent complete blood count or white cell count. The nurse can then notify the physician and receive treatment orders for the patient. It is important to notify the charge nurse and consult the wound nurse on the patient's status and on any new orders.

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

A. Ineffective tissue perfusion Rationale: The area on the heel has experienced a decreased supply of blood and oxygen (tissue perfusion), which has resulted in tissue damage. The most appropriate nursing diagnosis with this information is Ineffective tissue perfusion. Risk for infection, Acute pain, and Imbalanced nutrition may be part of this patient's nursing diagnosis, but the data provided do not support this nursing diagnosis.

The nurse is caring for a patient with wound healing by tertiary intention. Which factors does the nurse recognize as influencing wound healing? (Select all that apply.) a. Nutrition b. Evisceration c. Tissue perfusion d. Infection e. Hemorrhage f. Age

A. Nutrition C. Tissue perfusion D. Infection F. Age Rationale: Normal wound healing requires proper nutrition. Oxygen and the ability to provide adequate amounts of oxygenated blood are critical for wound healing. Wound infection prolongs the inflammatory phase, delays collagen synthesis, prevents epithelialization, and decreases the production of proinflammatory cytokines, which leads to additional tissue destruction. As patients age, all aspects of wound healing are delayed. Hemorrhage and evisceration are complications of wound healing.

The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. The nurse is able to identify that the major element involved in the development of a decubitus ulcer is? a. Pressure. b. Resistance. c. Stress. d. Weight.

A. Pressure Rationale: Pressure is the main element that causes pressure ulcers. Three pressure-related factors contribute to pressure ulcer development: pressure intensity, pressure duration, and tissue tolerance. When the intensity of the pressure exerted on the capillary exceeds 12 to 32 mm Hg, this occludes the vessel, causing ischemic injury to the tissues it normally feeds. High pressure over a short time and low pressure over a long time cause skin breakdown. Resistance (the ability to remain unaltered by the damaging effect of something), stress (worry or anxiety), and weight (individuals of all sizes, shapes, and ages acquire skin breakdown) are not major causes of pressure ulcers.

The nurse is caring for a patient with a stage II pressure ulcer and as the coordinator of care understands the need for a multidisciplinary approach. The nurse evaluates the need for several consults. Which of the following should always be included in the consults? (Select all that apply.) a. Registered dietitian b. Enterostomal and wound care nurse c. Physical therapist d. Case management personnel e. Chaplain f. Pharmacist

A. Registered dietitian B. Enterostomal and wound care nurse C. Physical therapist D. Case management personnel Rationale: A registered dietitian is useful in working with the nurse to determine a meal plan that will support wound healing. An enterostomal or wound care nurse specializes in caring for the needs of the patient with wounds. Physical therapy is concerned about the mobility of the patient and can assist an immobile patient to progress toward mobility and decrease the risk for pressure ulcers. Pressure ulcers take a long time to heal and usually require continued therapy in the home. Case management personnel are useful in obtaining care for the patient outside the home. If the patient has a spiritual need, the chaplain can assist. If the patient has a need associated with medications, the pharmacist can assist. However, chaplains and pharmacists usually are not part of the wound care multidisciplinary team, unless a special need arises.

The nurse is caring for a client who needs blood drawn for analysis. When gathering supplies, which dressing will the nurse select to cover the site where the needle was inserted to gather blood? A. gauze B. adhesive strips with eyelets C. hydrocolloid D. transparent

A. gauze

The nurse has started an intravenous catheter in the client's hand. What type of dressing will the nurse use to secure the IV catheter? A. transparent film B. 2 × 2 in (5 × 5 cm) gauze C. hydrogel sheet D. hydrocolloid dressing

A. transparent film

The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. The nurse recognizes that the risk factors that predispose a patient to pressure ulcer development include A. A diet low in calories and fat. B. Alteration in level of consciousness. C. Shortness of breath D. Muscular pain.

B. Alteration in level of consciousness. Rationale: Patients who are confused or disoriented or who have changing levels of consciousness are unable to protect themselves. The patient may feel the pressure but may not understand what to do to relieve the discomfort or to communicate that he or she is feeling discomfort. Impaired sensory perception, impaired mobility, shear, friction, and moisture are other predisposing factors. Shortness of breath, muscular pain, and a diet low in calories and fat are not included among the predisposing factors.

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

B. Hyperemia C. Induration D. Blanching E. Temperature of skin Rationale: Assessment of the skin includes both visual and tactile inspection. Assess for hyperemia and abnormal reactive hyperemia (when the skin turns red after an obstruction of blood flow returns and vasodilatation causes the tissue to turn red). Assess for indurated (hardened) areas on the skin and palpate reddened areas for blanching. Changes in temperature can indicate changes in blood flow to that area of the skin. Mobility and nutritional status are certainly part of the overall assessment for pressure ulcer risk but are not part of the actual skin assessment

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

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

The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by: a. Tertiary intention. b. Secondary intention. c. Partial-thickness repair. d. Primary intention.

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

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

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

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

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

A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider as an indication of infection? A. small amount of drainage that appears to be mostly fresh blood B. foul-smelling drainage that is grayish in color C. large amounts of drainage that is clear and watery and has no smell D. copious drainage that is blood-tinged

B. foul-smelling drainage that is grayish in color

The nurse is cleansing a wound site. As the nurse administers the procedure, what intervention should be included? a. Allowing the solution to flow from the most contaminated to the least contaminated b. Scrubbing vigorously when applying solutions to the skin c. Cleansing in a direction from the least contaminated area d. Utilizing clean gauge and clean gloves to cleanse a site

C. Cleansing in a direction from the least contaminated area

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

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

The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair? a. Eschar b. Slough c. Granulation d. Purulent drainage

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

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

C. Protein Rationale: Protein needs are especially increased in supporting the activity of wound healing. The physiological processes of wound healing depend on the availability of protein, vitamins (especially A and C), and the trace minerals of zinc and copper. A balanced diet of fat and carbohydrates, along with protein, vitamins, and minerals, is needed in any diet. Wound healing does not require increased amounts of fats or carbohydrates. Vitamin E has no known role in wound healing.

A nurse bandages the knee of a client who has recently undergone a knee surgery. What is the major purpose of the roller bandage? A. Maintains a moist environment B. Reduces swelling and inflammation C. Supports the area around the wound D. Keeps the wound clean

C. Supports the area around the wound

The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly? A. The nurse covers the heating pad with a heavy blanket. B. The nurse places the heating pad under the client's neck. C. The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly. D. The nurse uses a safety pin to attach the pad to the bedding.

C. The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.

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

C. The patient will remain free of an increase in temperature and of odorous or purulent drainage from the wound.

The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. What is the best method for repositioning the patient? a. Obtain assistance and use the drawsheet to place the patient into the new position. b. Place the patient in a 30-degree supine position. c. Utilize a transfer sliding board and assistance to slide the patient into the new position. d. Elevate the head of the bed 45 degrees.

C. Utilize a transfer sliding board and assistance to slide the patient into the new position. Rationale: When repositioning the patient, obtain assistance and utilize a transfer sliding board under the patient's body to prevent dragging the patient on bed sheets and placing the patient at high risk for shearing and friction injuries. The patient should be placed in a 30-degree lateral position, not supine position. The head of the bed should be elevated less than 30 degrees to prevent pressure ulcer development from shearing forces.

Tertiary intention of wound healing

Wound healing is delayed and occurs when the wound that was previously open is now closed. This process is usually associated with large infected and contaminated wounds.

Secondary Intention wound healing

Wound margins are not well approximated; larger wound area requires the formation of granulation tissue to fill in the gap. A longer period of time is needed to heal.

Primary intention wound healing

Wound margins are well approximated; examples include laceration and surgical incision. This process has the most rapid healing.

Mechanical forces that create ulcers

-Pressure, Friction, Shear

The nurse suspects that Aaron's wound has developed a sinus tract or tunneling. What equipment will the nurse use to assess the length of the tract?

Sterile cotton-tipped applicator

Individual Risk factors - Exposure to irritants

Radiation, temperature extremes, chemical or mechanical trauma, medical treatments

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

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

Which nursing observation would indicate that a wound healed by secondary intention? a. Minimal scar tissue b. Minimal loss of tissue function c. Permanent dark redness at site d. Scarring can be severe.

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

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

D. The incision has a mass, bluish in color. Rationale: A hematoma is a localized collection of blood underneath the tissues. It appears as swelling, change in color, sensation, or warmth or a mass that often takes on a bluish discoloration. A hematoma near a major artery or vein is dangerous because it can put pressure on the vein or artery and obstruct blood flow. Itching of an incision site can be associated with clipping of hair, dressings, or possibly the healing process. Incisions should be approximated with edges together. After surgery, when nerves in the skin and tissues have been traumatized by the surgical procedure, it is expected that the patient would experience pain.

Individual Risk factors - Tissue Trauma

Friction, shearing, moisture pressure

Which protective equipment will the nurse use when providing wound care for a MRSA Positive client that requires irrigation?

Gloves, gown, goggles, and facemask

stage 3 pressure ulcer

full thickness tissue loss with visible fat

Stage 1 pressure ulcer

intact skin with nonblanchable redness

Stage 2 pressure ulcer

partial thickness skin loss involving epidermis, dermis, or both

Treatment of Psoriasis

•Corticosteroids •Other topical therapies •Ultraviolet light therapy •Systemic therapy: -Immunosuppressants •Emotional support

Candida

•Fungal infection commonly called a yeast infection •Can occur on skin, orally or vaginally •Occurs on the skin due to prolonged wetness •Occurs orally or vaginally usually due to use of antibiotics •Assess patient's skin and oral mucous membranes •May appear red and scaly on skin •Oral form know as thrush •Treated with medicated powders or creams for skin form. Nystatin liquid for oral form

Tinea pedis

•Fungal infection commonly called athletes foot. •Spread through direct contact or by inanimate objects •Lesions may be scaly patches with raised borders •Pruritus common symptom •Treated with antifungal sprays and creams •Teach patient about medications, hygiene practices, and how to prevent infection

Impetigo

•Is a common skin infection usually caused by streptococcus or staphlococcus bacteria •Most common in children •Occurs when a break in the skin allows bacteria to enter causing inflammation and infection. •Clinical Manifestations include: -Blisters that itch and are filled with yellow fluid -Blisters ooze and crust over -Spread by direct contact with fluid in blisters -Can spread on the patient by patient scratching and then touching another part of body •Treatment -Topical antibiotics -If MRSA will need antibiotics that infection is sensitive to -Usually self-limiting

Pediculosis

•Pediculosis—infestation by human lice: -Head lice—pediculosis capitis -Body lice—pediculosis corporis -Pubic or crab lice—pediculosis pubis •Pruritus most common symptom •Treatment -Medications appropriate for infestation -Laundering of clothing and bed linen -Teach patient how to prevent infestation -Teach hygiene practices

Risk Factors for Tissue integrity

•Prolonged pressure •Poor hygiene •Poor nutrition •Incontinence •Breaks in the skin

Dermal Ulcers / Pressure Ulcers

•Tissue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period.

A collection of infected fluid that has not drained and can result in further tissue breakdown?

Abscess

After assessing the sinus tracts, the nurse irrigates the wound as prescribed with normal saline. Which irrigation technique is best?

Apply steady pressure using a 35-ml syringe and 19 gauge needle

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

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

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

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

A nurse is caring for clients on a medical-surgical unit. On the basis of known risk factors, the nurse understands that which client has the highest risk for developing a pressure injury? A. 70-year-old client with Alzheimer disease who wanders the nursing unit using a walker and refuses to sit and eat meals B. 45-year-old client who has cancer, is receiving chemotherapy, is incontinent, and is being admitted with leukopenia C. 65-year-old incontinent client, who eats over half the meals, with a hip fracture on bed rest D. 35-year-old client who was admitted after a motor vehicle accident, is on a liquid diet, and has bilateral casts on the upper extremities

C. 65-year-old incontinent client, who eats over half the meals, with a hip fracture on bed rest

The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. The nurse recognizes that the next step in caring for this patient includes a. Monitoring of the wound. b. Irrigation of the wound. c. Débridement of the wound. d. Management of drainage.

C. Débridement of the wound. Rationale: Débridement is the removal of nonviable necrotic tissue. Removal of necrotic tissue is necessary to rid the ulcer of a source of infection, to enable visualization of the wound bed, and to provide a clean base for healing. A wound will not move through the phases of healing if the wound is infected. Irrigating the wound with noncytotoxic cleaners will not damage or kill fibroblasts and healing tissue and will help to keep the wound clean once débrided. When treating a pressure ulcer, it is important to monitor and reassess the wound at least every 8 hours. Management of drainage will help keep the wound clean.

The nurse is caring for a postpartum patient. The patient has an episiotomy after experiencing birth. The physician has ordered heat to treat this condition, and the nurse is providing this treatment. This patient is at risk for a. Infection. b. Impaired skin integrity. c. Trauma. d. Imbalanced nutrition.

C. Trauma Rationale: Heat causes vasodilatation and is used to improve blood flow to an injured body part. The application of heat incorrectly when the treatment is too hot, or is applied too long or to the wrong place, can result in a burn for the patient and risk for additional trauma. The skin already has impaired integrity owing to the surgical procedure, and because of this has been at risk for infection since the surgical procedure was performed. This patient is of childbearing age and has had a child. Additional needs for nutrition are present during pregnancy and breastfeeding, but this is an established nursing diagnosis. Data are insufficient to support the nursing diagnosis of Imbalanced nutrition.

Stage 4 pressure ulcer

Full-thickness tissue loss with exposed bone, muscle, or tendon

Which is not true of a stage III Pressure ulcer?

Skin is intact with black bruising

Negative Consequences of Decubiti

- Occurs over bony prominence (heel, sacrum) prolonged pressure -can occur within 1-2hrs; change positions q2h -Friction: 2 surfaces rub together - Shear: Sliding; ex. pulling rather than lifting

Patient Education

- Identifying risk factors for impaired skin integrity and impaired tissue integrity - Importance of nutrition, mobility, and keeping skin clean and dry to prevent skin/tissue problems. -Hygiene and skin care discussed. -Safety behaviors to prevent trauma