Ch 48: Skin & Wound Care

Question 1

pressure ulcer

Answer 1

localized injury to the skin and other underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction

Question 2

tissue ischemia

Answer 2

pressure applied over a capillary exceeds the normal capillary pressure and the vessel is occluded for a prolonged period of time. if the pt has reduced sensation and cannot respond to the discomfort of the ischemia, tissue death can result.

Question 3

blanching

Answer 3

normal red tones of the light-skinned patient are absent. it does not occur in pts with darkly pigmented skin.

Question 4

Stage I Pressure Ulcer

Answer 4

nonblanchable redness of intact skin, usually a bony prominence. area may be painful, firm, soft, warmed, or cooler than adjacent tissue.

should use no dressing, transparent dressing, or hydrocolloid dressing to cover.

Question 5

Stage II Pressure Ulcer

Answer 5

partial-thickness loss of dermis. presents as a shallow open ulcer with a red-pink wound bed without slough. may also present as an intact or open/ruptured serum-filled or serosangineous filled blister.

should use composite film, hydrocolloid, or hydrogel dressings to cover.

Question 6

Stage III Pressure Ulcer

Answer 6

full-thickness tissue loss. subcutaneous fat may be visible, but bone, tendon, or muscle is NOT exposed. some slough may be present and it may include undermining and tunneling.

should use hydrocolloid, hydrogel covered with foam dressing, calcium alginate, gauze, or growth factors (with gauze) to cover.

Question 7

Stage IV Pressure Ulcer

Answer 7

full-thickness tissue loss with exposed bone, tendon, or muscle. slough or eschar may be present. it often includes undermining and tunneling. depth varies by anatomical location.

should use hydrogen covered with foam dressing, calcium alginate, gauze, or growth factors (with gauze) to cover.

Question 8

Unstageable/Unclassified

Answer 8

full-thickness tissue loss in which actual dept of the ulcer is completely obscured by slough and/or eschar in the wound bed. until enough slough and/or eschar are removed to expose the base of the wound, the tru depth cannot be determined; but it is either stage III or stage IV.

should use adherent film, gauze plus ordered solution, enzymes, or no dressing to cover.

Question 9

Suspected Deep-Tissue Injury - Depth Unknown

Answer 9

purple or maroon localied area of discolored intact skin or blood-filled blister caused by damage of underlying soft tissue from pressure and/or shear. may be difficult to detect in pts w/ dark skin tones.

Question 10

granulation tissue

Answer 10

red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing.

Question 11

slough

Answer 11

soft yellow or white tissue, stringy substance attached to wound bed. must be removed before the wound is able to heal.

Question 12

eschar

Answer 12

black or brown necrotic tissue, needs to be removed before healing can proceed.

Question 13

exudate

Answer 13

the amount, color, consistency, and odor of wound drainage. excessive exudate indicates infection.

Question 14

wound

Answer 14

disruption of the integrity and function of tissues in the body. ALL WOUNDS ARE NOT CREATED EQUAL!

Question 15

approximated

Answer 15

closed

Question 16

healing by primary intention

Answer 16

surgical incisions. skin edges are approximated, risk of infection is low, healing occurs quickly, minimal scar formation

Question 17

healing by secondary intention

Answer 17

wound is left open until it becomes filled by scar tissue, takes longer to heal; thus chance of infection is greater. if scarring is severe, loss of tissue function is often permanent.

Question 18

components of partial-thickness wound repair (3)

Answer 18

1. inflammatory response: limited to first 24 hours after wounding. redness and swelling w/ moderate amount of serous exudate.
2. epithelial proliferation (reproduction) & migration: start at both wound edges and epidermal cells lining epidermal appendates; quick resurfacing. open to air = 6-7 days. kept moist = 4 days.
3. reestablishment of the epidermal layers: cells slowly reestablish normal thickness and appear as dry, pink tissue.

Question 19

phases of full-thickness wound repair (4)

Answer 19

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

Question 20

hemostasis

Answer 20

series of events designed to control blood loss, establish bacterial control, and seal the defect. injured blood vesselt constrict, and platelets gather to stop bleeding. clots form a fibrin matrix that later provides a framework for cellular repair.

Question 21

inflammatory phase

Answer 21

damaged tissue and mast cells secrete histamine resulting in vasodilation of surrounding capillaries and exudation of serum and WBCs into damaged tissues. results in localized redness, edema, warmth, and throbbing.
within hours leukocytes (akaWBCs) arrive: neutrophils begin to ingest bacteria and small debris, monocytes transform into macrophages and clean wound of bacteria, dead cells, and debris via phagocytosis. as early as day 2 collagen is synthesized (main component of scar tissue).

Question 22

proliferative phase

Answer 22

lasts from 3 to 24 days. filling of the wound w/ granulation tissue, contraction of the wound, and resurfacing of the wound by epithelialization. fibroblasts synthesize collagen which mixes w/ granulation tissue to support epithelialization. wound contracts and epithelial cells migrate from wound edges to resurface.

Question 23

remodeling phase

Answer 23

sometimes takes place for more than a year, depending on depth and extent of wound. collagen scar reorganizes and gains strength for several months. usually scar tissue contains fewer pigmented cells (melanocytes) and has a lighter color than normal skin. in dark-skinned individuals the scar may be more highly pigmented than surrounding skin.

Question 24

hemorrhage

Answer 24

bleeding from a wound site, normal during and immediately after initial trauma

Question 25

hematoma

Answer 25

localized collection of blood underneath the tissues. appears as a swelling, change in color, sensation, or warmth or mass that often takes on a bluish discoloration.

Question 26

purulent

Answer 26

odorous yellow, green, or brown colored drainage

Question 27

dehiscence

Answer 27

the partial or total separation of wound layers. poor nutritional status, infection, and obesity are risk factors (obesity has higher risk b/c of constant strain placed on their wounds and poor healing qualities of fat tissue).

Question 28

Braden Scale

Answer 28

pressure ulcer risk assessment tool. composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. the total score ranges from 6 to 23; a lower score indicates a higher risk for pressure ulcer development. the cutoff score for onset of pressure ulcer risk in the general adult population is 18.

Question 29

abrasion

Answer 29

superficial wound with little bleeding and is considered a partial-thickness wound.

Question 30

laceration

Answer 30

sometimes bleeds more profusely, depending on the depth and location of the wound.

Question 31

puncture

Answer 31

wound that bleeds in relation to the depth and size of the wound. ex: a nail puncture does not cause as much bleeding as a knife wound.

Question 32

serous

Answer 32

type of wound drainage: clear, watery plasma

Question 33

serosanguineous

Answer 33

type of wound drainage: pale, pink, watery; mixture of clear and red fluid

Question 34

sanguineous

Answer 34

type of wound drainage: bright red; indicates active bleeding

Question 35

hemorrhage

Answer 35

bleeding from a wound site, normal during and immediately after initial trauma

Question 36

hematoma

Answer 36

localized collection of blood underneath the tissues. it appears as a swelling, change in color, sensation, or warmth or mass that often takes on a bluish discoloration.

Question 37

dehiscence

Answer 37

partial or total separation of wound layers. a pt who is at risk for poor wound healing (poor nutritional status, infection, or obesity) is at risk for dehiscence. Obese pts have a higher risk b/c of the constant strain placed on their wounds and the poor healing qualities of fat tissue.

Question 38

evisceration

Answer 38

total separation of wound layers with protrusion of visceral organs through a wound opening. This is a surgical emergency because blood supply to the organs protruding through the wound is compromised.

Question 39

penrose drain

Answer 39

drain that lies under a dressing; at the time of placement a pen or clip is placed through the drain to prevent it from slipping farther into the wound. it is usually the health care provider's responsibility to pull or advance the drain as drainage decreases to permit healing deep within the drain site.

Question 40

evacuator units

Answer 40

Hemovac or Jackson-Pratt. drains that exert a constant low pressure as long as the suction device (bladder or container) is fully compresses. often referred to as self-suction.

Question 41

debridement

Answer 41

removal of nonviable, necrotic tissue. necessary to rid the wound of a source of infection, enable visualization of the wound bed, and provide a clean base necessary for healing.

Question 42

autolytic debridement

Answer 42

uses synthetic dressings over a wound to allow the eschar to be self-digested by the action of enzymes that are present in wound fluids. accomplished by using dressings that support moisture at the wound surface. ex: transparent film, hydrocolloid dressings.

Question 43

chemical debridement

Answer 43

debridement with the use of a topical enzyme preparation, Dakin's solution, or sterile maggots.

Question 44

surgical debridement

Answer 44

the removal of devitalized tissue by using a scalpel, scissors, or other sharp instrument.

Question 45

purposes of dressings

Answer 45

``` protect from contamination aid in hemostasis promote healing support/splint the wound site protect pt's from seeing wound promote thermal insulation of wound surface provide moist environment ```

Question 46

recommended protein intake necessary for healing

Answer 46

up to 1.8 g/kg/day

Question 47

vacuum-assisted closure (V.A.C.)

Answer 47

device that assists in wound closure by applying localize d negative pressure to draw the edges of a wound together

Question 48

steps to clean an incision or area surrounding a drain (3)

Answer 48

1. clean in a direction from least contaminated (from wound/incision/isolated drain site to surrounding skin) 2. use gentle friction when applying solutions locally to the skin 3. when irrigating, allow the solution to flow from the least to the most contaminated area

Question 49

irrigation

Answer 49

with an irrigating syringe, flush the area with a constant low pressure flow of solution. use a 35-mL syringe with a 19-gauge needle.

Question 50

sutures

Answer 50

threads or metal used to sew body tissues together. available in silk, steel, cotton, linen, wire, nylon and Dacron.

Question 51

drainage evacuators

Answer 51

convenient portable units that connect to tubular drains lying within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage.

Question 52

contraindications of heat therapy (2)

Answer 52

1. acute, localized inflammation (ex: appendicitis b/c heat causes appendix to rupture) 2. applying heat to large portions of the body with a pt w/ cardiovascular problems (massive vasodilation disrupts blood supply to vital organs)

Question 53

contraindications of cold therapy (4)

Answer 53

1. edematous injury site (retard circulation and prevents absorption of interstitial fluid) 2. impaired circulation (further reduces blood supply to affected area) 3. neuropathy (pt is unable to perceive temp) 4. shivering (dangerously increase body temp)

Question 54

effects of heat therapy

Answer 54

improved blood flow to injured part. prolonged exposure causes reflex vasoconstriction to control heat loss from the area, so periodic removal and reapplication is essential. continuous exposure causes damage to epithelial cells, localized tenderness, and even blistering

Question 55

effects of cold therapy

Answer 55

diminishes swelling and pain. prolonged exposure results in reflex vasodilation - cells aren't receiving adequate blood flow and nutrients which leads to tissue ischemia. the skin initially takes on a reddened appearance, followed by a bluish-purple mottling with numbness and burning pain. skin tissues freeze from exposure to extreme cold.

Question 56

epidermis

Answer 56

top layer of the skin

Question 57

dermis

Answer 57

inner layer of the skin that provides tensile strength and mechanical support

Question 58

collagen

Answer 58

tough, fibrous protein

Question 59

darkly pigmented skin

Answer 59

does not blanch

Question 60

identify the pressure factors that contribute to ulcer development (3)

Answer 60

1. pressure intensity 2. pressure duration 3. tissue tolerance

Question 61

identify risk factors that predispose a pt to pressure ulcer formation (6)

Answer 61

1. decreased mobility 2. decreased sensory perception 3. change in level of consciousness 4. shear 5. friction 6. moisture

Question 62

list the factors that influence pressure ulcer formation (5)

Answer 62

1. nutrition 2. tissue profusion 3. age 4. psychological impact of wounds 5. infection

Question 63

explain how mobility places a patient at risk for a pressure ulcer

Answer 63

potential effects of impaired mobility. muscle tone and strength

Question 64

explain how body fluids place a patient at risk for a pressure ulcer

Answer 64

continual exposure of skin to body fluids especially gastric and pancreatic drainage increases the risk for breakdown. low risk body fluids: saliva, serosanguineous fluid moderate risk: urine, bile, stool, ascitic fluid, purulent wound drainage.

Question 65

explain how nutritional status places a pt at risk for a pressure ulcer

Answer 65

malnutrition is a major risk factor; a loss of 5% of usual weight, weight less than 90% of ideal body weight, or a decrease of 10 lb in a brief period also increase risk.

Question 66

explain how pain places a pt at risk for a pressure ulcer

Answer 66

maintaining adequate pain control and pt comfort increases pts willingness and ability to increase mobility, which in turn decreases pressure ulcer risk.

Question 67

explain how a nurse would assess wound appearance

Answer 67

observe whether wound edges are closed. look for dehiscence and evisceration. the first 2-3 days the outer edges normally appear inflamed. within 7-10 days a normally healing wound resurfaces with epithelial cells and edges close.

Question 68

explain how a nurse would assess the character of wound drainage

Answer 68

note amount, color, odor, and consistency. can weigh a the used dressing and compare it to the weight of a clean dressing of the same size. 1 g of drainage = 1 mL of volume of drainage

Question 69

explain how a nurse would assess a wound drain

Answer 69

assess the number of drains, drain placement, character and volume of drainage, condition of collecting equipment (patency of drain tubing), security of drain and its location with respect to the wound.

Question 70

explain how a nurse would assess wound closure

Answer 70

normally for the first 2-3 days after surgery the skin around sutures/staples is edematous. continued swelling may indicate that closures are too tight and the sutures can cut the skin leading to wound separation.

Question 71

dermabond

Answer 71

tissue adhesive that forms a strong bond across opposed wound edges, allowing normal healing to occur below. can be used to replace small sutures, some surgeons use it on larger wounds where subcutaneous sutures are needed.. the dermabond is applied to the approximated tissue and the edges are held together until the solution dries.

Question 72

mechanical debridement

Answer 72

use of wet-to-dry saline gauze dressing. place moistened gauze into the wound and allow the dressing to dry thoroughly before "pulling" the gauze that has adhered to tissue out of the pressure ulcer. not used routinely b/c the technique removes viable tissue.

Question 73

list principles to maintain a healthy wound environment (6)

Answer 73

1. manage infection 2. cleanse the wound 3. remove nonviable tissue 4. manage exudates 5. maintain wound in moist environment 6. protect wound

Question 74

explain the rationale for debriding a wound

Answer 74

debriding rids the wound of source of infection, enables visualization of wound bed, and provides a clean base necessary for healing.

Question 75

identify the 4 methods of debridement (4)

Answer 75

1. mechanic 2. autolytic 3. chemical 4. sharp/surgical

Question 76

list the purposes of dressings (7)

Answer 76

1. protects wound from microorganism contamination 2. aids in hemostasis 3. promotes healing by absorbing drainage and debriding a wound 4. supports or splints wound site 5. protects pts from seeing the wound (if perceived as unpleasant) 6. promotes thermal insulation of wound surface 7. provides a moist environment

Question 77

list the clinical guidelines to use when selecting the appropriate dressing (6)

Answer 77

1. use a dressing that will continuously provide moist environment 2. perform wound care using topical dressings as determined by assessment 3. choose a dressing that keeps surrounding skin dry 4. choose a dressing that controls exudate 5. consider caregiver time, availability, and cost 6. eliminate wound dead space by loosely filling all cavities with dressing material

Question 78

list the advantages of a transparent film dressing (5)

Answer 78

1. adheres to undamaged skin 2. oxygen passes through; still a barrier to external fluids and bacteria 3. promotes moist environment that speeds epithelial cell growth 4. can be removed without damaging underlying tissue 5. does not require secondary dressing

Question 79

list the functions of hydrocolloid dressings (7)

Answer 79

1. absorbs drainage via exudate absorbers in dressing 2. maintains wound moisture 3. slowly liquefies necrotic debris 4. impermeable to bacteria and other contaminants 5. self-adhesive and molds well 6. acts as preventive dressing for high-risk friction areas 7. may be left in place for 3-5 days minimizing skin trauma and disruption of healing

Question 80

list the advantages of hydrogel dressing (4)

Answer 80

1. soothing and can reduce pain 2. provides moist environment 3. debrides necrotic tissue (by softening necrotic tissue) 4. does not adhere to wound bast and is easy to remove

Question 81

list the guidelines to follow during a dressing change procedure (4)

Answer 81

1. assess skin beneath tape 2. perform thorough hand hygiene before and after wound care 3. wearing sterile gloves before directly touching an open or fresh wound 4. remove or change dressings over closed wounds when they become wet or if patient has signs or symptoms of infection and as ordered.

Question 82

summarize the principles of packing a wound

Answer 82

1. assess the size, depth, and shape of the wound 2. moist dressing needs to be flexible and in contact with all of the wound surface 3. do not pack tightly b/c overpacking causes pressure 4. do not overlap the wound edges b/c it causes maceration of the tissue

Question 83

describe how the wound vacuum-assisted closure (wound vac) device works

Answer 83

applies local negative pressure to draw the edges of a wound together by evacuating wound fluids and stimulating granulation tissue formation and reduces the bacterial burden of a wound and maintains a moist environment

Question 84

identify 3 principles that are important when cleaning an incision

Answer 84

1. cleanse in a direction from the least contaminated area to the surrounding skin 2. use gentle friction when applying solutions locally to the skin 3. when irrigating, allow the solution to flow from the least to the most contaminated area

Question 85

summarize the principles of wound irrigation

Answer 85

use an irrigation syringe to flush the area with a constant low-pressure flow of solution of exudates and debris. never occlude a wound opening with a syringe.

Question 86

explain the purpose for drainage evacuation

Answer 86

portable units that connect tubular drains lying within a wound bed and exert a safe, constant low-pressure vacuum to remove and collect drainage

Question 87

explain the benefits of binders and bandages

Answer 87

1. create pressure over a body part 2. immobilize a body part 3. support a wound 4. reduce or prevent edema 5. securing a splint 6. securing dressings

Question 88

list the nursing responsibilities when applying a bandage or binder

Answer 88

1. inspect the skin for abrasions, edema, discoloration, or exposed wound edges 2. covering exposed wounds or open abrasions with a sterile dressing 3. assessing the condition of underlying dressings and changing if soiled 4. assessing the skin for underlying areas that will be distal to the bandage for signs of circulatory impairment

Question 89

list the factors that influence heat and cold tolerance

Answer 89

1. better able to tolerate short exposure to temp extremes 2. neck, inner aspect of wrist and forearm, and perineal region are more sensitive to temp variations 3. body responds best to minor temp adjustments 4. pts have less tolerance to temp changes to which a large area of the body is exposed 5. tolerance to temp variations changes with age 6. physical conditions that reduce the reception or perception of sensory stimuli (ex: diabetic neuropathy) 7. uneven temp distribution suggests that the equipment is not functioning properly

Question 90

explain the rationale for warm, moist compresses

Answer 90

improve circulation, relieve edema, and promote consolidation of pus and drainage

Question 91

explain the rationale for warm soaks

Answer 91

promote circulation, lessens edema, increases muscle relaxation, and provides a means to debride wounds and apply medicated solutions

Question 92

explain the rationale for sitz baths

Answer 92

the pelvic area is immersed in warm fluid, causing wide vasodilation

Question 93

explain the rationale for commercial hot packs

Answer 93

disposable hot packs that apply warm, dry heat to an area

Question 94

explain the rationale for cold, moist, and dry compresses

Answer 94

relieves inflammation and swelling

Question 95

explain the rationale for cold soaks

Answer 95

immersing a body part for 20 minutes

Question 96

explain the rationale for ice bags or collars

Answer 96

used for muscle sprain, localized hemorrhage, or hematoma

Question 97

list the questions to ask if the identified outcomes were not met

Answer 97

1. was the etiology of the skin impairment addressed? 2. was wound healing supported by providing the wound base with a moist, protected environment? 3. were issues such as nutrition assessed and a plan of care developed?

Question 98

Mr. Post is in a Fowlers position to improve his oxygenation status. The nurse notes that he frequently slides down in the bed and needs to be repositioned. Mr. Post is now at risk for developing a pressure ulcer on his coccyx because of: 1. Friction 2. Maceration 3. Shearing force 4. Impaired peripheral circulation

Answer 98

3. Shearing force. Rationale: the force exerted parallel to the skin resulting from both gravity pushing down on the body and resistance between the patient and the surface.

Question 99

Which of the following is not a subscale on the Braden scale for predicting pressure ulcer risk? 1. Age 2. Activity 3. Moisture 4. Sensory perception

Answer 99

1. Age Rationale: age is not a subscale. Perception, moisture, activity, mobility, nutrition, friction, and shear are the subscales.

Question 100

Which of these patients has a nutritional risk for pressure ulcer development? 1. Patient A has an ablumin level of 3.5. 2. Patient B has a hemoglobin level within normal limits. 3. Patient C has a protein intake of 0.5 g/kg/day. 4. Patient D has a body weight that is 5% greater than his ideal weight.

Answer 100

3. Patient C has a protein intake of 0.5 g/kg/day. Rationale: The recommended protein intake of adults is 0.8 g/kg/day. A higher intake of up to 1.8 g/kg/day is necessary for healing.

Question 101

Mr. Perkins has a stage II ulcer on his right heel. What would be the most appropriate treatment for this ulcer? 1. Apply a heat lamp to the area for 20 minutes twice daily. 2. Apply a hydrocolloid dressing and change it as necessary. 3. Apply a calcium alginate dressing and change when strikethrough is noted. 4. Apply a thick layer of enzymatic ointment to the ulcer and the surrounding skin.

Answer 101

2. Apply a hydrocolloid dressing and change it as necessary. Rationale: stage II ulcers should be treated with hydrocolloid or hydrogel dressings.