Chapter 32 Skin integrity and Wound care

Question 1

During wound irrigation the nurse notes bleeding from the wound. This has not been documented as happening with previous irrigations

Answer 1

Stop the procedure. Assess the patient for other symptoms, obtain vital signs, report the findngs to the primary care provider and document the event in the patient’s record.

Question 2

The patient experiences pain when the wound irrigation is begun

Answer 2

Stop the procedure and administer an analgesic as ordered. Obtain new sterile supplies and begin the procedure after an appropriate amount of time has elapsed to allow the analgesic to begin working. Note the document the pain so pain medication can be given before future wound Tx.

Question 3

A Jackson-Pratt drain is completely removed from the patient

Answer 3

Assess the patient for any new and abnormal SxS, assess the surgical site and drain site. Apply a sterile dressing with gauze and tape to the drain site. Notify the physician of the findings and document.

Question 4

why is cleaning the wound prior to obtaining a specimen for culture important

Answer 4

it removes previous drainage, wound debris, and skin flora which could introduce extraneous organisms into the specimen, resulting in inaccurate result.

Question 5

using heat for more than 45 minutes results in ?

Answer 5

tissure congestion and vasoconstriction (rebound phenomenon)

Question 6

Granulation tissue

Answer 6

new tissue composed of many small blodd vessels, is pinkish red, and fills an open wound when it starts to heal.

Question 7

Involves partial thickness loss of dermis and presents as a shallow open ulcer with a red pick wound bed, without slough, it may also present as an intact or open/reptured serum-filled blister

Answer 7

stage II pressure ulcer

Question 8

An open lesion with full thickness tissure loss and visible subcutaneous fat

Answer 8

Stage III pressure ulcer

Question 9

notice a stable (dry, adherent, intact, without erythema or fluctuance) eschar on the heels.

Answer 9

should not be removed, it serves as “the body’s natural (biological) cover”

Question 10

Wound dressing is dry upon removal

Answer 10

Reduce the time interval between changes to prevent drying of the materials, which may disrupt healing tissure

Question 11

dressing around a Jackson-Pratt Drain is saturated with serosanguineous secretions and there is minimal drainage in the collection chamber.

Answer 11

Inspect the tubing for kinks or obstruction, assess the patient for changes in condition, remove the dressing and assess the site, cleanse the area and redress the site, notify the Dr. and document.

Question 12

when the patient with a drain is ready to ambulate.

Answer 12

empty and compress the drain before activity, secure the drain to the patient’s gown below the wound making sure there is no tension on the drainage tubing

Question 13

The wound assessment reveals several depressions or craterlike areas on inspection.

Answer 13

Notify the Dr., or wound care specialist, for order to pack the wound. pack the wound cavities loosely.

Question 14

Assessment findings on a wound are different from previous findings

Answer 14

Assess the patient for any other SxS such as pain, malasie, fever and paresthesias, place a dry sterile dressing over the wound site, report findings to Dr. document and be prepared to obtain a wound culture.

Question 15

How to clean a wound

Answer 15

clean the wound from top to bottom and from the center to the outside.

Question 16

Thick, leathery scab or dry crust that is necrotic and must be removed before a wound stage can be accurately determined.

Answer 16

Eschar

Question 17

Intact skin with nonblanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue

Answer 17

Stage I pressure ulcers

Question 18

describe Stage II pressure ulcers

Answer 18

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

Question 19

Results when one layer of tissue slides over another layer.

Answer 19

shear

Question 20

Full thickness tissue loss. Subcutaneous fat may be visible, slough may be present, may include undermining and tunneling.

Answer 20

Stage III pressure ulcers

Question 21

Factors in the developments of pressure ulcers

Answer 21

immobility, nutrition and hydration, skin moisture, mental statues, age, poor circulation, obesity or thinness, diabetes mellitus, immunosuppression, history of corticosteroid therapy

Question 22

deficiency of blood in a particular area

Answer 22

ischemia

Question 23

A wound with a localized area of tissue necrosis

Answer 23

pressure ulcer

Question 24

What occurs when two surfaces rub against each other.

Answer 24

Friction

Question 25

Describe Stage IV pressure ulcer

Answer 25

full thickness tissue loss with exposed bone, tendon, or muscle, slough or eschar may be present on some parts of the wound bed, undermining and tunneling.

Question 26

Full thinkness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Answer 26

unstageable pressure ulcers

Question 27

symptoms of wound infection

Answer 27

purulent drainage; increased drainage, pain, redness and swelling the and around the wound, increase body temp, increase WBC.

Question 28

what other complications can wound infections lead to?

Answer 28

osteomyelitis (bone infection) | sepsis (pathogenic organisms in the blood or tissues)

Question 29

An abnormal passage from an internal organ to the outside of the body or from one internal organ to another.

Answer 29

Fistula

Question 30

It formation is often the result of infection that has developed into an abscess.

Answer 30

Fistula

Question 31

The presence of a fistula increases the patient's risk for?

Answer 31

delayed healing, additonal infection, fluid and electrolye imbalances and skin breakdown

Question 32

Wound complications

Answer 32

infections, hemorrhage, dehiscence and evisceration, fistual formation

Question 33

what to do when dehiscence occures?

Answer 33

Cover the wound area with sterile towels moistened with sterile 0.9% NaCl solution and notify the physician. The wound is managed like any opened wound.

Question 34

An increase in the flow of fluied from the wound between postoperative days 4 and 5 may be a sign of?

Answer 34

impending dehiscence

Question 35

Evisceration

Answer 35

most serious complication of dehiscence. The wound completely separates with protrusion of viscera through the incisional area.

Question 36

Patients at greater risk for dehiscence and Evisceration

Answer 36

obese, malnourished, smoke tobacco, use anticoagulants, have infected wounds, experience excessive coughing

Question 37

which vitamins are essential for epithelialization and collagen synthesis

Answer 37

vitamins A and C

Question 38

Zinc

Answer 38

plays a role in proliferation of cells

Question 39

factors affecting wound healing

Answer 39

desiccation, maceration, necrosis, pressure, trauma, edema, infection,

Question 40

what are the phase of wound healing

Answer 40

Hemostasis, inflammatory phase, proliferation, maturation

Question 41

purple blotches of the skin may be indicative of

Answer 41

kaposi's sarcome

Question 42

heat application causes

Answer 42

vasodilation and sweating which dissipates heat | increased body temperature

Question 43

heat application can be use to treat

Answer 43

infections, surgical wounds, inflamed tissue, arthritis, joint and muscle pain, dysmenorrhea, chronic pain.

Question 44

maximum therapeutic effects from heat occurs in

Answer 44

20-30 minutes

Question 45

extensive, prolonged heat

Answer 45

increase CO, sweating, increase pulse and decrease BP (hypovolemic shock)

Question 46

prolonged exposure for cold application

Answer 46

rebound phenomenon-compensatory vasodilation begins at 60 F | increase BP, shivering, piloerection

Question 47

cutting or sharp instrument; wound edges in close approximation and aligned

Answer 47

Incision

Question 48

contusion

Answer 48

blunt instrument, overlying skin remains intact, with injury to underlying soft tissue, possible resultant bruising and or hematoma

Question 49

friction; rubbing or scraping epidermal layers of skin

Answer 49

Abrasion

Question 50

Tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue

Answer 50

Laceration

Question 51

Avulsion

Answer 51

tearing a structure from normal anatomic position; possible damage to blood vessels, nerves and other structures

Question 52

injury and poor venous return resulting from underlying conditions, such as incompetent valves or obstruction

Answer 52

venous ulcers

Question 53

injury and underlying ischemia, resulting from underlying conditions, such as atherosclerosis or thrombosis

Answer 53

Arterial ulcers

Question 54

injury and underlying diabetic neuropath, peripheral arterial disease

Answer 54

diabetic ulcers

Question 55

Type of wound where the dermis and underlying subcutaneous fat tissue are damaged or destroyed

Answer 55

complex wound

Question 56

Example of close wounds

Answer 56

ecchymosis | hematomas

Question 57

The accumulation of exudate causes

Answer 57

swelling and pain

Question 58

How long is the inflammatory phase of wound healing

Answer 58

4 to 6 days

Question 59

Acute inflammation is characterized by

Answer 59

pain, heat, redness, and swelling at the site of injury

Question 60

what some important nursing considerations during the proliferation phase of wound healing

Answer 60

adequate nutrition and oxygenation

Question 61

Laboratory criteria indicating a patient is nutritionally at risk for development of a pressure ulcer

Answer 61

Albumin 15 total lymphocyte count < 1,8000 hgb A1C >8% glucose >120

Question 62

Normal glucose level

Answer 62

70-120 mg/dL

Question 63

normal hemoglobin A1C

Answer 63

6%

Question 64

3.5-5.5

Answer 64

normal albumin level

Question 65

normal prealbumin

Answer 65

16-40

Question 66

normal total lymphocyte count

Answer 66

1, 000-4, 000/mm3

Question 67

The edges of a healthy healing surgical wound should appear

Answer 67

clean and well approximate, with crust along the edges

Question 68

wound is swollen and deep red, it feels hot on palpation and drainage is increased with possible purulent

Answer 68

infection is present

Question 69

Type of exudate composed primarily of the clear (and watery) serous portion of the blood and from serous membranes

Answer 69

serous

Question 70

sanguineous exudate (drainage)

Answer 70

consists of large numbers of red blood cells. Bright-red is indicative of fresh bleeding, whereas darker drainage indicates older bleeding.

Question 71

A mixture of serum and red blood cells. it light pink to blood tinged

Answer 71

serosanguineous drainage

Question 72

How is a wound treated when all the colors (RYB) are present?

Answer 72

The most serious color first..black, followed by yellow and finally red

Question 73

Nursing interventions for wounds in the proliferative stage (Red) of healing

Answer 73

gentle cleansing, use of moist dressing, and changing of dressing only when necessary.

Question 74

nursing interventions for wound with yellow color (drainage)

Answer 74

use of wound cleaners and irrigating

Question 75

After debridement wound is treated as---

Answer 75

yellow wound; use of wound cleansers and irrigating

Question 76

This type of wound are cared for by advanced practice nurses who are educated in the care of wounds.

Answer 76

black= debridement (removal)

Question 77

why are drains inserted in or near a wound

Answer 77

to promote drainage, thereby reducing the risk of abscess formation and promoting healing.

Question 78

Retention sutures

Answer 78

used to provide extra support for patients who are obese and for wounds with increase risk for dehiscence.

Question 79

A type of drainage that provides sinus tract

Answer 79

Penrose | use after incision and drainage of abscess in abdominal surgery

Question 80

Jackson-Pratt

Answer 80

decrease dead space by collecting drainage. | after breast removal, abdominal surgery

Question 81

allow healing from base of wound, use for infected wounds, after removal of hemorrhoids

Answer 81

Gauze, iodoform gauze, NuGauze

Question 82

purpose of dressing wounds

Answer 82

``` comfort debridement infection protection/control Absorption Maintain moisture protect wound protect skin ```

Question 83

when should wound dressings be changed?

Answer 83

when ordered when wet through when medication or special agent no longer effective

Question 84

which environment is best for wound healing

Answer 84

moist

Question 85

(T/F) pressure ulcers are nonsterile wounds. There is no need to use sterile dressing

Answer 85

True.

Question 86

Surgical wounds that have dehisced required what type of cleaning technique

Answer 86

sterile

Question 87

cleaning wounds with approximate edges

Answer 87

Clean from top to bottom

Question 88

cleaning wounds with unapproximated edges

Answer 88

clean in full or half circles, beginning in the center and working toward the outside. clean to at least 1 inch beyond the end of the new dressing if a dressing is not being applied, clean at least 2 inches beyond the wound margins.

Question 89

The inflammatory phase follows hemostasis and lasts about

Answer 89

4 to 6 days

Question 90

in wounds that heal by first intention, epidermal cells seal the wound within?

Answer 90

24 to 48 hours | granulation tissue is not visible

Question 91

The inflammatory phase follows hemostasis and lasts about

Answer 91

4 to 6 days

Question 92

in wounds that heal by first intention, epidermal cells seal the wound within?

Answer 92

24 to 48 hours | granulation tissue is not visible

Question 93

The inflammatory phase follows hemostasis and lasts about

Answer 93

4 to 6 days

Question 94

in wounds that heal by first intention, epidermal cells seal the wound within?

Answer 94

24 to 48 hours | granulation tissue is not visible

Question 95

The inflammatory phase follows hemostasis and lasts about

Answer 95

4 to 6 days

Question 96

in wounds that heal by first intention, epidermal cells seal the wound within?

Answer 96

24 to 48 hours | granulation tissue is not visible