Chapter 48 Flashcards
Skin Integrity and Wound Care
Because of the foul-smelling tan-colored drainage from Mrs. Stein’s hip incision, the staples were removed by the health care provider, and an order was written for moist saline gauze dressing to the area 3 times a day. When the dressing is removed, which factors are critical to assess?
Examine the dressing for signs of excessive wound drainage such as discoloration, number of gauzes saturated, and any odor. Since institutional policy mandates a thorough wound assessment on a daily basis of all acute wounds, measure the wound depth, length, and width at one dressing change every 24 hours. Examine the periwound skin for signs of redness, warmth, edema, or maceration. Chart all findings and communicate any critical changes to the health care provider managing the patient.
A head-to-toe skin assessment is done per institutional policy on a daily basis. At the most recent assessment of Mrs. Stein’s skin, redness was noted over the sacral area; on direct examination a small area of denuded tissue was noted. The area was assessed and was found to have minimal depth and a red, moist base. How would you describe the impairment in skin integrity in your charting?
Include the following: depth of skin injury (partial thickness), contributing factors (friction from limited mobility and inappropriate transfers), assessment of pain (on a scale of 0 to 10), color of tissue in wound base (red, moist tissue, granulation tissue).
What will you include in your plan of care for Mrs. Stein to address the impairment in skin integrity in the sacral area?
One of the most important interventions is to correct the etiology of the skin breakdown. The partial-thickness ulcer over Ms. Stein’s sacral area is related to friction from inappropriate transfers; consider ordering a trapeze for her to use when transferring or repositioning. Instruct her not to scoot over the sheets when she is moving. Assess her pain level when moving and offer pain medication before helping her move. Ensure adequate nutritional intake. Use a moisture-barrier ointment over the denuded area to prevent further tissue loss and friction to the area. Provide thorough pericare.
Mrs. Stein will be discharged tomorrow. Which issues must be assessed regarding her care before discharge? Describe why these issues are of importance.
The issues that must be assessed and a developed plan include:
- Assess the patient’s ability to transfer correctly and with minimal assistance because her independence determines if she can return to her home setting.
- Assess pain control; she must be able to control pain to increase her ambulation.
- Assess nutrition, which must be adequate to support healing of her incisional area.
- Assess her caregivers if she is discharged home since they need instruction in helping her ambulate and care for the surgical wound and the ulcer over her sacral area.
When repositioning an immobile patient, the nurse notices redness over a bony prominence. What is indicated when a reddened area blanches on fingertip touch?
1 A local skin infection requiring antibiotics
2 Sensitive skin that requires special bed linen
3 A stage III pressure ulcer needing the appropriate dressing
4 Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.
4
When repositioning an immobile patient, it is important to assess all bony prominences for the presence of redness, which can be the first sign of impaired skin integrity. Pressing over the area compresses the blood vessels in the area; and, if the integrity of the vessels is good, the area turns lighter in color and then returns to the red color. However, if the area does not blanch when pressure is applied, tissue damage is likely.
Which type of pressure ulcer is noted to have intact skin and may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or soft), and/or pain?
1 Stage I
2 Stage II
3 Stage III
4 Stage IV
1
A stage I pressure ulcer does not have a break in the skin but has a redness that does not blanch. Depending on the skin color, there may be a discoloration; the area may feel warm because of the vasodilation or cool if blood is constricted in the area; and the tissue may feel firm if there is edema in the area or soft if the blood flow is compromised. The patient may report pain in the area.
When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?
1 Necrotic tissue
2 Wound drainage
3 Drainage on the dressing
4 Wound after it has first been cleaned with normal saline
4
Drainage that has been present on the wound surface can contain bacteria from the skin, and the culture may not contain the true causative organisms of a wound infection.
By cleaning the area before obtaining the culture, the skin flora is removed.
After surgery the patient with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which corrective intervention should the nurse do first?
1 Allow the area to be exposed to air until all drainage has stopped
2 Place several cold packs over the area, protecting the skin around the wound
3 Cover the area with sterile, saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration
4 Cover the area with sterile gauze, place a tight binder over it, and ask the patient to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly
3
a patient has an opening in the surgical incision and a portion of the small bowel is noted, the small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist.
Which description best fits that of serous drainage from a wound?
1 Fresh bleeding
2 Thick and yellow
3 Clear, watery plasma
4 Beige to brown and foul smelling
3
Serous fluid generally is serum and presents as light red, almost clear fluid.
For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part?
1 Binder
2 Ice bag
3 Elastic bandage
4 Absorptive diaper
2
An ice bag helps to constrict excess fluid in tissues, which prevents edema. The blood vessels become constricted, help to control bleeding, and can decrease pain where the ice bag is placed.
Which skin care measures are used to manage a patient who is experiencing fecal and urinary incontinence?
1 Keeping the buttocks exposed to air at all times
2 Using a large absorbent diaper, changing when saturated
3 Using an incontinence cleaner, followed by application of a moisture-barrier ointment
4 Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel
3
Skin that is in contact with stool and urine can become moist and soft, allowing it to become damaged. The stool contains bacteria and in some cases enzymes that can harm the skin if in contact for a prolonged period of time. The use of an incontinence cleaner provides a gentle removal of stool and urine, and the use of the moisture-barrier ointment provides a protective layer between the skin and the next incontinence episode.
Which of the following describes a hydrocolloid dressing?
1 A seaweed derivative that is highly absorptive
2 Premoistened gauze placed over a granulating wound
3 A debriding enzyme that is used to remove necrotic tissue
4 A dressing that forms a gel that interacts with the wound surface
4
A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing.
Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound?
1 Collection of wound drainage
2 Reduction of abdominal swelling
3 Reduction of stress on the abdominal incision
4 Stimulation of peristalsis (return of bowel function) from direct pressure
3
A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreasing stress from coughing and movement.
When is an application of a warm compress indicated? (Select all that apply.)
1 To relieve edema
2 For a patient who is shivering
3 To improve blood flow to an injured part
4 To protect bony prominences from pressure ulcers
1,3
Warm compresses can improve circulation by dilating blood vessels, and they reduce edema. The moisture of the compress conducts heat.
What is the removal of devitalized tissue from a wound called?
1 Debridement
2 Pressure reduction
3 Negative pressure wound therapy
4 Sanitization
1
Debridement is the removal of nonliving tissue, cleaning the wound to move toward healing.
Name the three important dimensions to consistently measure to determine wound healing.
With, length, and depth
Consistent measurement of the wound using the dimensions of width, length, and depth provide information on the overall change in wound size that indicates if the wound is moving toward healing.
What does the Braden Scale evaluate?
1 Skin integrity at bony prominences, including any wounds
2 Risk factors that place the patient at risk for skin breakdown
3 The amount of repositioning that the patient can tolerate
4 The factors that place the patient at risk for poor healing
2
The Braden Scale measures factors in six subscales that can predict the risk of pressure ulcer development. It does not assess skin or wounds.
On assessing your patient’s sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct stage for this patient’s pressure ulcer?
1 Stage II
2 Stage IV
3 Unstageable
4 Suspected deep tissue damage
3
To determine the stage of a pressure ulcer you examine the depth of the tissue involvement. Since the pressure ulcer assessed was covered with necrotic tissue, the depth could not be determined. Thus this pressure ulcer cannot be staged.
15 Name one intervention and the rationalization to use that intervention to reduce the likelihood of a shear injury to a patient.
A transfer device can pick up a patient and prevent his or her skin from sticking to the bed sheet as he is repositioned. A second intervention would be to position the patient with the head of the bed to be elevated at 30 degrees, which prevents him or her from sliding. A third intervention would be to educate the patient and his or her caregiver on the importance of not sliding on the sheets when repositioning.
Localized injury to skin and or underlying tissue, usually over a body prominence, as a result of pressure or pressure in combination with shear and/or friction is know as what?
A. Pressure ulcer
B. Abrasion
C. Laceration
D. Wound
Pressure Ulcer
Which of the following actions would place a client at the greatest risk for a shearing force injury to the skin?
A. Walking without shoes
B. Sitting in a Fowler’s position
C. Lying supine in bed
D. using a heating pad
B
What are the three pressure-related factors which contribute to pressure ulcer development?
Intensity
Duration
Tissue tolerance
What is the major cause of pressure ulcer development?
Pressure
What factors do not contribute to the development of ulcer development? (Select all that apply)
- pressure
- Impaired mobility
- Race
- Fecal and/or urinary incontinence
- Culture
- Poor nutrition
- Aging skin
- Chronic illness
- Altered level of consciousness
- hygiene
- Spinal cord and brain injuries
- Neuromuscular disorders
- Friction
- Shear
- Moisture
1, 2, 4, 6, 7, 8, 11, 12, 15
3, 5, 10,
What is friction defined as?
A. the force exerted parallel to the skin resulting from gravity pushing down on the body and resistance between the client and a surface.
B. the force of two surfaces moving across one another.
C. The removal of exudate from a wound.
B
What is shear defined as?
A. the force exerted parallel to the skin resulting from gravity pushing down on the body and resistance (friction) between the client and a surface.
B. full thickness tissue loss with exposed bone, tendon, or muscle.
C. Full thickness tissues loss with visible fat.
A
Moisture…
A. increased the skin’s resistance to other physical factors such as pressure and/or shear force.
B. reduces the skin’s resistance to other physical factors such as pressure and/or shear force.
C. May be undermining and tunneling.
B
Matching
Stage I
Stage II
Stage III
Stage IV
- Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
- Intact skin with nonblanchable redness of localized area usually over a bony prominence.
- Partial-thickness skin loss involving epidermis and/or dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Abrasion, blister, or shallow crater.
- Full thickness tissue loss with visible fat involving damage or necrosis of subcutaneous tissue (deep crater) Bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of the tissue loss. May be undermining and tunneling.
Stage I 2
Stage II 3
Stage III 4
Stage IV 1
The amount of viable and nonviable tissue is measured in terms of what?
A. Percentage
B. centimeter
C. exudate
A. Percentage
What is granulation?
A. Black or brown necrotic tissue that must be removed before healing can proceed.
B. Red, moist tissue indicated progressing toward healing.
C. Stringy tissue attached to wound bed which is tissue that must be removed before healing.
B
What is slough?
A. Black or brown necrotic tissue that must be removed before healing can proceed.
B. Red, moist tissue indicated progressing toward healing.
C. Stringy tissue attached to wound bed which is tissue that must be removed before healing.
C
What is eschar?
A. Black or brown necrotic tissue that must be removed before healing can proceed.
B. Red, moist tissue indicated progressing toward healing.
C. Stringy tissue attached to wound bed which is tissue that must be removed before healing.
A
How do you measure wound dimensions?
(Select all that apply)
A. length
B. height
C. width
D. depth
A. C. D.
