Chapter 48: Skin Integrity and Wound Care Flashcards
The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. Which risk factor will the nurse assess for that predisposes a patient to pressure ulcer development?
a. Decreased level of consciousness
b. Adequate dietary intake
c. Shortness of breath
d. Muscular pain
ANS: A
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 an adequate dietary intake are not included among the predisposing factors.
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. Which priority element will the nurse consider when planning care to decrease the development of a decubitus ulcer?
a. Resistance
b. Pressure
c. Weight
d. Stress
ANS: B
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 15 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, stress, and weight are not the priority causes of pressure ulcers.
Which nursing observation will indicate the patient is at risk for pressure ulcer formation?
a. The patient has fecal incontinence.
b. The patient ate two thirds of breakfast.
c. The patient has a raised red rash on the right shin.
d. The patient’s capillary refill is less than 2 seconds.
ANS: A
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.
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 should the nurse document this ulcer in the patient’s medical record?
a. Stage I pressure ulcer
b. Healing Stage II pressure ulcer
c. Healing Stage III pressure ulcer
d. Stage III pressure ulcer
ANS: C
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” or healing Stage III pressure ulcer. Once an ulcer has been staged, the stage endures even as the ulcer heals. This ulcer was labeled a Stage III, and 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 admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
ANS: B
This would be a Stage II pressure ulcer because it presents as partial-thickness skin loss involving epidermis and dermis. The ulcer 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.
The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which item should the nurse use first to assist in staging an ulcer on this patient?
a. Disposable measuring tape
b. Cotton-tipped applicator
c. Sterile gloves
d. Halogen light
ANS: D
When assessing a patient with darkly pigmented skin, proper lighting is essential to accurately complete the first step in assessment—inspection—and the entire 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 are not the first items used.
The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient?
a. Partial-thickness wound repair
b. Full-thickness wound repair
c. Primary intention
d. Tertiary intention
ANS: B
Stage IV 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 four phases: hemostasis, inflammatory, proliferative, and maturation. 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 are approximated. Wound closure is delayed until risk of infection is resolved.
The nurse is caring for a group of patients. Which patient will the nurse see first?
a. A patient with a Stage IV pressure ulcer
b. A patient with a Braden Scale score of 18
c. A patient with appendicitis using a heating pad
d. A patient with an incision that is approximated
ANS: C
The nurse should see the patient with an appendicitis first. Warm applications are contraindicated when the patient has an acute, localized inflammation such as appendicitis because the heat could cause the appendix to rupture. Although a Stage IV pressure ulcer is deep, it is not as critical as the appendicitis patient. The total Braden score ranges from 6 to 23; a lower total score indicates a higher risk for pressure ulcer development. A score of 18 can be assessed later. A healing incision is approximated (closed); this is a normal finding and does not need to be seen first.
The nurse is caring for a patient who is experiencing a full-thickness repair. Which type of tissue will the nurse expect to observe when the wound is healing?
a. Eschar
b. Slough
c. Granulation
d. Purulent drainage
ANS: C
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 caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan?
a. Partial-thickness repair
b. Secondary intention
c. Tertiary intention
d. Primary intention
ANS: D
A clean surgical incision is an example of a wound with little loss of tissue that heals with primary intention. 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 are approximated. Wound closure is delayed until the risk of infection is resolved. 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.
The nurse is caring for a patient in the burn unit. Which type of wound healing will the nurse consider when planning care for this patient?
a. Partial-thickness repair
b. Secondary intention
c. Tertiary intention
d. Primary intention
ANS: B
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 is 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.
A nurse is assessing a patient’s wound. Which nursing observation will indicate the wound healed by secondary intention?
a. Minimal loss of tissue function
b. Permanent dark redness at site
c. Minimal scar tissue
d. Scarring that may be severe
ANS: D
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 abdominal hysterectomy. Which nursing observation of the incision will indicate the patient is experiencing a complication of wound healing?
a. The site is hurting.
b. The site is approximated.
c. The site has started to itch.
d. The site has a mass, bluish in color.
ANS: D
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 is not a complication. Incisions should be approximated with edges together; this is a sign of normal healing. After surgery, when nerves in the skin and tissues have been traumatized by the surgical procedure, it is expected that the patient will experience pain.
A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence?
a. Protrusion of visceral organs through a wound opening
b. Chronic drainage of fluid through the incision site
c. Report by patient that something has given way
d. Drainage that is odorous and purulent
ANS: C
Patients often report feeling as though something has given way with dehiscence. Dehiscence occurs when an incision 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. Evisceration is seen when vital organs protrude through a wound opening. When there is an increase in serosanguineous drainage from a wound in the first few days after surgery, be alert for the potential for dehiscence. Infection is characterized by drainage that is odorous and purulent.
A patient has developed a pressure ulcer. Which laboratory data will be important for the nurse to check?
a. Vitamin E
b. Potassium
c. Albumin
d. Sodium
ANS: C
Normal wound healing requires proper nutrition. Serum proteins are biochemical indicators of malnutrition, and serum albumin is probably the most frequently measured of these parameters. The best measurement of nutritional status is prealbumin because it reflects not only what the patient has ingested but also what the body has absorbed, digested, and metabolized. Zinc and copper are the minerals important for wound healing, not potassium and sodium. Vitamins A and C are important for wound healing, not vitamin E.
A nurse is caring for a patient with a wound. Which assessment data will be most important for the nurse to gather with regard to wound healing?
a. Muscular strength assessment
b. Pulse oximetry assessment
c. Sensation assessment
d. Sleep assessment
ANS: B
Oxygen fuels the cellular functions essential to the healing process; the ability to perfuse tissues with adequate amounts of oxygenated blood is critical in wound healing. Pulse oximetry measures the oxygen saturation of blood. Assessment of muscular strength and sensation, although useful for fitness and mobility testing, does not provide any data with regard to wound healing. Sleep, although important for rest and for integration of learning and restoration of cognitive function, does not provide any data with regard to wound healing.
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, including current treatment, vital signs, and laboratory results.
b. Notify the health care provider by utilizing Situation, Background, Assessment, and Recommendation (SBAR).
c. Consult the wound care nurse about the change in status and the potential for infection.
d. Check with the charge nurse about the change in status and the potential for infection.
ANS: A
The patient is showing signs and symptoms associated with infection in the wound. 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 primary care provider 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 is collaborating with the dietitian about a patient with a Stage III pressure ulcer. Which nutrient will the nurse most likely increase after collaboration with the dietitian?
a. Fat
b. Protein
c. Vitamin E
d. Carbohydrate
ANS: B
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. Wound healing does not require increased amounts of fats or carbohydrates. Vitamin E will not be increased for wound healing.
The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. Which statement by the patient indicates issues with self-concept?
a. “I am so weak and tired. I want to feel better.”
b. “I am thinking I will be ready to go home early next week.”
c. “I am ready for my bath and linen change right now since this is awful.”
d. “I am hoping there will be something good for dinner tonight.”
ANS: C
Body image changes can influence self-concept. The wound is odorous, and a drain is in place. The patient who is asking for a bath and change in linens and states that this is awful gives you a clue that he or she may be concerned about the smell in the room. Factors that affect the patient’s perception of the wound include the presence of scars, drains, odor from drainage, and temporary or permanent prosthetic devices. The patient’s stating that he or she wants to feel better, talking about going home, and caring about what is for dinner could be interpreted as positive statements that indicate progress along the health journey.
A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, what is the next best step for the nurse to take?
a. Inspect the wound for foreign bodies.
b. Inspect the wound for bleeding.
c. Determine the size of the wound.
d. Determine the need for a tetanus antitoxin injection.
ANS: B
After determining that a patient’s condition is stable, inspect the wound for bleeding. An abrasion will have limited bleeding, a laceration can bleed more profusely, and a puncture wound bleeds in relation to the size and depth of the wound. Address any bleeding issues. Inspect the wound for foreign bodies; traumatic wounds are dirty and may need to be addressed. Determine the size of the wound. A large open wound may expose bone or tissue and be protected, or the wound may need suturing. When the wound is caused by a dirty penetrating object, determine the need for a tetanus vaccination.
