Skin integrity Flashcards
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 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
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
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.
. 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.
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 action should the nurse take first?
a. Provide analgesic medications as ordered.
b. Avoid accidentally removing the drain.
c. Don sterile gloves.
d. Gather supplies.
ANS: A
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 who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. Which action will the nurse take next?
a. Call the health care provider; a blockage is present in the tubing.
b. Chart the results on the intake and output flow sheet.
c. Do nothing, as long as the evacuator is compressed.
d. Remove the drain; a drain is no longer needed.
ANS: A
Because a drainage system needs to be patent, look for drainage flow through the tubing, as well as around the tubing. A sudden decrease in drainage through the tubing may indicate a blocked drain, and you will need to notify the health care provider. The health care provider, not the nurse, determines the need for drain removal and removes drains. Charting the results on the intake and output flow sheet does not take care of the problem. The evacuator may be compressed even when a blockage is present.
The nurse is caring for a patient who has a Stage IV pressure ulcer with grafted surgical sites. Which specialty bed will the nurse use for this patient?
a. Low-air-loss
b. Air-fluidized
c. Lateral rotation
d. Standard mattress
ANS: B
For a patient with newly flapped or grafted surgical sites, the air-fluidized bed will be the best choice; this uses air and fluid support to provide pressure redistribution via a fluid-like medium created by forcing air through beads as characterized by immersion and envelopment. A low-air-loss bed is utilized for prevention or treatment of skin breakdown by preventing buildup of moisture and skin breakdown through the use of airflow. A standard mattress is utilized for an individual who does not have actual or potential altered or impaired skin integrity. Lateral rotation is used for treatment and prevention of pulmonary, venous stasis and urinary complications associated with mobility.
. The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. Which next step will the nurse anticipate?
a. Monitor the wound.
b. Document the wound.
c. Debride the wound.
d. Manage drainage from wound.
ANS: C
Debridement is the removal of nonviable necrotic (black) 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. Documentation occurs after completion of skill. 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, but that is not the next step.
The nurse is caring for a patient with a healing Stage III pressure ulcer. The wound is clean and granulating. Which health care provider’s order will the nurse question?
a. Use a low-air-loss therapy unit.
b. Irrigate with Dakin’s solution.
c. Apply a hydrogel dressing.
d. Consult a dietitian.
ANS: B
Clean pressure ulcers with noncytotoxic cleansers such as normal saline, which will not kill fibroblasts and healing tissue. Cytotoxic cleansers such as Dakin’s solution, acetic acid, povidone-iodine, and hydrogen peroxide can hinder the healing process and should not be utilized on clean granulating wounds. Consulting a dietitian for the nutritional needs of the patient, utilizing a low-air-loss therapy unit to decrease pressure, and applying hydrogel dressings to provide a moist environment for healing are all orders that would be appropriate.
The nurse collects the following assessment data: right heel with reddened area that does not blanch. Which nursing diagnosis will the nurse assign to this patient?
a. Imbalanced nutrition: less than body requirements
b. Ineffective peripheral tissue perfusion
c. Risk for infection
d. Acute pain
ANS: B
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 peripheral tissue perfusion. Risk for infection, Acute pain, and Imbalancednutrition do not support the data in the question.
The nurse is caring for a patient who is immobile. The nurse wants to decrease the formation of pressure ulcers. Which action will the nurse take first?
a. Offer favorite fluids.
b. Turn the patient every 2 hours.
c. Determine the patient’s risk factors.
d. Encourage increased quantities of carbohydrates and fats.
ANS: C
The first step in prevention is to assess the patient’s risk factors for pressure ulcer development. When a patient is immobile, the major risk to the skin is the formation of pressure ulcers. Nursing interventions focus on prevention. Offering favorite fluids, turning, and increasing carbohydrates and fats are not the first steps. Determining risk factors is first so interventions can be implemented to reduce or eliminate those risk factors.
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. Which is the best goal for this patient?
a. The patient will state what to look for with regard to an infection.
b. The patient’s family will demonstrate specific care of the wound site.
c. The patient’s family members will wash their hands when visiting the patient.
d. The patient will remain free of odorous or purulent drainage from the wound.
ANS: D
Because the patient has an open wound and the skin is no longer intact to protect the tissue, the patient is at increased risk for infection. The nurse will be assessing the patient for signs and symptoms of infection, including an increase in temperature, an increase in white count, and odorous and purulent drainage from the wound. The patient is unconscious and is unable to communicate the signs and symptoms of infection. It is important for the patient’s family to be able to demonstrate how to care for the wound and wash their hands, but these statements are not goals or outcomes for this nursing diagnosis.
ANS: D Because the patient has an open wound and the skin is no longer intact to protect the tissue, the patient is at increased risk for infection. The nurse will be assessing the patient for signs and symptoms of infection, including an increase in temperature, an increase in white count, and odorous and purulent drainage from the wound. The patient is unconscious and is unable to communicate the signs and symptoms of infection. It is important for the patient’s family to be able to demonstrate how to care for the wound and wash their hands, but these statements are not goals or outcomes for this nursing diagnosis. a. 4, 3, 1, 5, 6, 2 b. 1, 3, 4, 5, 6, 2 c. 4, 1, 3, 5, 6, 2 d. 1, 4, 3, 5, 6, 2
ANS: B
The steps for a moist-to-dry dressing are as follows:
(1) Apply sterile gloves;
(2) assess appearance of surrounding skin;
(3) moisten gauze with prescribed solution.
(4) Gently wring out excess solution and unfold; apply gauze as single layer directly onto wound surface.
(5) If wound is deep, gently pack dressing into wound base by hand until all wound surfaces are in contact with gauze;
(6) cover with sterile dry gauze and secure topper dressing.
The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial actions should the nurse take to decrease this risk?
a. Use gentle cleansers, and thoroughly dry the skin.
b. Use therapeutic bed and mattress.
c. Use absorbent pads and garments.
d. Use products that hold moisture to the skin.
ANS: A
Use cleansers with nonionic surfactants that are gentle to the skin. After you clean the skin, make sure that it is completely dry. Absorbent pads and garments are controversial and should be considered only when other alternatives have been exhausted. Depending on the needs of the patient, a specialty bed may be needed, but again, this does not provide the initial defense for skin breakdown. Use only products that wick moisture away from the patient’s skin.
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. Which is the best method for repositioning the patient?
a. Place the patient in a 30-degree supine position.
b. Utilize a transfer device to lift the patient.
c. Elevate the head of the bed 45 degrees.
d. Slide the patient into the new position.
ANS: B
When repositioning the patient, obtain assistance and utilize a transfer device to lift rather than drag the patient. Sliding the patient into the new position will increase friction. The patient should be placed in a 30-degree lateral position, not a supine position. The head of the bed should be elevated less than 30 degrees to prevent pressure ulcer development from shearing forces.
A nurse is assigned most of the patients with pressure ulcers. The nurse leaves the pressure ulcer open to air and does not apply a dressing. To which patient did the nurse provide care?
a. A patient with a clean Stage I
b. A patient with a clean Stage II
c. A patient with a clean Stage III
d. A patient with a clean Stage IV
ANS: A
Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14 days do not require a dressing. A composite film, hydrocolloid, or hydrogel can be utilized on a clean Stage II. A hydrocolloid, hydrogel covered with foam, calcium alginate, and gauze can be utilized with a clean Stage III. Hydrogel covered with foam, calcium alginate, and gauze can be utilized with a clean Stage IV. An unstageable wound covered with eschar should utilize a dressing of adherent film or gauze with an ordered solution of enzymes.
The nurse is cleansing a wound site. As the nurse administers the procedure, which intervention should be included?
a. Allow the solution to flow from the most contaminated to the least contaminated.
b. Scrub vigorously when applying noncytotoxic solution to the skin.
c. Cleanse in a direction from the least contaminated area.
d. Utilize clean gauze and clean gloves to cleanse a site.
ANS: C
Cleanse in a direction from the least contaminated area, such as from the wound or incision, to the surrounding skin. While cleansing surgical or traumatic wounds by applying noncytotoxic solution with sterile gauze or by irrigations is correct, vigorous scrubbing is inappropriate and can cause damage to the skin. Use gentle friction when applying solutions to the skin, and allow irrigation to flow from the least to the most contaminated area.
The nurse is caring for a patient after an open abdominal aortic aneurysm repair. The nurse requests an abdominal binder and carefully applies the binder. Which is the best explanation for the nurse to use when teaching the patient the reason for the binder?
a. It reduces edema at the surgical site.
b. It secures the dressing in place.
c. It immobilizes the abdomen.
d. It supports the abdomen.
ANS: D
The patient has a large abdominal incision. This incision will need support, and an abdominal binder will support this wound, especially during movement, as well as during deep breathing and coughing. A binder can be used to immobilize a body part (e.g., an elastic bandage applied around a sprained ankle). A binder can be used to prevent edema, for example, in an extremity but in this case is not used to reduce edema at a surgical site. A binder can be used to secure dressings such as elastic webbing applied around a leg after vein stripping.
The nurse is caring for a postoperative medial meniscus repair of the right knee. Which action should the nurse take to assist with pain management?
a. Monitor vital signs every 15 minutes.
b. Check pulses in the right foot.
c. Keep the leg dependent.
d. Apply ice.
ANS: D
Ice assists in preventing edema formation, controlling bleeding, and anesthetizing the body part. Elevation (not dependent) assists in preventing edema, which in turn can cause pain. Monitoring vital signs every 15 minutes is routine postoperative care and includes a pain assessment but in itself is not an intervention that decreases pain. Checking the pulses is important to monitor the circulation of the extremity but in itself is not a pain management intervention.
The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed?
a. 12
b. 13
c. 20
d. 23
ANS: D
The best sign is a perfect score of 23. The Braden Scale is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The total score ranges from 6 to 23, and a lower total score indicates a higher risk for pressure ulcer development. The cutoff score for onset of pressure ulcer risk with the Braden Scale in the general adult population is 18.
ANS: D
The best sign is a perfect score of 23. The Braden Scale is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The total score ranges from 6 to 23, and a lower total score indicates a higher risk for pressure ulcer development. The cutoff score for onset of pressure ulcer risk with the Braden Scale in the general adult population is 18.
ANS: A, C, E
The presence of an evisceration (protrusion of visceral organs through a wound opening) is a surgical emergency. Immediately place damp sterile gauze over the site, contact the surgical team, do not allow the patient anything by mouth (NPO), observe for signs and symptoms of shock, and prepare the patient for emergency surgery.
The nurse is caring for a patient with a wound healing by full-thickness repair. Which phases will the nurse monitor for in this patient? (Select all that apply.)
a. Hemostasis
b. Maturation
c. Inflammatory
d. Proliferative
e. Reproduction
f. Reestablishment of epidermal layers
ANS: A, B, C, D
The four phases involved in the healing process of a full-thickness wound are hemostasis, inflammatory, proliferative, and maturation. Three components are involved in the healing process of a partial-thickness wound: inflammatory response, epithelial proliferation (reproduction) and migration, and reestablishment of the epidermal layers.
The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.)
a. “Can you easily change your position?”
b. “Do you have sensitivity to heat or cold?”
c. “How often do you need to use the toilet?”
d. “What medications do you take?”
e. “Is movement painful?”
f. “Have you ever fallen?”
ANS: A, B, C, E
Changing positions is important for decreasing the pressure associated with long periods of time in the same position. If the patient is able to feel heat or cold and is mobile, she can protect herself by withdrawing from the source. Knowing toileting habits and any potential for incontinence is important because urine and feces in contact with the skin for long periods can increase skin breakdown. Knowing whether the patient has problems with painful movement will alert the nurse to any potential for decreased movement and increased risk for skin breakdown. Medications and falling are safety risk questions.
. The nurse is caring for a patient with potential skin breakdown. Which components will the nurse include in the skin assessment? (Select all that apply.)
a. Vision
b. Hyperemia
c. Induration
d. Blanching
e. Temperature of skin
ANS: B, C, D, E
Assessment of the skin includes both visual and tactile inspection. Assess for hyperemia and palpate for blanching or nonblaching. Early signs of skin damage include induration, bogginess (less-than-normal stiffness), and increased warmth at the injury site compared to nearby areas. Changes in temperature can indicate changes in blood flow to that area of the skin. Vision is not included in the skin assessment.
The nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder. Which actions will the nurse take before applying the bandage and binder? (Select all that apply.)
a. Cover exposed wounds.
b. Mark the sites of all abrasions.
c. Assess the condition of current dressings.
d. Inspect the skin for abrasions and edema.
e. Cleanse the area with hydrogen peroxide.
f. Assess the skin at underlying areas for circulatory impairment.
ANS: A, C, D, F
Before applying a bandage or a binder, the nurse has several responsibilities. The nurse would need to inspect the skin for abrasions, edema, and discoloration or exposed wound edges. The nurse also is responsible for covering exposed wounds or open abrasions with a dressing and assessing the condition of underlying dressings and changing if soiled, as well as assessing the skin of underlying areas that will be distal to the bandage. This checks for signs of circulatory impairment, so that a comparison can be made after bandages are applied. Marking the sites of all abrasions is not necessary. Although it is important for the skin to be clean, and even though it may need to be cleaned with a noncytotoxic cleanser, cleansing with hydrogen peroxide can interfere with wound healing.
The nurse is updating the plan of care for a patient with impaired skin integrity. Which findings indicate achievement of goals and outcomes? (Select all that apply.)
a. The patient’s expectations are not being met.
b. Skin is intact with no redness or swelling.
c. Nonblanchable erythema is absent.
d. No injuries to the skin and tissues are evident.
e. Granulation tissue is present.
ANS: B, C, D, E
Optimal outcomes are to prevent injury to skin and tissues, reduce injury to skin, reduce injury to underlying tissues, and restore skin integrity. Skin intact, nonblanchable erythema absent, no injuries, and presence of granulation tissue are all findings indicating achievement of goals and outcomes. The patient’s expectations not being met indicates no progression toward goals/outcomes.
The nurse is caring for patients who need wound dressings. Match the type of dressing the nurse applies to its description.
a. Absorbs drainage through the use of exudate absorbers in the dressing
b. Very soothing to the patient and do not adhere to the wound bed
c. Barrier to external fluids/bacteria but allows wound to “breathe”
d. Manufactured from seaweed and comes in sheet and rope form
e. Oldest and most common absorbent dressing
1. Gauze
2. Transparent
3. Hydrocolloid
4. Hydrogel
5. Calcium alginate
- ANS:E
- ANS:C
- ANS:A
- ANS:B
- ANS:D
