Skin Integrity

Question 1

A wound that heals by approximating two surfaces of granulation tissue

Answer 1

Tertiary intention

Question 2

A wound that heals from inner layer to the surface

Answer 2

Secondary intention

Question 3

A wound that is sutured and has minimal or no tissue loss

Answer 3

Primary intention

Question 4

A wound with approximated edges

Answer 4

Primary and tertiary intention

Question 5

Absorption dressings

Answer 5

are used to soak up drainage from a wound.

Question 6

Alginate dressings

Answer 6

are highly absorbent dressing made of fibers from brown seaweed and kelp.

Question 7

Antimicrobial dressings

Answer 7

are topical antifungal and antibiotic agents that are available as ointments,
CHAPTER 36 ■ Questions & Answers 303 impregnated gauzes, pads, gels, foams, hydrocol-
loids, and alginates.

Question 8

Collagen dressings

Answer 8

are made from bovine or porcine sources and made into sheets, pads, powders, and gels to absorb wound drainage.

Question 9

Describe four types of wound closures.

Answer 9

Adhesive strips (Steri-Strips) are used to close super- ficial low-tension wounds, such as skin tears or lacer- ations, or to close the skin on a wound that has been closed subcutaneously. They may also be used to give additional support to a wound after sutures or sta- ples have been removed. The strips extend at least 2 to 3 cm on either side of the wound to ensure closure and are placed 2 to 3 cm apart along the wound.
• Sutures are the most traditional wound-closure tech- nique. They are available in a variety of sizes and materials. Absorbent sutures are used deep in the tis- sues. They may be used to close an organ or anasto- mose (connect) tissue. Absorbent sutures are made of material that will gradually dissolve; there is no need to remove these sutures. Nonabsorbent sutures are placed in superficial tissues. These sutures require removal. Nurses often remove sutures.
• Surgical staples are made of lightweight titanium and may be used as an alternative wound-closure tech- nique. Staples are easy to use and provide a rapid way to close an incision. Removal requires a staple remover.
• Surgical glue is a relatively new method for wound closure. It is safe for use in clean, low-tension wounds. It is an ideal wound-closure method for skin tears.
• Negative-pressure wound closure uses a piece of open-cell foam in the wound that is attached with a tube to a negative-pressure pump to remove wound drainage, provide subatmospheric pressure for improved wound healing, create a clean and moist environment, and form a barrier to bacterial infec- tion. The negative-pressure device is computerized and can be programmed for continuous or intermit- tent negative pressure.
• Compression stockings are used with venous stasis ulcers on the lower extremities. They apply continu- ous pressure to the veins, which facilitate venous return and helps the ulcers to heal.

Question 10

Describe the five types of wound débridement.

Answer 10

The five types of wound débridement are sharp, mechanical, enzymatic, autolysis, and biotherapy, or maggot débridement:
• Sharp débridement is the use of a sharp instru- ment, such as scalpel or scissors, to remove devitalized tissue.
• Mechanical débridement may be performed via the use of wet-to-dry dressings, hydrotherapy (whirlpool), or lavage.
• Enzymatic débridement is the application of a topical enzymatic agent to the wound.
• Autolysis is the use of an occlusive moisture- retaining dressing and the body’s own mechanisms for ridding itself of necrotic tissue.
• Biotherapy, or maggot débridement therapy, is the use of medical-grade larvae to dissolve dead and infected tissue from wounds.

Question 11

Describe the wound categorization system based on the level of contamination.

Answer 11

Wounds are categorized based on four levels of contamination:
• Clean wounds are uninfected wounds with minimal inflammation. They may be open or closed and do not involve the gastrointestinal, respiratory, or geni- tourinary tract (these systems frequently harbor bacteria). There is very little risk of infection for these wounds.
• Clean-contaminated wounds are surgical incisions that enter the gastrointestinal, respiratory, or genitourinary tract. There is an increased risk of infection for these wounds, but there is no obvious infection.
• Contaminated wounds include open, traumatic wounds or surgical incisions in which a major break in asepsis occurred. The risk of infection is high for these wounds.
• Infected wounds are wounds with evidence of infec- tion, such as purulent drainage or necrotic tissue. Wounds are considered infected when bacteria counts in the wound tissues are above 100,000 organisms per gram of tissue or in which there is the presence
of beta-hemolytic streptococci in any number.

Question 12

Describe three signs of internal hemorrhage.

Answer 12

Answers may include any three of the following signs of internal bleeding:
• Swelling of the affected body part;
• Pain
• Changes in vital signs
• A hematoma (a red-blue collection of blood under the skin). A hematoma often forms as a result
of internal bleeding. The amount of blood in a hematoma varies. A large hematoma causes pres- sure on surrounding tissues. When the hematoma is located near a major artery or vein, it may impede blood flow.

Question 13

Differentiate between dehiscence and evisceration

Answer 13

Dehiscence and evisceration have the following differences:
• Dehiscence is the separation of one or more layers of the wound.
• Evisceration is the total separation of the layers of a wound with internal viscera protruding through the incision.

Question 14

Explain the difference between an acute and a chronic wound.

Answer 14

Acute and chronic wounds have different durations and causes.
• Acute wounds are expected to be of short duration. Acute wounds may be intentional (surgical incisions) or unintentional (trauma).
• Wounds are classified as chronic when they exceed the anticipated length of recovery. Chronic wounds include pressure, arterial, venous, and diabetic ulcers. These wounds are frequently colonized with bacteria, and healing is very slow because of the underlying disease process. A chronic wound may linger for months or years.

Question 15

Gauze dressings

Answer 15

absorb wound drainage with woven and nonwoven fibers of cotton, rayon, polyester, or a combination of these.

Question 16

How can you control the amount of force applied for wound irrigation?

Answer 16

The amount of force applied during wound irrigation is controlled by the size of the syringe
•
and angiocatheter used. Ideal irrigation pressures range from 4 to 15 pounds per square inch (psi). Pressures below 4 psi may not adequately cleanse the wound. Pressures above 15 psi increase the risk of impaling bacteria into the tissues and causing mechanical damage. Current recommendations
are to use a 36-mL syringe with a 19-gauge angiocatheter attached. This will deliver the solution at approximately 8 psi. Commercial irrigation systems are available. Closely evaluate the amount of pressure delivered before you use these devices.

Question 17

How does wound depth affect healing?

Answer 17

Wound depth is a major determinant of healing time. As wound depth increases, healing time also increases.

Question 18

How long should heat or cold be applied to an area?

Answer 18

Heat or cold should be applied intermittently, leaving either on for no more than 15 minutes at a time to avoid tissue injury.

Question 19

Identify five types of wound complications.

Answer 19

Five types of complications can occur with wounds:
• Hemorrhage • Infection
• Dehiscence • Evisceration • Fistula

Question 20

Identify goals for wound care before applying a dressing to a wound.

Answer 20

Nursing interventions have the following goals for wound care:
• Protect wounds from further injury and infection.
• Cleanse wounds to prevent infection.
• Drain wounds to aid in the healing process and prevent infection.
• Débride to aid in the healing process and reduce scarring

Question 21

Identify the factors that affect skin integrity.

Answer 21

Eleven factors affect skin integrity: 1. Age

2. Mobility status
3. Nutrition
4. Hydration
5. Sensory and cognitive status
6. Circulation
7. Medications, tobacco
8. Exposure to moisture
9. Exposure to harmful microorganisms
10. Fever 11. Lifestyle

Question 22

Identify the major functions of the skin.

Answer 22

five major functions:
• Protection of the internal organs
• Thermoregulation
• Metabolism of nutrients and metabolic waste products
• Sensation
• Unique identification of an individual

Question 23

Identify the major interventions for preventing pressure injury.

Answer 23

The following major interventions prevent pressure injury:
• Inspect skin daily
• Manage moisture
• Adequate nutrition and hydration
• Frequent position changes
• Use of therapeutic mattresses and cushions to minimize pressure
• Adjunctive wound care therapies
• Patient and family teaching

Question 24

Identify the purposes of a wound dressing.

Answer 24

The primary purposes of dressings are as follows: • Protect from contamination and heat loss
• Aid hemostasis
• Absorb drainage
• Débride the wound
• Splint the wound site
• Prevent drying of the wound bed
• Keep the surrounding tissue dry and intact • Provide comfort to the patient
• Eliminate dead space
• Control odor

Question 25

Identify three nursing responsibilities when caring for a client with a wound drain.

Answer 25

Answers may include any three of the following nursing responsibilities for wound drains:
• Monitor wound drains. The surgeon will describe the number and type of drains present.
• Describe drain placement using the positions on the clock face. Consider the patient’s head to be at the 12 o’clock position (e.g., “Penrose drain at 3 o’clock”).
• Label the drains numerically with a marker or by placing tape on the collection apparatus, so that each caregiver provides consistent care. Some patients have more than one drainage device in
a wound.
• When removing dressings or irrigating wounds, take care to avoid dislodging drains. Remember, many drains are not sutured in place.
• Monitor the amount and character of the drainage and the condition of the collection apparatus. Record this information in your nursing notes
and on the I&O record.
• Report to the surgeon any change in the amount or character of the drainage.
• If you suspect that a drain is occluded, check the drain line from the insertion site to the collection device. Remove any kinks in the tubing. If this does not correct the problem, notify the physician of the blockage.
• Empty the collection apparatus at a designated volume to maintain suction. As the device fills, suction pressure decreases. If there is significant drainage, you may need to empty the device several times during your shift.

Question 26

Identify three types of laboratory data that may be associated with a delay in wound healing.

Answer 26

Answers may include any three of the following lab data that may be associated with a delay in wound healing:
• A low WBC count
• A low serum protein, albumin, or pre-albumin levelProlonged coagulation times
• Needle aspiration result indicative of infection

Question 27

NWPT has been prescribed for a patient. What nursing responsibilities are associated with initiating NWPT?

Answer 27

Assess the type of wound to be treated with NWPT.
• Determine whether there is any contraindication to NWPT use.
• Assess the patient’s risk for active or prolonged bleeding.
• Assess the wound for bone fragments or sharp edges.
• Assess the wound for infection.
• Assess wound characteristics including size, location, depth, character and odor of drainage, and periwound condition.
• Assess the patient’s nutritional status. • Assess for pain.

Question 28

What effect does aging have on skin?

Answer 28

The activity of the sebaceous and sweat glands diminishes, resulting in drier skin.
• The subcutaneous tissue layer thins, giving the individual a sharp, angular appearance. Excess
36
caloric intake and weight gain can offset this change of appearance.
• The strong bond between the epidermal and dermal layers decreases as the dermal layer loses elasticity.
• These changes make the skin prone to breakdown and slow the healing of a wound.

Question 29

What effect does immobility have on skin?

Answer 29

Patients with impaired mobility often cannot reposition themselves, leading to pressure over bony prominences, which can lead to skin breakdown.

Question 30

What form of dressing is appropriate for a wound with an eschar that needs to be eliminated?

Answer 30

Hydrogel is most appropriate for a wound
with an eschar that needs to be eliminated.
You may state that a wet-to-wet dressing is also appropriate, but this dressing type is difficult to maintain and may cause damage to surrounding tissue.

Question 31

What is the effect of adding moisture to heat or cold treatments?

Answer 31

The addition of moisture amplifies the intensity

of the treatment.

Question 32

What is the function of the stratum corneum, the outermost layer of the skin?

Answer 32

The stratum corneum serves as a barrier, which has three functions:
• Restricts water loss
• Prevents entry of fluids into the body
• Protects the body against the entry of pathogens and chemicals

Question 33

What is the function of the subcutaneous layer?

Answer 33

The subcutaneous layer, which is primarily connective and adipose tissues, has three functions:
• Insulates
• Protects
• Reserves calories in the event of severe malnutrition

Question 34

What is the preferred method of wound culture that may be performed by a registered nurse (RN)?

Answer 34

Needle aspiration of a wound is the preferred method for a culture obtained by nursing staff. Nurses can culture wounds by swabbing and aspirating with a needle, but not biopsy, unless certified as advanced practice.

Question 35

What nursing diagnosis is most appropriate for a patient at risk for pressure injury development?

Answer 35

Risk for Impaired Skin Integrity

Question 36

What nutritional components are essential to maintain skin?

Answer 36

Adequate intakes of five nutritional components are essential to maintain skin:

1. Protein
2. Calories
3. Fluid
4. Vitamin C
5. Minerals

Question 37

What precautions should you take before using heat or cold therapy?

Answer 37

The following precautions should be taken before heat or cold therapy:
• Avoid direct contact with the heating or cooling device. Cover the hot or cold pack with a wash- cloth, towel, or fitted sleeve.
• Apply hot or cold intermittently, leaving either on for no more than 15 minutes at a time in an area. This helps prevent tissue injury (e.g., burns, impaired circulation). It also makes the therapy more effective by preventing reboundphenomenon: At the time the heat or cold reaches maximum therapeutic effect, the opposite effect begins.
• Check the skin frequently for extreme redness, blistering, cyanosis (turning blue), or blanching. When heat or cold is first applied, the thermal receptors react strongly and the person feels the temperature intensely. During about 30 minutes, the receptors adapt to the new temperature, and the person notices it less. Caution clients not to change the temperature when this occurs because this can cause tissue injury.

Question 38

What should be included in a wound assessment?

Answer 38

A wound assessment should include the following parameters:
• The type of wound
• Location of the wound
• The color of the wound and surrounding skin
• The condition of the wound bed and surrounding skin
• The color, consistency, amount, and odor of exudate or drainage
• Pain or discomfort related to the wound or wound care

Question 39

What should you consider when choosing a dressing?

Answer 39

When choosing a dressing, ask yourself these questions: Will the dressing provide a moistwound environment? Will it contain all the wound drainage and keep it off the surrounding skin? Can it be removed without damaging fragile skin or the wound itself? Will it protect the wound from outside contamination or infection? How long should it stay in place, or how often does
it need to be changed?

Question 40

What solutions are used to cleanse a wound?

Answer 40

Wounds may be cleansed with the following solutions:
• Saline
• Water
• Dilute antimicrobial solutions
• Commercially prepared wound cleansers

Question 41

What types of dressing may be used for wounds with a large amount of exudate?

Answer 41

Gauze, foam, alginates, or absorption dressings are best used for a wound with a large amount of exudate.

Question 42

You are caring for a patient who has a new skin graft. What education would you provide to this patient regarding the use of NWPT?

Answer 42

You would teach your patient with NWPT about the signs and symptoms of wound infection, as well as information about sounds and alarms of the NWPT system. Because there is some question about the effectiveness of this therapy to promote faster wound healing, you would urge him to report changes in the appearance of his wound
to the healthcare provider, including failure to improve healing.
• Instruct the client or family to visually check the dressing every 2 hours to ensure it is firm and collapsed in the wound bed.
• Advise the client or family regarding conditions in which to seek medical care: bleeding, infection, unresolved alarms, or loss of suction.