Skin Integrity and Wound Care Flashcards
Thirty-six hours after having surgery, a patient has a slightly elevated body temperature and generalized malaise as well as pain with redness at the surgical site. Which action is most appropriate?
MAR:
Acetaminophen 650 mg every 6 hours prn fever
Cefazolin (antibiotic) 1 g 1 hour preoperatively
Cefazolin 1 g, every 6 hours 3 times, postoperatively
a. Documenting the findings and continuing to monitor the patient
b. Administering antipyretics and contacting the provider for an antibiotic prescription
c. Increasing the frequency of assessment to every hour and notifying the patient’s primary care provider
d. Obtaining a wound culture and increasing the frequency of wound care
a
The assessment findings are normal for this stage of healing following surgery. The patient is in the inflammatory phase of the healing process, which involves a response by the immune system. This acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury (surgery, in this case). The patient also has a generalized body response, including a mildly elevated temperature, leukocytosis, and generalized malaise.
A nurse on a surgical unit has assessed and documented a patient’s wound and drainage. Which statements most accurately describe the characteristic of the wound drainage?
Graphic Record
T 99.9 P100 RR 20 BP 138/88
Nursing note: Patient postoperative day 2. Dry sterile dressing changed on abdominal incision. Incision edges are well approximated with a slight ½-cm opening at inferior edge; incisional edges reddened. Hemovac draining sanguineous material, 60 mL for the shift. Patient reports moderate pain, relieved by oxycodone X1.
a. Sanguineous drainage is composed of the clear portion of the blood and serous membranes.
b. Sanguineous drainage is composed of a large number of red blood cells and looks like blood.
c. Sanguineous drainage is composed of white blood cells, dead tissue, and bacteria.
d. Sanguineous drainage is thin, cloudy, and watery and may have a musty or foul odor.
b
Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Serous drainage, generally watery, is composed primarily of the clear, serous portion of the blood and serous membranes. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. It is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism.
A postoperative patient who has a large abdominal incision suddenly calls out for help, shouting, “Something is falling out of my incision!” The nurse notes the wound is gaping open with tissue bulging outward. Place the nursing interventions in the order they should be performed, arranged from first to last.
a. Notify the health care provider of the situation.
b. Cover exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution.
c. Place the patient in the low Fowler position.
d. Document the findings and outcome of interventions.
e. Maintain NPO status for return to the OR for repair.
c, b, a, e, d
The correct order of nursing interventions for this postoperative emergency is to place the patient in the low Fowler position (to prevent further damage or protrusion from increased intraabdominal pressure), cover exposed tissue with sterile towels moistened with sterile 0.9% sodium chloride solution (to protect the viscera), and notify the health care provider of the situation (to address the issue, likely with surgery). The patient is kept NPO, as prompt surgical repair will be needed. After the patient has received attention, the nurse documents all assessments and interventions in a timely manner.
A patient was in an automobile accident and received a wound across the nose and cheek. After surgery to repair the wound, the patient says, “I am so ugly now.” Based on this statement, what psychosocial problem will the nurse plan to address?
a. Pain
b. Wound healing
c. Body image
d. Change in cognition
c
Wounds cause emotional as well as physical stress.
A patient is admitted with a nonhealing surgical wound. Which nursing interventions will the nurse use to promote wound healing? Select all that apply.
a. Applying sterile dressing supplies
b. Discussing zinc supplementation with the health care provider
c. Maintaining bedrest
d. Performing careful hand hygiene
e. Teaching the patient to increase protein in the diet
f. Suggesting the patient consume vitamin C–containing foods.
a, b, d, e, f
Careful hand washing (medical asepsis) is the most important. The nurse will use sterile dressings and supplies and promote intake of vitamins, zinc, and protein. Depending on the site of the wound and condition of the patient, bedrest may be indicated.
A nurse on a surgical unit is working with a nursing student and discussing various phases of wound healing for postoperative patients. Which statements accurately describe these stages? Select all that apply.
a. Hemostasis occurs immediately after the initial injury.
b. A liquid called exudate is formed during the proliferation phase.
c. White blood cells move to the wound in the inflammatory phase.
d. Granulation tissue forms in the inflammatory phase.
e. During the inflammatory phase, the patient has generalized body response.
f. A scar forms during the proliferation phase.
a, c, e
Hemostasis occurs immediately after the initial injury, and exudate occurs in this phase as plasma and blood components leak out into the injured area. White blood cells, predominantly leukocytes and macrophages, move to the wound in the inflammatory phase to ingest bacteria and cellular debris. During the inflammatory phase, the patient has a generalized body response, including a mildly elevated temperature, leukocytosis (increased number of white blood cells in the blood), and generalized malaise. New tissue, called granulation tissue, forms the foundation for scar tissue development in the proliferation phase. New collagen continues to be deposited in the maturation phase, which forms a scar.
The nurse preceptor is supervising a new graduate nurse as they assess a patient with a pressure injury. The graduate nurse documents the presence of biofilm in the wound. The preceptor recognizes the graduate nurse understands this concept when the graduate makes which of these statements? Select all that apply.
a. Enhanced healing occurs due to the presence of sugars and proteins.
b. Delayed healing develops due to dead tissue present in the wound.
c. Antibiotics against the bacteria become less effective.
d. Skin loses its integrity due to overhydration of the cells of the wound.
e. Delayed healing due to cells dehydrating and dying occurs.
f. Decreased effectiveness of the patient’s normal immune process results.
c, f
Wound biofilms are the result of wound bacteria growing in clumps, embedded in a thick, self-made, protective, slimy barrier of sugars and proteins. This barrier contributes to decreased effectiveness of antibiotics against the bacteria (antibiotic resistance) and decreases the effectiveness of the normal immune response by the patient (Baranoski & Ayello, 2020). Necrosis (dead tissue) in the wound delays healing. Maceration or overhydration of cells related to urinary and fecal incontinence can lead to impaired skin integrity. Desiccation is the process of drying up, in which cells dehydrate and die in a dry environment.
The nurse is cleaning an open abdominal wound that has edges that are not approximated. What are accurate steps in this procedure? Select all that apply.
a. Use standard precautions or transmission-based precautions when indicated.
b. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution.
c. Clean the wound in full or half circles beginning on the outside and working toward the center.
d. Work outward from the incision in lines that are parallel to it from the dirty area to the clean area.
e. Clean to at least 1 inch beyond the end of the new dressing if one is being applied.
f. Clean to at least 3 inches beyond the wound if a new dressing is not being applied.
a, b, e
The correct procedure for cleaning an open wound with edges that are not approximated is: (1) use standard precautions and appropriate transmission-based precautions when indicated, (2) moisten sterile gauze pad or swab with prescribed cleansing agent and squeeze out excess solution, (3) use a new swab or gauze for each circle, (4) clean the wound in full or half circles beginning in the center and working toward the outside, (5) clean to at least 1 inch beyond the end of the new dressing, and (6) clean to at least 2 inches beyond the wound margins if a dressing is not being applied.
A nurse is developing a care plan for an older adult patient who is recovering from a hip arthroplasty (hip replacement). Which assessment findings indicate a high risk for this patient to develop area(s) of pressure injury? Select all that apply.
a. The patient takes time to think about responses to questions.
b. The patient is an older adult with a poor appetite.
c. The patient reports inability to control their urine.
d. The patient’s albumin level is <3.2 mg/dL (normal, 3.4 to 5.4 g/dL).
e. Lab findings include BUN 12 (older adult, normal 8 to 23 mg/dL) and creatinine 0.9 (adult female, normal 0.61 to 1 mg/dL).
f. The patient reports increased pain in right hip when repositioning in bed or chair.
b, c, d, f
Pressure, friction, and shear, as well as other factors, usually combine to contribute to pressure injury development. The skin of older adults is more susceptible to injury; incontinence contributes to prolonged moisture on the skin, as well as negative effects related to urine in contact with skin; hip surgery involves decreased mobility during the postoperative period, as well as pain with movement, contributing to immobility; and increased pain in the hip may contribute to increased immobility. A low albumin level signals a risk for poor wound healing related to malnutrition. Apathy, confusion, and/or altered mental status are risk factors for pressure injury development; however, taking time to formulate responses is consistent with normal aging. This patient’s BUN and creatinine are within normal range; however, dehydration (indicated by an elevated BUN and creatinine) is a risk for pressure injury development.
A nurse is explaining to a patient the anticipated effect of the application of cold to an injured area. What response indicates that the patient understands the explanation?
a. “There will be more discomfort in the area where the cold is applied.”
b. “I should expect more drainage from the incision after the ice has been in place.”
c. “Redness and swelling should decrease after cold treatment.”
d. “My incision may bleed more when the ice is first applied.”
c
The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues, decreases the local release of pain-producing substances, decreases metabolic needs, and capillary permeability. The resulting effects include decreased edema, coagulation of blood at the wound site, promotion of comfort, decreased drainage from wound, and decreased bleeding.
A nurse is providing education to a patient and their family regarding the use of negative pressure wound therapy (NPWT). The nurse documents that the teaching has been effective when the patient and family make which statement?
a. “This therapy is used to collect excess blood loss and prevent formation of a scab.”
b. “The suction created will prevent infection and promote wound healing with less scar tissue.”
c. “Suction stimulates blood flow to the wound, removes excess fluid, and promotes a moist environment for healing.”
d. “This treatment irrigates the wound, suctions the irrigation fluid from the wound, and keeps it free from debris wound exudate.”
c
Negative pressure wound therapy (NPWT) promotes wound healing and wound closure through the application of uniform negative pressure on the wound bed, reduction in bacteria in the wound, and the removal of excess wound fluid, while providing a moist wound healing environment. The negative pressure results in mechanical tension on the wound tissues, stimulating cell proliferation, blood flow to wounds, and the growth of new blood vessels. It is used to treat a variety of acute or chronic wounds, wounds with heavy drainage, wounds failing to heal, or healing slowly.
After an initial skin assessment, the nurse documents the presence pressure area that is reddened and has a 1-cm blister. How will the nurse document the wound stage?
a. Stage 1 dark maroon wound, skin intact
b. Stage 2 with 1-cm blister noted
c. Stage 3 wound base with red granulation tissue
d. Stage 4 blanchable reddened area, 2 cm
b
A stage 2 pressure injury involves partial-thickness loss of dermis and presents as a shallow open ulcer with a red–pink wound bed, without slough. It may also present as an intact or open/ruptured serum-filled blister. Dark maroon or purple wounds with intact skin represent deep tissue injury. Red granulation tissue is present in stage 3 or 4 pressure injuries that are healing. A blanchable, red area is a stage 1 pressure injury.
A nurse notes a pressure wound base is red. Using the RYB system for documentation, what intervention is indicated?
a. Irrigating the wound and applying an absorbent dressing
b. Gently cleansing the wound and applying a moist dressing
c. Discussing consultation for surgical debridement with the provider
d. Performing frequent dressing changes to keep the wound and dressing dry
b
Red wounds are in the proliferative stage of healing and reflect the color of normal granulation tissue. Wounds in this stage need protection with nursing interventions that include gentle cleansing, use of moist dressings, and dressing changes only when necessary (or based on product manufacturer’s recommendations). To cleanse yellow wounds, nursing interventions include the use of wound cleansers and irrigation. The eschar found in black wounds requires debridement (removal) before the wound can heal.
A nurse is developing education for nurses and UAPs related to prevention of pressure injuries for residents in a long-term care facility. Which action to prevent pressure injury will the nurses delegate to the UAP?
a. Maintaining the head of the bed elevated consistently
b. Massaging over bony prominences
c. Repositioning bedbound patients every 4 hours
d. Using a mild cleansing agent when cleansing the skin
d
To prevent pressure injuries, the nurse teaches the UAP to cleanse the skin routinely and whenever soiling occurs by using a mild cleansing agent with minimal friction, and avoiding hot water. The nurse educates the UAP to minimize the effects of shearing force by limiting the amount of time the head of the bed is elevated, when possible. Bony prominences should not be massaged, and bed-bound patients should be repositioned every 2 hours.
A nurse caring for a patient with a stage 3 pressure wound with tunneling. How will the nurse best assess the tunneled area?
a. Moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down.
b. Photograph the wound per policy and describe the estimated depth in centimeters.
c. Gently insert a sterile applicator into the wound and move it in a clockwise direction.
d. Insert a calibrated probe gently into the wound and mark the point that is even with the surrounding skin surface.
a
To measure the depth of a wound, the nurse should perform hand hygiene and apply gloves; moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down; mark the point on the swab that is even with the surrounding skin surface, or grasp the applicator with the thumb and forefinger at the point corresponding to the wound’s margin; and remove the swab and measure the depth with a ruler.
