Skin Integrity and Wound Healing Chapter 34 Flashcards
Identify the major functions of the skin.
Answer:
The skin has five major functions:
● Protection of the internal organs
● Unique identification of an individual
● Thermoregulation
● Metabolism of nutrients and metabolic waste products
● Sensation
What is the function of the stratum corneum, the outermost layer of the skin?
Answer:
The stratum corneum serves as a barrier, which has three functions:
● Restrict water loss
● Prevent entry of fluids into the body
● Protect the body against the entry of pathogens and chemicals
What is the function of the subcutaneous layer?
Answer:
The subcutaneous layer, which is primarily connective and adipose tissues, has three functions:
● Insulation
● Protection
● Reserve of calories in the event of severe malnutrition
What effect does aging have on skin?
Answer:
As adults age, aging has the following effects on the skin:
● 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 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 looses elasticity.
● These changes make the skin prone to breakdown and slow the healing of a wound.
What effect does immobility have on skin?
Answer:
Patients with impaired mobility often cannot reposition themselves, leading to pressure over bony prominences, which can lead to skin breakdown.
Identify the factors that affect skin integrity.
Answer:
Eleven factors affect skin integrity:
- Age
- Mobility status
- Nutrition
- Hydration
- Sensory and cognitive status
- Circulation
- Medications
- Exposure to moisture
- Exposure to harmful microorganisms
- Fever
- Lifestyle
What nutritional components are essential to maintain skin?
Adequate intakes of five nutritional components are essential to maintain skin:
- Protein
- Calories
- Fluid
- Vitamin C
- Minerals
Explain the difference between an acute and a chronic wound.
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.
Describe the wound-categorization system based on the level of contamination.
Clean
Clean-contaminated
Contaminated
Infected
Clean wounds are
uninfected wounds with minimal inflammation. They may be open or closed and do not involve the gastrointestinal, respiratory, or genitourinary tracts (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 tracts. 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 infection, 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.
How does wound depth affect healing?
Answer:
Wound depth is a major determinant of healing time. As wound depth increases, healing time also increases.
A wound that heals from inner layer to the surface
Answer:
Secondary intention
A wound with approximated edges
Answer:
Primary and tertiary intention
A wound that heals by approximating two surfaces of granulation tissue
Answer:
Tertiary intention
A wound that is sutured and has minimal or no tissue loss
Answer:
Primary intention
Name at least four types of wound closures.
Adhesive strips (Steri-strips) Sutures Surgical staples Surgical glue Negative-pressure Compression stockings
Adhesive strips (Steri-strips)
are used to close superficial low-tension wounds, such as skin tears or lacerations, 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 staples 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 technique. They are available in a variety of sizes and materials. Absorbent sutures are used deep in the tissues. They may be used to close an organ or anastomose (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 lightweight titanium and may be used as an alternative wound-closure technique. 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 infection. The negative-pressure device is computerized and can be programmed for continuous or intermittent negative pressure.
Compression stockings
are used with venous stasis ulcers on the lower extremities. They apply continuous pressure to the veins, which facilitates venous return and allows the ulcers to heal.
Identify five types of wound complication.
Answer:
Five types of complications can occur with wounds:
● Hemorrhage
● Infection
● Dehiscence
● Evisceration
● Fistula
Describe three signs of internal hemorrhage.
Answer:
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 pressure on surrounding tissues. When the hematoma is located near a major artery or vein, it may impede blood flow.
Differentiate between dehiscence and evisceration.
Answer:
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.
What should be included in a wound assessment?
Answer:
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
What is the preferred method of wound culture that may be performed by a registered nurse?
Answer:
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.
Identify three types of laboratory data that may be associated with a delay in wound healing.
Answer:
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 level
Prolonged coagulation times
Needle aspiration result indicative of infection
Identify the major interventions for preventing pressure ulcers.
The following major interventions prevent pressure ulcers:
Inspect skin daily Manage moisture Adequate nutrition Frequent position changes Use of therapeutic mattresses and cushions to minimize pressure Adjunctive wound care therapies Patient and family teaching
What nursing diagnosis is most appropriate for a patient at risk for pressure ulcer development?
Answer:
Risk for Impaired Skin Integrity
Identify goals for wound care before applying a dressing to a wound.
Answer:
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
What solutions are used to cleanse a wound?
Answer:
Wounds may be cleansed with the following solutions:
● Saline
● Water
● Dilute antimicrobial solutions
● Commercially prepared wound cleansers
How can you control the amount of force applied to wound irrigation?
Answer:
The amount of force applied during wound irrigation is controlled by the size of the syringe and Angiocath 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 35-mL syringe with a 19-gauge Angiocath attached. This will deliver the solution at approximately 8 psi (Branom, 2002; Campton-Johnston & Wilson, 2001). Commercial irrigation systems are available. Closely evaluate the amount of pressure delivered before you use these devices.
Identify three nursing responsibilities when caring for a client with a wound drain.
Answer:
Answers may include any three of the following nursing responsibilities for wound drains:
● Monitoring 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.
What should you consider when choosing a dressing?
Answer:
When choosing a dressing, ask yourself these questions. Will the dressing provide a moist wound 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?
Name the five types of wound débridement.
Sharp Mechanical Enzymatic Autolysis Biotherapy, or maggot débridementtherapy
Sharp
débridement is the use of a sharp instrument, 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 débridementtherapy
is the use of medical-grade larvae to dissolve dead and infected tissue from wounds.
Identify the purposes of a wound dressing.
Answer:
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
Absorption dressings
are used to soak up drainage from a wound.
Alginate dressings
are highly absorbent dressing made of fibers from brown seaweed and kelp.
Antimicrobial dressings
are topical antifungal and antibiotic agents that are available as ointments, impregnated gauzes, pads, gels, foams, hydrocolloids, and alginates.
Collagen dressings
are made from bovine or porcine sources and made into sheets, pads, powders, and gels to absorb wound drainage.
Gauze dressings
absorb wound drainage with woven and nonwoven fibers of cotton, rayon, polyester, or a combination of these.
What types of dressing may be used for wounds with a large amount of exudate?
Answer:
Gauze, foam, alginates, or absorption dressings are best used for a wound with a large amount of exudate.
What form of dressing is appropriate for a wound with an eschar that needs to be eliminated?
Answer:
Hydrogel is most appropriate for a wound with an eschar that needs to be eliminated. Some students 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.
What is the effect of adding moisture to heat or cold treatments?
Answer:
The addition of moisture amplifies the intensity of the treatment.
For how long should heat or cold be applied to an area?
Answer:
Heat or cold should be applied intermittently, leaving on for no more than 15 minutes at a time to avoid tissue injury.
What precautions should you take before using heat or cold therapy?
Answer:
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 washcloth, towel, or fitted sleeve.
● Apply hot or cold intermittently, leaving 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 rebound phenomenon: 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. Over 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.
Montgomery straps
Tie tapes used for dressings that require frequent changing
Jackson-Pratt
Type of surgical drain
Maceration
Softening of the skin
Autolysis
Occurs under a transparent, non-occlusive dressing
Fistula
Abnormal passage between two body cavities
Which of the following factors puts the patient at greatest risk for impaired skin integrity?
A. Peripheral vascular disease
B. Tanning once a week
C. An 1,800-calorie diet
D. A temperature of 101.5°F
Answer:
A. Peripheral vascular disease
Rationale:
Although tanning and a high fever are risk factors for impaired skin integrity, arterial peripheral vascular disease directly affects the delivery of oxygen and nutrients to the skin and the removal of waste products. An 1,800-calorie diet is not, in and of itself, a risk factor.
Mr. Smith had a small basal cell carcinoma lesion removed from his back. The plastic surgeon removed an area of skin 3 inches (7.5 cm) in diameter and ½ inch (1.2 cm) deep around and under the lesion and left the wound open to heal. The wound will heal by:
A. primary intention.
B. secondary intention.
C. third intention.
D. tertiary intention.
Answer:
B. secondary intention.
Which of the following is a complication of wound healing?
A. Three centimeters of sanguineous fluid on a surgical dressing
B. Hypotension and increased pain at the surgical site
C. Presence of beefy red tissue in the center of a closing wound
D. Low-grade temperature
Answer:
B. Hypotension and increased pain at the surgical site
Answer:
Falling blood pressure and increasing pain may indicate internal hemorrhage. Responses A and C, sanguineous fluid and red tissue, are normal findings. Response D, low-grade temperature, has other potential causes.
Jan is an RN, and today she is working with Mary, the new aide. The nursing supervisor knows that Jan understands proper delegation in relationship to wound care when she asks Mary to:
A. débride a clean wound healing by primary intention.
B. evaluate how treatment is working for a decubitus ulcer.
C. turn a comatose patient every 2 hours.
D. irrigate an open wound using vigorous flushing.
Answer:
C. turn a comatose patient every 2 hours.
Rationale:
Responses A and B, débridement and treatment evaluation, are the responsibility of the licensed nurse. Response D, vigorous flushing of a wound, may cause damage to healing tissue.
The nurse is ambulating Mr. Sanchez, who had a bowel resection yesterday. Suddenly, Mr. Sanchez states, “It feels like I’ve popped open.” The nurse observes that the abdominal incision has opened 3 inches and a small section of the bowel is protruding. In addition to calling the physician immediately, the nurse would do which of the following?
A. Place the patient supine in bed, knees flexed, and cover the wound with sterile gauze soaked with sterile saline.
B. Lay the patient prone to put pressure on the area, and instruct him not to cough.
C. Place the patient supine in bed, legs flat, and cover the wound with dry sterile dressings.
D. Place the patient in Trendelenburg’s position, knees flexed, and cover the wound with an occlusive dressing.
Answer:
A. Place the patient supine in bed, knees flexed, and cover the wound with sterile gauze soaked with sterile saline.
The Braden scale is a way to measure the depth of a decubitus (pressure) ulcer.
Answer:
False
Rationale:
The Braden scale is used to calculate a patient’s risk for skin breakdown.
Deeper level tissue damage, known as undermining, may be present in a stage IV pressure ulcer.
Answer:
True
Serosanguineous drainage on a surgical dressing is an abnormal finding and should be reported to the physician immediately.
Answer:
False
Rationale:
Serosanguineous drainage is a common finding during the immediate postoperative period.
When applying an Ace wrap (roller bandage) to a limb, it is important to begin at the most distal point and wrap toward the body.
Answer:
True
Rationale:
This prevents blood and fluid from becoming trapped in the most distal area.
1.How do the Langerhans cells protect the skin from injury? Langerhans cells:
1) contain protein that give the skin strength and elasticity.
2) are able to filter out beta ultraviolet light waves.
3) are mobile and phagocytize foreign material.
4) are located in the dermal layer of the skin.
Answer:
3) are mobile and phagocytize foreign material.
Rationale:
Langerhans cells are located in the epidermal layer of the skin. They are mobile and able to phagocytize foreign material and trigger an immune response. Keratinocytes are protein-containing cells that give the skin strength and elasticity. Melanocytes provide protection from ultraviolet light.
2.When performing an assessment for a patient with a 2-week-old wound, the nurse notes the formation of granulation tissue in the wound bed and recognizes the wound is most likely in which stage of wound healing?
1) Proliferative phase
2) Maturation phase
3) Aggregation phase
4) Inflammatory phase
Answer:
1) Proliferative phase
Rationale:
The proliferative phase occurs from days 5 to 21. It is characterized by cell development aimed at filling the wound defect and resurfacing the skin. Granulation tissue forms during this stage, as fibroblasts migrate to the wound to form collagen, and new blood and lymph vessels sprout from the existing capillaries at the edge of the wound.
3.A postsurgical patient who is morbidly obese informs the nurse that as she was coughing, she felt a “pop” at her abdominal incision site. Upon inspection, the nurse notes the sutures to the incision are intact; however, there is an increase in the amount of serosanguineous drainage. The nurse would suspect wound:
1) Evisceration
2) Fistula
3) Hemorrhage
4) Dehiscence
Answer:
4) Dehiscence
Rationale:
Wound dehiscence is a rupture of one or more layers of a wound and usually occurs in the inflammatory phase before large amounts of collagen have been deposited in the wound to strengthen it. Dehiscence is usually associated with abdominal wounds, and patients often report feeling a pop or tear, especially with sudden straining from coughing, vomiting, or changing positions in bed. Usually there is an immediate increase in serosanguineous drainage. Patients with obesity are more likely to experience wound dehiscence because fatty tissue does not heal readily, and the patient’s body mass increases the strain on the suture line.
4.An older adult had a colon resection 1 week ago. When assessing the abdominal incision, the nurse notes foul-smelling brown drainage seeping from the middle of the incision site. The nurse suspects he has:
1) an infected wound.
2) wound dehiscence.
3) a hematoma.
4) a fistula.
Answer:
4) a fistula.
Rationale:
A fistula is an abnormal passage connecting two body cavities or a cavity and the skin. Based on the type of surgery and drainage present, the nurse would suspect fistula formation.
5.The most appropriate nursing diagnosis for a patient with a draining wound would be:
1) Risk for Infection related to dehiscence of wound.
2) Body Image Disturbance related to nonhealing surgical wound.
3) Risk for Impaired Skin Integrity related to wound drainage.
4) Pain related to surgical incision.
Answer:
3) Risk for Impaired Skin Integrity related to wound drainage.
Rationale:
The drainage from a wound places the patient at an increased risk for skin breakdown because of the dampness and presence of enzymes in the drainage. The risk of infection is present, but the data provided do not indicate this is a problem. There are no data indicating the patient is having a problem with body image or that he is in pain.
6.The nurse is assessing an ischial pressure ulcer on a client. She observes that the pressure ulcer is 3 cm × 2 cm × 1 cm and involves only subcutaneous tissue. The nurse also notes an area extending 3 cm from 12 o’clock to 3 o’clock under the wound edges. The nurse would document this as:
1) Stage IV pressure ulcer with undermining of 3 cm from 12:00 to 3:00.
2) Stage III pressure ulcer with undermining of 3 cm from 12:00 to 3:00.
3) Stage IV pressure ulcer with sinus tract from 12:00 to 3:00.
4) Stage III pressure ulcer with sinus tract from 12:00 to 3:00.
Answer:
2) Stage III pressure ulcer with undermining of 3 cm from 12:00 to 3:00.
Rationale:
A stage III pressure ulcer is characterized by full-thickness skin loss involving damage or necrosis of subcutaneous tissue, which may extend down to, but not through, the underlying fascia. Undermining is deeper-level damage of adjacent tissue. Sinus tracts are narrow, blind tracts underneath the epidermis.
7.To obtain the most accurate culture information of a chronic wound, the nurse would recommend:
1) tissue biopsy.
2) swab culture.
3) sterile culture.
4) needle aspiration culture.
Answer:
1) tissue biopsy.
Rationale:
A tissue biopsy, in which a piece of tissue is removed from the wound bed and analyzed, provides the most definitive information about infection status of a chronic wound. Chronic wounds are frequently colonized with bacteria; therefore, surface culture (swab) would not be accurate.
8.An older adult has a 3 cm × 2 cm eschar on the right heel. The initial treatment choice for this wound is:
1) elevate the right heel off the surface of the bed.
2) request a surgical consult for débridement of the area.
3) apply a hydrocolloid to promote autolytic débridement of the wound.
4) request an order for an enzymatic débridement medication.
Answer:
1) elevate the right heel off the surface of the bed.
Rationale:
A black wound (eschar) requires débridement of the necrotic tissue except at the heel. The Agency for Healthcare Quality and Research (AHQR) does not recommend débridement of this site. Therefore, your best treatment choice would be elevation of the heel off of the bed. This will relieve pressure to the affected area.
9.The patient with a new colostomy refuses to participate in the care of her colostomy or meet with a support member from the ostomy society. She will not look at the site and describes the colostomy as disgusting. Based on these data, the priority nursing diagnosis for Mrs. Lore is:
1) Anxiety related to colostomy.
2) Disturbed Body Image related to colostomy.
3) Disturbed Body Image related to incontinence of stool.
4) Impaired Skin Integrity related to fecal drainage.
Answer:
2) Disturbed Body Image related to colostomy.
Rationale:
Mrs. Lore is having difficulty adjusting to her colostomy. The colostomy is covered by a collection device, so there is no incontinence. There is no evidence of either anxiety or actual skin impairment.
10.The nurse will know ostomy care teaching is most likely successful when the patient with a new ostomy device:
1) demonstrates the proper method of cleansing her skin.
2) demonstrates proficiency when providing treatment to excoriated skin.
3) states she will start caring for the colostomy after she gets home.
4) proficiently performs colostomy care prior to discharge.
Answer:
4) proficiently performs colostomy care prior to discharge.
Rationale:
By performing colostomy care, Mrs. Lore’s behavior reflects acceptance of her colostomy. There is no information to suggest that her skin is excoriated. Waiting until she gets home to start care is delaying acceptance and will not allow her to get assistance or further instruction. Demonstrating correct skin cleansing does not ensure that the client is actually performing colostomy care or has accepted her condition.
