TBRQ Ch: 48 - Skin Integrity and Wound Care

Question 1

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch?

1. A local skin infection requiring antibiotics
2. Sensitive skin that requires special bed linen
3. A stage III pressure ulcer needing the appropriate dressing
4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

Answer 1

Answer: 4. 


When repositioning an immobile patient, it is important to assess all bony prominences for the presence of redness, which can be the first sign of impaired skin integrity. Pressing over the area compresses the blood vessels in the area; and, if the integrity of the vessels is good, the area turns lighter in color and then returns to the red color. However, if the area does not blanch when pressure is applied, tissue damage is likely.

Question 2

Match the pressure ulcer categories/stages with the correct definition.

1. Category/stage I
2. Category/stage II
3. Category/stage III
4. Category/stage IV
   a. Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present.
   b. Full-thickness skin loss; subcutaneous fat may be visible. May include undermining.
   c. Full thickness tissue loss; muscle and bone visible. May include undermining.
   d. Partial-thickness skin loss or intact blister with serosanguinous fluid.

Answer 2

Answer:

1a, 2d, 3b, 4c. 
Category/stage I pressure ulcer does not have a break in the skin but has a redness that does not blanch. Category/stage II ulcer has a shallow open ulcer (partial-thickness wound). It may also have an intact fluid-filled blister. Category/ stage III is full-thickness damage without visible fat; however, bone, tendon, and muscle are not exposed. Category/stage IV has full-thickness damage with visible bone, tendon, or muscle exposed.

Question 3

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken?

1. Necrotic tissue
2. Wound drainage
3. Wound circumference
4. Cleansed wound

Answer 3

Answer: 4. 


Drainage that has been present on the wound surface can contain bacteria from the skin, and the culture may not contain the true causative organisms of a wound infection. By cleaning the area before obtaining the culture, the skin flora is removed.

Question 4

After surgery the patient with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.)

1. Notify the surgeon.
2. Allow the area to be exposed to air until all drainage has stopped.
3. Place several cold packs over the area, protecting the skin around the wound
4. Cover the area with sterile, saline-soaked towels immediately.
5. Cover the area with sterile gauze and apply an abdominal binder.

Answer 4

Answer: 1, 4. 


If a patient has an opening in the surgical incision and a part of the small bowel is noted, this is evisceration. The small bowel must be protected until an emergency surgical repair can be done. The small bowel and abdominal cavity should be maintained in a sterile environment; thus sterile towels that are moistened with sterile saline should be used over the exposed bowel for protection and to keep the bowel moist.

Question 5

What is the correct sequence of steps when performing wound irrigation to a large open wound?

1. Use slow, continuous pressure to irrigate wound.
2. Attach 19-gauge angiocatheter to syringe.
3. Fill syringe with irrigation fluid.
4. Place waterproof bag near bed.
5. Position angiocatheter over wound.

Answer 5

Answer: 4, 3, 2, 5, 1. 


Organized steps ensure a safe, effective irrigation of the wound.

Question 6

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound-care product helps prevent edema formation, control bleeding, and anesthetize the body part?
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1. Binder
2. Ice bag
3. Elastic bandage
4. Absorptive dressing

Answer 6

Answer: 2. 


An ice bag helps to constrict excess fluid in tissues, which prevents edema. The blood vessels become constricted, help to control bleeding, and can decrease pain where the ice bag is placed

Question 7

Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.)

1. Frequent position changes
2. Keeping the buttocks exposed to air at all times
3. Using a large absorbent diaper, changing when saturated
4. Using an incontinence cleaner
5. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel
6. Applying a moisture barrier ointment

Answer 7

Answer: 1, 4, 6. 


Skin that is in contact with stool and urine can become moist and soft, allowing it to become damaged. The stool contains bacteria and in some cases enzymes that can harm the skin if in contact for a prolonged period of time. The use of an incontinence cleaner provides a gentle removal of stool and urine, and the use of the moisture-barrier ointment provides a protective layer between the skin and the next incontinence episode. However, skin-care and moisture barriers must also be used with frequent position changes to help reduce the risk for pressure ulcers.

Question 8

Which of the following describes a hydrocolloid dressing?

1. A seaweed derivative that is highly absorptive
2. Premoistened gauze placed over a granulating wound
3. A debriding enzyme that is used to remove necrotic tissue
4. A dressing that forms a gel that interacts with the wound surface

Answer 8

Answer: 4.


A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing.

Question 9

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.)

1. Collection of wound drainage
2. Providing support to abdominal tissues when coughing or walking
3. Reduction of abdominal swelling
4. Reduction of stress on the abdominal incision
5. Stimulation of peristalsis (return of bowel function) from direct pressure

Answer 9

Answer: 2, 4. 


A binder placed over the abdomen can provide protection to the abdominal incision by offering support and decreasing stress from coughing and movement.

Question 10

When is an application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.)

1. To relieve edema
2. To reduce shivering
3. To improve blood flow to an injured part
4. To protect bony prominences from pressure ulcers
5. To immobilize area

Answer 10

Answer: 1, 3. 


Warm compresses can improve circulation by dilating blood vessels, and they reduce edema. The moisture of the compress conducts heat.

Question 11

What is the removal of devitalized tissue from a wound called?

1. Debridement
2. Pressure reduction
3. Negative pressure wound therapy
4. Sanitization

Answer 11

Answer: 1. 


Debridement is the removal of nonliving tissue, cleaning the wound to move toward healing.

Question 12

Name the three important dimensions to consistently measure to determine wound healing.

Answer 12

Answer:

Width, length, and depth. 
Consistent measurement of the wound using the dimensions of width, length, and depth provide information on the overall change in wound size that indicates if the wound is moving toward healing.

Question 13

What does the Braden Scale evaluate?

1. Skin integrity at bony prominences, including any wounds
2. Risk factors that place the patient at risk for skin breakdown
3. The amount of repositioning that the patient can tolerate
4. The factors that place the patient at risk for poor healing

Answer 13

Answer: 2.

The Braden Scale measures factors in six subscales that can predict the risk of pressure ulcer development. It does not assess skin or wounds.

Question 14

On assessing your patient’s sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient’s pressure ulcer?

1. Category/stage II
2. Category/stage IV
3. Unstageable
4. Suspected deep-tissue damage

Answer 14

Answer: 3. 


To determine the category/stage of a pressure ulcer you examine the depth of the tissue involvement. Since the pressure ulcer assessed was covered with necrotic tissue, the depth could not be determined. Thus this pressure ulcer cannot be staged.

Question 15

Which of the following are measures to reduce tissue damage from shear? (Select all that apply.)

1. Use a transfer device (e.g., transfer board)
2. Have head of bed elevated when transferring patient
3. Have head of bed flat when repositioning patient
4. Raise head of bed 60 degrees when patient positioned supine
5. Raise head of bed 30 degrees when patient positioned supine

Answer 15

Answer: 1, 3, 5. 


A transfer device can pick up a patient and prevent his or her skin from sticking to the bedsheet as he or she is repositioned. Positioning the patient flat when repositioning reduces shear. Positioning the patient with the head of the bed elevated at 30 degrees prevents him or her from sliding. The head of bed in higher position causes patient to slide down, causing shear.