Flashcards in Chapter 48: Skin Integrity and Wound Care [Practice Test] Deck (106):
This type of dressing is used for partial thickness and full-thickness wounds, deep wounds with some exudate, necrotic wounds, burns, and radiation damage skin.
A patient can lose ___ g of protein per day from an open weeping pressure ulcer. It would increase the protein intake up to ____ g/kg/day as necessary for healing
What kind of dressing would you put on a clean stage III pressure ulcer. How does the wound heal and what are the effects?
Must change when Seal of dressing breaks.
Maximum wear time seven days. Hydrogel
covered with foam dressing.
Applied over wanted to protect and absorb moisture.
Used with significant exit date must cover with secondary dressing.
used with normal saline or other prescribe solution. must unfold to make contact with wound.
Use with gauze per manufacturer instructions.
Heals through granulation and reepithelialization.
The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. The nurse recognizes that the risk factors that predispose a patient to pressure ulcer development include
a. A diet low in calories and fat.
b. Alteration in level of consciousness.
c. Shortness of breath.
d. Muscular pain.
Patients who are confused or disoriented or who have changing levels of consciousness are unable to protect themselves. The patient may feel the pressure but may not understand what to do to relieve the discomfort or to communicate that he or she is feeling discomfort. Impaired sensory perception, impaired mobility, shear, friction, and moisture are other predisposing factors. Shortness of breath, muscular pain, and a diet low in calories and fat are not included among the predisposing factors.
4 commonly used cytotoxic solutions are? These ____ used to clean granulating wounds.
Dakin's Solution (Sodium Hypochlorite) Acetic Acid
This form of wound debridement is the removal of devitalized tissue by using a scalpel, scissors, or other sharp instruments.
____ is contraindicated if the wound site is edematous, or the patient has neuropathy
_________ is the oldest and most common dressing they are absorbent and are useful in wicking away wound exudate. _____ is the most common size.
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. The nurse is able to identify that the major element involved in the development of a decubitus ulcer is
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 12 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 (the ability to remain unaltered by the damaging effect of something), stress (worry or anxiety), and weight (individuals of all sizes, shapes, and ages acquire skin breakdown) are not major causes of pressure ulcers.
Which nursing observation would indicate that the patient was at risk for pressure ulcer formation?
a. The patient ate two thirds of breakfast.
b. The patient has fecal incontinence.
c. The patient has a raised red rash on the right shin.
d. The patient's capillary refill is less than 2 seconds.
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 would the nurse stage this ulcer?
a. Stage I pressure ulcer
b. Healing stage II pressure ulcer
c. Healing stage III pressure ulcer
d. Stage III pressure ulcer
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." Once an ulcer has been staged, the stage endures even as the ulcer heals. This ulcer was labeled a stage III, 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.
________ breaks down and loosens dead tissue in a wound. Apply the solution to gauze and apply to wound. ________ are used in a wound because it is thought that they digest the dead tissue.
The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer would be staged as stage
This would be a stage II pressure ulcer because it presents as partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and 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.
Topical enzymes induced changes in the substrate resulting in the breakdown of necrotic tissue. Depending on the enzyme it either _____ or _____ the tissue. These require a ______.
digests or dissolves
Use nonadherent dressing such as ______ on clean wounds with little or no drainage. This gauze has a shiny non-adherents service that does not stick to incisions or one openings but allows drainage to pass through to the gauze topper.
An order to reinforce dressings PRN as in add dressings without removing the original one is _____ right after surgery.
Rationale: when the doctor does not want accidental disruption of the suture line or bleeding.
The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which of the following would be used first to assist in staging an ulcer on this patient?
a. Cotton-tipped applicator
b. Disposable measuring tape
c. Sterile gloves
d. Halogen light
When assessing a patient with darkly pigmented skin, proper lighting is essential to accurately complete the first step in assessment inspection and the whole 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 not the first item used.
The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a pressure ulcer takes time to heal and is an example of
a. Primary intention.
b. Partial-thickness wound repair.
c. Full-thickness wound repair.
d. Tertiary intention.
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 three phases: inflammatory, proliferative, and remodeling. 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 approximated. Wound closure is delayed until risk of infection is resolved.
If the wound base is dry use a dressing that adds moisture, if there is excessive exudate use a dressing that absorbs the excess moisture while maintaining moisture at the wound bed during this form of wound debridement?
______ and _______ are used for creating pressure over a body part. Immobilizing a body part.
Supporting the wound.
Reducing and preventing edema.
Securing the splint.
Bandages and binders
The nurse is caring for a patient with a large abrasion from a motorcycle accident. The nurse recalls that if the wound is kept moist, it can resurface in _____ day(s).
A partial-thickness wound repair has three compartments: the inflammatory response, epithelial proliferation and migration, and re-establishment of the epidermal layers. Epithelial proliferation and migration start at all edges of the wound, allowing for quick resurfacing. Epithelial cells begin to migrate across the wound bed soon after the wound occurs. A wound left open to air resurfaces within 6 to 7 days, whereas a wound that is kept moist can resurface in 4 days. One or 2 days is too soon for this process to occur, moist or dry.
The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair?
d. Purulent drainage
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.
When irrigating allow the solution to flow from the _____ contaminated area.
least to most
The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse recalls that this type of wound heals by
a. Tertiary intention.
b. Secondary intention.
c. Partial-thickness repair.
d. Primary intention.
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.
This is a nonselective method of debridement because devitalized and viable tissues are both removed. This is not used routinely. Never use this method and a clean granulating wound. What is this defined as?
_______ are via available in a variety of materials including silk steel cotton linen wire nylon and Dacron.
The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by
a. Tertiary intention.
b. Secondary intention.
c. Partial-thickness repair.
d. Primary intention.
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 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.
This form of wound debridement uses topical enzyme preparation, Dakin's solution, or sterile maggots.
Pressure dressing to use during the first ______ hours after trauma helps maintain hemostasis.
24 to 48
Which nursing observation would indicate that a wound healed by secondary intention?
a. Minimal scar tissue
b. Minimal loss of tissue function
c. Permanent dark redness at site
d. Scarring can be severe.
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.
When a laceration is bleeding profusely what is your number one concern?
This type of dressing is most useful on shallow to moderately deep dermal ulcers. This dressing leaves a residue in the wound bed that is easy to confuse with purulent drainage.
________ can be saturated with solution and used to clean and pack a wound. It is saturated with solution usually saline, wrung out, unfolded, and lightly packed into the wound. The purpose of this is to provide moisture to the wound yet allow wound drainage to be wicked into the pad. ______ the dressing allows easier wicking action.
High pressure wound irrigation.
Pulsitile high-pressure Lavage. Whirlpool treatments.
These are all what method of wound debridement.
The nurse is caring for a patient who has experienced a total hysterectomy. Which nursing observation would indicate that the patient was experiencing a complication of wound healing?
a. The incision site has started to itch.
b. The incision site is approximated.
c. The patient has pain at the incision site.
d. The incision has a mass, bluish in color.
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 of an incision site can be associated with clipping of hair, dressings, or possibly the healing process. Incisions should be approximated with edges together. After surgery, when nerves in the skin and tissues have been traumatized by the surgical procedure, it is expected that the patient would experience pain.
What kind of dressing would you put on a clean stage IV pressure ulcer? What are the effects? how does the wound heal?
covered with foam dressing.
Applied over wound to protect and absorb moisture.
Calcium alginate. Used with significant exudate.
Must cover with secondary dressing.
Use with normal saline or other prescribe solution.
Must unfold to make contact with wild. Fills all dead space with gauze.
Used with gauze.
Heals through granulation and re-epithelialization.
Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence?
a. Complaint by patient that something has given way
b. Protrusion of visceral organs through a wound opening
c. Chronic drainage of fluid through the incision site
d. Drainage that is odorous and purulent
occurs is when a wound fails to heal properly and the layers of skin and tissue separate. It involves abdominal surgical wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. Patients often report feeling as though something has given way. Evisceration is seen when vital organs protrude through a wound opening. A fistula is an abnormal passage between two organs or between an organ and the outside of the body that can be characterized by chronic drainage of fluid. Infection is characterized by drainage that is odorous and purulent.
What kind of dressing would you put on an unstageable pressure ulcer and what are the effects? How does the wound heal?
Facilitates softening of Eschar.
Gauze plus ordered solution.
Deliver solution in wicks wound drainage and softens eschar.
Facilitates the debridement.
If eshar is dry and intact no dressing used allowing eschar to act as physiological cover maybe indicated for treatment of heal eschar.
Eschar lifts at edges of debridement progresses.
Gauze plus solution
A patient has developed a decubitus ulcer. What laboratory data would be important to gather?
a. Serum albumin
b. Creatine kinase
c. Vitamin E
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. Measurement of creatine kinase helps in the diagnosis of myocardial infarcts and has no known role in wound healing. Potassium is a major electrolyte that helps to regulate metabolic activities, cardiac muscle contraction, skeletal and smooth muscle contraction, and transmission and conduction of nerve impulses. Vitamin E is a fat-soluble vitamin that prevents the oxidation of unsaturated fatty acids. It is believed to reduce the risk of coronary artery disease and cancer. Vitamin E has no known role in wound healing.
Hemoglobin needs to be maintained at _______. If not maintained decreases delivery of oxygen to the tissues and leads to further ischemia.
Which of the following would be the most important piece of assessment data to gather with regard to wound healing?
a. Muscular strength assessment
b. Sleep assessment
c. Pulse oximetry assessment
d. Sensation assessment
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. Blood flow through the pulmonary capillaries provides red blood cells for oxygen attachment. Oxygen diffuses from the alveoli into the pulmonary blood; most of the oxygen attaches to hemoglobin molecules within the red blood cells. Red blood cells carry oxygenated hemoglobin molecules through the left side of the heart and out to the peripheral capillaries, where the oxygen detaches, depending on the needs of the tissues. 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 her assessment
B. Document findings as normal
C. Notify the Physician
D. Notify the Charge Nurse
The patient is showing signs and symptoms associated with infection in the wound. It is serious and needs treatment but is not a life-threatening emergency, where care is needed immediately or the patient will suffer long-term consequences. 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 physician 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. After the collaboration, the nurse orders a meal plan that includes increased
d. Vitamin E.
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. A balanced diet of fat and carbohydrates, along with protein, vitamins, and minerals, is needed in any diet. Wound healing does not require increased amounts of fats or carbohydrates. Vitamin E has no known role in wound healing.
What kind of dressing would you put on a clean stage two pressure ulcer And what are the effects of each dressing? how does the wound heal?
Change when seal of dressing breaks. Maximum wear time 7 days.
Provides a moist environment.
Heals by Re-epithelialization.
The nurse is completing an assessment on an individual who has a stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. The nurse determines that the patient is experiencing issues with self-concept when the patient states which of the following?
a. "I think I will be ready to go home early next week."
b. "I am so weak and tired, I want to feel better."
c. "I am ready for my bath and linen change as soon as possible."
d. "I am hoping there will be something good for dinner tonight."
The patient's psychological response to any wound is part of the nurse's assessment. Body image changes can influence self-concept. Factors that affect the patient's perception of the wound include the presence of scars, drains, odor from drainage, and temporary or permanent prosthetic devices. The wound is odorous, and a drain is in place. The patient who is asking for a bath and change in linens gives you a clue that he or she may be concerned about the smell in the room. The patient stating that he or she wants to feel better, talking about going home, and caring about what is for dinner could be interpreted as positive statements that indicate progress along the health journey.
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, the next best step is to
a. Inspect the wound for bleeding.
b. Inspect the wound for foreign bodies.
c. Determine the size of the wound.
d. Determine the need for a tetanus antitoxin injection.
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.
This tool addresses 15 wound characteristics you score individual items and calculate the total providing an overall indication of one status. The scoring assists in evaluating whether the goals of the one management are effective.
Bates-Jensen Wound Assessment Tool
The treatment plan needs to be altered as a one heels. A transparent film dressing is used to initially ______ Debridement (liquefy the tissue using body moisture) in the chronic wound. Once the wound is cleaned of the necrotic tissue, discontinue the transparent film dressing. And based on the wound characteristics choose a new dressing.
The most common type of binder is?
This type of dressing absorbs drainage through the wound exudate absorbers in the dressing.
Maintains wound moisture.
Slowly liquefies necrotic debris.
Is impermeable to bacteria and other contaminants.
Is self adhesive and molds well.
Acts as a preventative dressing for high-risk friction areas. May be left in place for 3 to 5 days minimizing skin trauma and disruption of healing.
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 of these actions should the nurse take first?
a. Don sterile gloves.
b. Provide analgesic medications as ordered.
c. Avoid accidentally removing the drain.
d. Gather supplies.
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. What would be the nurse's next best step?
a. Remove the drain; a drain is no longer needed.
b. Call the physician; a blockage is present in the tubing.
c. Call the charge nurse to look at the drain.
d. As long as the evacuator is compressed, do nothing.
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 physician. The health care provider determines the need for drain removal and removes drains. Notifying the charge nurse, although important for communication, is not the next step in providing care for this patient. The evacuator may be compressed when a blockage is present.
A low-air-loss therapy unit is utilized for stage IV pressure ulcers and when prevention or treatment of skin breakdown is needed. If the patient has a stage III or stage IV ulcer or a postoperative myocutaneous flap, the low-air-loss therapy unit would be an appropriate selection. A static air mattress or nonpowered redistribution is utilized for the patient at high risk for skin breakdown. A standard mattress is utilized for an individual who does not have actual or potential altered or impair skin integrity. Lateral rotation is used for treatment and prevention of pulmonary complications associated with mobility.
The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. The nurse recognizes that the next step in caring for this patient includes
a. Monitoring of the wound.
b. Irrigation of the wound.
c. Debridement of the wound.
d. Management of drainage.
Debridement is the removal of nonviable necrotic 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. Irrigating the wound with noncytotoxic cleaners will not damage or kill fibroblasts and healing tissue and will help to keep the wound clean once debrided. 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.
The nurse is caring for a patient with a healing stage III pressure ulcer. The wound is clean and granulating. Which of the following orders would the nurse question?
a. Use a low-air-loss therapy unit.
b. Consult a dietitian.
c. Irrigate with hydrogen peroxide.
d. Utilize hydrogel dressing.
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.
Changing the dressing is a sterile procedure true or false?
The nurse is completing an assessment of the skin's integrity, which includes
a. Pressure points.
b. All pulses.
c. Breath sounds.
d. Bowel sounds.
The nurse continually assesses the skin for signs of ulcer development. Assessment of tissue pressure damage includes visual and tactile inspection of the skin. Observe pressure points such as bony prominences and areas next to treatments such as a binasal cannula and the nares. Assessment of pulses, breath sounds, and bowel sounds is part of a head-to-toe assessment and could influence the function of the body and ultimately skin integrity; however, this assessment is not a specific part of a skin assessment.
The nurse is completing a skin risk assessment utilizing the Braden scale. The patient has some sensory impairment and skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. What would be the patient's Braden scale total score?
With use of the Braden scale, the patient receives 3 for slight sensory impairment, 4 for skin being rarely moist, 3 for walks occasionally, 3 for slightly limited mobility, 4 for intake of meals, and 4 for no problem with friction and shear. The total score is 20.
A dressing needs to support a moist wound environment of the wound is healing by _________. A moist wound base for facilitates the movement of _______ thus allowing the wound to resurface as quickly as possible.
The nurse is caring for a medical-surgical patient. To decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility, which intervention is most important for the nurse to complete?
a. Encourage the patient to sit up in the chair.
b. Provide analgesic medication as ordered.
c. Explain the risks of immobility to the patient.
d. Turn the patient every 3 hours while in bed.
Maintaining adequate pain control and patient comfort increases the patient's willingness and ability to increase mobility, which in turn reduces pressure ulcer risks. It is good to encourage a patient to move about but even better if the patient actually sits up in the chair. Explaining the risk of immobility is important for the patient because it may impact the patient's willingness but not his or her ability. Turning the patient is important for decreasing pressure ulcers but needs to be done every 2 hours, and again does not influence the patient's ability to increase mobility.
The nurse is caring for a patient with a stage IV pressure ulcer. The nurse assigns which of the following nursing diagnoses?
a. Readiness for enhanced nutrition
b. Impaired physical mobility
c. Impaired skin integrity
d. Chronic pain
After the assessment is completed and the information that the patient has a stage IV pressure ulcer is gathered, a diagnosis of Impaired skin integrity is selected. Readiness for enhanced nutrition would be selected for an individual with an adequate diet that could be improved. Impaired physical mobility and Chronic pain, as well as the nutrition nursing diagnosis, could well be the nursing diagnoses selected for this patient, but current data in the question strongly support Impaired skin integrity.
The nurse has collected the following assessment data: right heel with reddened area that does not blanch. What nursing diagnosis would the nurse assign?
a. Ineffective tissue perfusion
b. Risk for infection
c. Imbalanced nutrition: less than body requirements
d. Acute pain
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 tissue perfusion. Risk for infection, Acute pain, and Imbalanced nutrition may be part of this patient's nursing diagnosis, but the data provided do not support this nursing diagnosis.
The nurse is caring for a patient with a stage III pressure ulcer. The nurse has assigned a nursing diagnosis of Risk for infection. Which intervention would be most important for this patient?
a. Teach the family how to manage the odor associated with the wound.
b. Discuss with the family how to prepare for care of the patient in the home.
c. Encourage thorough handwashing of all individuals caring for the patient.
d. Encourage increased quantities of carbohydrates and fats.
The number one way to decrease the risk of infection by breaking the chain of infection is to wash hands. Encouraging fluid and food intake helps with overall wellness and wound healing, especially protein, but an increase in carbohydrates and fats does not relate to the risk of infection. If the patient will be discharged before the wound is healed, the family will certainly need education on how to care for the patient. Teaching the family how to manage the odor associated with a wound is certainly important, but these interventions do not directly relate to the risk of infection and breaking the chain of the infectious process.
What type of dressing would you put on an intact stage one pressure ulcer and what are the effects?
Allows visual assessment
Protects from shear.
Not to be used in presence of excessive moisture.
Does not always allow visual assessment.
The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. The nurse consults a
a. Respiratory therapist.
b. Registered dietitian.
d. Case manager.
Assessment and a plan for the patient to optimize the diet are essential. Adequate calories, protein, vitamins, and minerals promote wound healing. The nurse is the coordinator of care, and collaborating with the dietitian would result in planning the best meals for the patient. The respiratory therapist can be consulted when a patient has issues with the respiratory system. Case management can be consulted when the patient has a discharge need. A chaplain can be consulted when the patient has a spiritual need.
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. What is the best goal for this patient?
a. The patient's family will demonstrate specific care of the wound site.
b. The patient will state what to look for with regard to an infection.
c. The patient will remain free of an increase in temperature and of odorous or purulent drainage from the wound.
d. The patient's family members will wash their hands when visiting the patient.
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; also, this is an intervention, not a goal for this diagnosis. 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 interventions, not goals or outcomes for this nursing diagnosis.
This type of dressing is very useful in painful wounds because it is soothing to the patient and does not adhere to the wound bed and this causes little trauma during removal. disadvantage is that they require a secondary dressing and you must take care to prevent peri-wound maceration.
The nurse is caring for a postpartum patient. The patient has an episiotomy after experiencing birth. The physician has ordered heat to treat this condition, and the nurse is providing this treatment. This patient is at risk for
b. Impaired skin integrity.
d. Imbalanced nutrition.
Heat causes vasodilatation and is used to improve blood flow to an injured body part. The application of heat incorrectly when the treatment is too hot, or is applied too long or to the wrong place, can result in a burn for the patient and risk for additional trauma. The skin already has impaired integrity owing to the surgical procedure, and because of this has been at risk for infection since the surgical procedure was performed. This patient is of childbearing age and has had a child. Additional needs for nutrition are present during pregnancy and breastfeeding, but this is an established nursing diagnosis. Data are insufficient to support the nursing diagnosis of Imbalanced nutrition.
The home health nurse is caring for a patient with impaired skin integrity in the home. The nurse is reviewing dressing changes with the caregiver. Which intervention assists in managing the expenses associated with long-term wound care?
a. Sterile technique
b. Clean dressings and no touch technique
c. Double bagging of contaminated dressings
d. Ability of the caregiver
Clean dressings as opposed to sterile dressings are recommended for home use. This recommendation is in keeping with principles regarding nosocomial infection, and it takes into account the expense of sterile dressings and the dexterity required for application. The caregiver can use the same no touch technique for dressing changes that is used for changing surface dressings without touching the wound or the surface that might come in contact with the wound. Double bagging is required for the disposal of contaminated dressings. The dressings go in a bag, which is fastened and then placed in the household trash. The ability of the caregiver certainly is a component of the success of home treatment, but it does not influence the cost of supplies.
This type of dressing are impregnated with water or glycerin based amorphous gel. This type of dressing hydrates wounds and absorb some smaller amounts of exudate.
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 interventions should the nurse select to decrease this risk?
a. Gentle cleaners and thorough drying of the skin
b. Absorbent pads and garments
c. Positioning with use of pillows
d. Therapeutic beds and mattresses
Assessment and skin hygiene are two initial defenses for preventing skin breakdown. Avoid soaps and hot water when cleansing the skin. Use gentle cleansers with nonionic surfactants. After bathing, make sure to dry the skin completely, and apply moisturizer to keep the epidermis well lubricated. Absorbent pads and garments are controversial and should be considered only when other alternatives have been exhausted. Positioning the patient reduces pressure and shearing force to the skin and is part of the plan of care but is not one of the initial components. 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.
The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair?
a. At least 3 hours
b. Not longer than 30 minutes
c. Less than 2 hours
d. As long as the patient remains comfortable
When patients are able to sit up in a chair, make sure to limit the amount of time to 2 hours or less. The chair sitting time should be individualized. In the sitting position, pressure on the ischial tuberosities is greater than in a supine position. Utilize foam, gel, or an air cushion to distribute weight. Longer than 2 hours can increase the chance of ischemia.
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. What is the best method for repositioning the patient?
a. Obtain assistance and use the drawsheet to place the patient into the new position.
b. Place the patient in a 30-degree supine position.
c. Utilize a transfer sliding board and assistance to slide the patient into the new position.
d. Elevate the head of the bed 45 degrees.
When repositioning the patient, obtain assistance and utilize a transfer sliding board under the patient's body to prevent dragging the patient on bed sheets and placing the patient at high risk for shearing and friction injuries. The patient should be placed in a 30-degree lateral position, not supine position. The head of the bed should be elevated less than 30 degrees to prevent pressure ulcer development from shearing forces.
These dressings cannot absorb the amount of drainage from heavily draining wounds and some are contra indicated for use in full thickness and infected wounds.
The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers. The nurse has become competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage
Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14 days do not require a dressing. This allows visual inspection and monitoring. A transparent dressing could be used to protect the patient from shear but cannot be used in the presence of excessive moisture. A composite film, hydrocolloid, or hydrogel can be utilized on a clean stage II. A hydrocolloid, hydrogel covered with foam, calcium alginate, gauze, and growth factors can be utilized with a clean stage III. Hydrogel, calcium alginate, gauze, and growth factors can be utilized with a clean stage IV. An unstageable wound cover with eschar should utilize a dressing of adherent film or gauze with an ordered solution of enzymes. In rare cases when eschar is dry and intact, no dressing is used, but this is an unstaged ulcer.
The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. What should the nurse do to decrease the patient's anxiety?
a. Tell the patient to close his eyes.
b. Explain the procedure.
c. Turn on the television.
d. Ask the family to leave the room.
Explaining the procedure educates the patient regarding the dressing change and involves him in his care, thereby allowing the patient some control in decreasing anxiety. Telling the patient to close his eyes and turning on the television are distractions that do not usually decrease a patient's anxiety. If the family is a support system, asking support systems to leave the room can actually increase a patient's anxiety.
Cleanse surgical or traumatic wounds by applying noncytotoxic solution with sterile gauze or irrigations. Cleanse in a direction from the least contaminated area. Use gentle friction when applying solutions to the skin, and allow irrigation to flow from the least to the most contaminated area.
Clean pressure ulcers only with this type of wound cleanser.
Ex. normal saline or commercial wound cleaners.
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. What is the best explanation for the nurse to use when teaching the patient the reason for the binder?
a. The binder creates pressure over the abdomen.
b. The binder supports the abdomen.
c. The binder reduces edema at the surgical site.
d. The binder secures the dressing in place.
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 create pressure over a body part, for example, over an artery after it has been punctured. A binder can be used to prevent edema, for example, in an extremity but 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. To assist with pain management following the procedure, which intervention should the nurse implement?
a. Monitor vital signs every 15 minutes.
b. Apply brace to right knee.
c. Elevate right knee and apply ice.
d. Check pulses in right foot.
Ice assists in preventing edema formation, controlling bleeding, and anesthetizing the body part. Elevation 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. Applying a brace provides support and decreases the opportunity for additional trauma, which in turn assists in the healing process. Checking the pulses is important to monitor the circulation of the extremity but in itself is not a pain management intervention.
The patient has been provided a nursing diagnosis of Risk for skin impairment and has a 15 on the Braden scale upon admission. The nurse has implemented interventions for this nursing diagnosis. Upon reassessment, which Braden score would be the best sign that the risk for skin breakdown is decreasing?
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. The best sign is a perfect score of 23.
This form of wound debridement involves the use of wet to dry saline gauze dressings. Press moistened gauze into the wound and allow the dressing to dry thoroughly before pulling the gauze that has adhered to the tissue out of the pressure ulcer. What is this defined as?
The nurse is caring for a patient with a stage II pressure ulcer and as the coordinator of care understands the need for a multidisciplinary approach. The nurse evaluates the need for several consults. Which of the following should always be included in the consults? (Select all that apply.)
a. Registered dietitian
b. Enterostomal and wound care nurse
c. Physical therapist
d. Case management personnel
ANS: A, B, C, D
A registered dietitian is useful in working with the nurse to determine a meal plan that will support wound healing. An enterostomal or wound care nurse specializes in caring for the needs of the patient with wounds. Physical therapy is concerned about the mobility of the patient and can assist an immobile patient to progress toward mobility and decrease the risk for pressure ulcers. Pressure ulcers take a long time to heal and usually require continued therapy in the home. Case management personnel are useful in obtaining care for the patient outside the home. If the patient has a spiritual need, the chaplain can assist. If the patient has a need associated with medications, the pharmacist can assist. However, chaplains and pharmacists usually are not part of the wound care multidisciplinary team, unless a special need arises.
The nurse is caring for a patient with wound healing by tertiary intention. Which factors does the nurse recognize as influencing wound healing? (Select all that apply.)
c. Tissue perfusion
ANS: A, C, D, F
Normal wound healing requires proper nutrition. Oxygen and the ability to provide adequate amounts of oxygenated blood are critical for wound healing. Wound infection prolongs the inflammatory phase, delays collagen synthesis, prevents epithelialization, and decreases the production of proinflammatory cytokines, which leads to additional tissue destruction. As patients age, all aspects of wound healing are delayed. Hemorrhage and evisceration are complications of wound healing.
One method to ensure an irrigation pressure within the correct range is to use a ___ gauge needle or an ______ and a ___ ML syringe that delivers say to Celine to a pressure ulcer at ___ psi.
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. "Is movement painful?"
e. "What medications do you take?"
f. "Have you ever fallen?"
ANS: A, B, C, D
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, he can protect himself 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 mobility such as pain will alert the nurse to any potential for decreased movement and increased risk for skin breakdown. Medications and falling are safety risk questions.
This form of wound debridement uses synthetic dressings over a wound to allow the eschar to be self digested by the action of enzymes that are present in the wound fluids. You accomplish this by using dressings that support moisture at the one surface.
Ex. Transparent film and Hydrocolloid dressings.
The nurse is caring for a patient with potential skin breakdown. Which components would the nurse include in the skin assessment? (Select all that apply.)
e. Temperature of skin
f. Nutritional status
ANS: B, C, D, E
Assessment of the skin includes both visual and tactile inspection. Assess for hyperemia and abnormal reactive hyperemia (when the skin turns red after an obstruction of blood flow returns and vasodilatation causes the tissue to turn red). Assess for indurated (hardened) areas on the skin and palpate reddened areas for blanching. Changes in temperature can indicate changes in blood flow to that area of the skin. Mobility and nutritional status are certainly part of the overall assessment for pressure ulcer risk but are not part of the actual skin assessment.
The nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder. The nurse's responsibilities and activities before applying the bandage and binder include which of the following? (Select all that apply.)
a. Inspecting the skin for abrasions and edema
b. Covering exposed wounds
c. Assessing condition of current dressings
d. Assessing the skin at underlying areas for circulatory impairment
e. Marking the sites of all abrasions
f. Cleansing the area with hydrogen peroxide
ANS: A, B, C, D
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 sterile 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 a stage III pressure ulcer and a nursing diagnosis of Impaired skin integrity. Which of the following outcomes when met indicate progression toward goals? (Select all that apply.)
a. Ask whether patient's expectations are being met.
b. Prevent injury to the skin and tissues.
c. Obtain the patient's perception of interventions.
d. Reduce injury to the skin.
e. Reduce injury to the underlying tissues.
f. Restore skin integrity.
ANS: B, D, E, F
Optimal outcomes are to prevent injury to skin and tissues, reduce injury to skin, reduce injury to underlying tissues, and restore skin integrity. Asking the patient's perceptions and whether expectations are being met allows one to obtain information regarding the experience, but these are not actual measurable outcomes.
Non-cytotoxic cleaners do not damage or kill ______ and ______ tissue.
When wounds heal by _______it is common to remove dressings as soon as drain it stops. When wounds heal by _______ the dressing material becomes a means for providing waster to the wound and assisting in debridement.
To maintain a healthy wound environment you need to address the following 6 principles?
Prevent and manage infection.
Clean the wound.
Remove non-viable tissue.
Maintain the wound in moist environment.
Protect the wound.
If addressing is sticking to a surgical incision what would you do and why?
Moisten the gauze with saline to prevent trauma to the incisional area after removal.
Doctors and and some street nurse practitioners perform this on an ulcer or wound. This is the quickest method of debridement. It is usually used on a patient with cellulitis or sepsis.
This vitamin promotes collagen synthesis, capillary wall integrity, fibroblast function, and immunological function.
When a patient has a penetrating object wound such as a knife blade it is important to remember?
Do not remove the object.
Rationale: Holds pressure and controls some bleeding.
Protects wound from microorganism contamination.
Aids in hemostasis.
Promotes healing by absorbing drainage and debriding wounds. Supports or splints the wound site. Protect patients from seeing the wound.
Promotes thermal insulation of the
Provides a moist environment.
What is this defined as?
Purpose of dressings
To avoid damage to the periwound skin it is important that the dressing technique that you use to treat pressure ulcers and other wound is not.
Check _______ dressings to be sure that they do not interfere with circulation to a body part. Assesses skin color, pulses in distal extremities, the patient's comfort, and changes in sensation. These are not removed routinely.
The primary function of a dressing on healing wound is to absorb drainage many surgical gauze dressings have these three layers?
Contact or primary layer, an observant layer, and a secondary or protective layer.
The stage of the pressure ulcer. Thorough assessment of the pressure research.
Stage of the pressure ulcer.
Goal of treatment of the pressure ulcer. Mechanism of action of the dressing. Principles of wound care.
This is important to know before doing what?
Before placing a dressing on a pressure ulcer.
Use this type of dressing to trap moisture over the wound providing a moist environment. This dressing is ideal for small superficial wounds such as _____ thickness wounds or to protect ________ skin. This can be used as a secondary dressing and for _______ debridement of small wounds.
Adheres to undamaged skin. Serves as a barrier to external fluids and bacteria but still allows the one surface to breathe because oxygen passes through the dressing. Promote a moist environment that speeds epithelial cell growth. Can be removed without damaging underlying tissues. Permits viewing a wound. Does not require a secondary dressing.
These dressings are dressings with complex formulations of colloids, elastomeric, and adhesive components. They are adhesive and occlusive. The wound contact layer of this dressing forms a gel as fluid is absorbed and maintains a moist healing environment. They support healing in clean granulating wounds and autolytically debride necrotic wounds they are available in a variety of shapes and sizes.