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Questions and Answers
What should the nurse assess in a postoperative client who feels like something has just given away?
What should the nurse assess in a postoperative client who feels like something has just given away?
Dehiscence of the wound
Which client has the highest risk for developing a pressure ulcer?
Which client has the highest risk for developing a pressure ulcer?
What action should the nurse take to prevent a pressure ulcer in a 78-year-old client on bed rest?
What action should the nurse take to prevent a pressure ulcer in a 78-year-old client on bed rest?
Use pillows to maintain a side-lying position as needed.
Which complications of wounds are accurately described? Select all that apply.
Which complications of wounds are accurately described? Select all that apply.
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In which situations has the nurse used a dressing properly? Select all that apply.
In which situations has the nurse used a dressing properly? Select all that apply.
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What is true about the dermis? Select all that apply.
What is true about the dermis? Select all that apply.
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Which dressing will the nurse select to cover the site where blood was drawn?
Which dressing will the nurse select to cover the site where blood was drawn?
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What should the nurse immediately assess for if a postoperative client describes feeling like something just popped?
What should the nurse immediately assess for if a postoperative client describes feeling like something just popped?
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What is the best practice regarding wound healing when applying a saline-moistened dressing?
What is the best practice regarding wound healing when applying a saline-moistened dressing?
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What should the nurse do to keep the swab and inside of the culture tube sterile when obtaining a wound culture?
What should the nurse do to keep the swab and inside of the culture tube sterile when obtaining a wound culture?
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Which teaching should the nurse provide to a caregiver about wound healing for an 85-year-old client? Select all that apply.
Which teaching should the nurse provide to a caregiver about wound healing for an 85-year-old client? Select all that apply.
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What requires further nursing teaching regarding Steri-Strips after a Cesarean section?
What requires further nursing teaching regarding Steri-Strips after a Cesarean section?
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Which client is particularly susceptible to impaired wound healing?
Which client is particularly susceptible to impaired wound healing?
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What is the primary goal of debridement in wound care?
What is the primary goal of debridement in wound care?
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What activity should the nurse implement to decrease shearing force on a client with a stage II pressure ulcer?
What activity should the nurse implement to decrease shearing force on a client with a stage II pressure ulcer?
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How long will the inflammation phase last for a fissure due to chafing?
How long will the inflammation phase last for a fissure due to chafing?
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Which implement should a nurse use to measure the depth of a client's tunneled wound accurately?
Which implement should a nurse use to measure the depth of a client's tunneled wound accurately?
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What does wound dehiscence indicate?
What does wound dehiscence indicate?
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Which guideline should the nurse follow when cleaning a wound?
Which guideline should the nurse follow when cleaning a wound?
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What type of diet should the nurse recommend to promote wound healing?
What type of diet should the nurse recommend to promote wound healing?
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What is the appropriate action for the nurse when applying a heating pad for neck pain?
What is the appropriate action for the nurse when applying a heating pad for neck pain?
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Which client is most likely to develop a pressure ulcer from shearing forces?
Which client is most likely to develop a pressure ulcer from shearing forces?
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Which wound would most likely heal by primary intention?
Which wound would most likely heal by primary intention?
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Which of the following is not considered a skin appendage?
Which of the following is not considered a skin appendage?
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How should the nurse document well-approximated edges of a wound with no signs of infection?
How should the nurse document well-approximated edges of a wound with no signs of infection?
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How long should a client refrain from douching before a Pap procedure?
How long should a client refrain from douching before a Pap procedure?
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What indicates effective nursing teaching regarding the use of an ice pack?
What indicates effective nursing teaching regarding the use of an ice pack?
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What type of injury results from falling onto both knees?
What type of injury results from falling onto both knees?
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What does a Jackson-Pratt drain do?
What does a Jackson-Pratt drain do?
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What should the nurse instruct the client with a Cesarean section about caring for her incision?
What should the nurse instruct the client with a Cesarean section about caring for her incision?
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Which dressing supply should the nurse gather for expected blood and drainage?
Which dressing supply should the nurse gather for expected blood and drainage?
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To determine a client's risk for pressure ulcer development, what question should the nurse ask?
To determine a client's risk for pressure ulcer development, what question should the nurse ask?
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Which skin layer should a student nurse recognize as a source of energy in an undernourished client?
Which skin layer should a student nurse recognize as a source of energy in an undernourished client?
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What laboratory finding increases a client's risk for pressure ulcer development?
What laboratory finding increases a client's risk for pressure ulcer development?
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What statement describes common skin characteristics in children?
What statement describes common skin characteristics in children?
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What factor is responsible for the increased risk of developing a decubitus ulcer when clients are pulled up in bed?
What factor is responsible for the increased risk of developing a decubitus ulcer when clients are pulled up in bed?
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What should the nurse recognize when assessing pale white skin over a client's coccyx?
What should the nurse recognize when assessing pale white skin over a client's coccyx?
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What skin infection is caused by beta-hemolytic streptococci and common in children?
What skin infection is caused by beta-hemolytic streptococci and common in children?
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How will the nurse respond to a client asking why their large surgical wound is still open?
How will the nurse respond to a client asking why their large surgical wound is still open?
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A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.
A Penrose drain typically exits a client's skin through a stab wound created by the surgeon.
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What is the wound measurement method for determining depth?
What is the wound measurement method for determining depth?
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What should be done before removing sutures encrusted with blood?
What should be done before removing sutures encrusted with blood?
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What response should the nurse give about the potential for curing psoriasis?
What response should the nurse give about the potential for curing psoriasis?
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What type of burn is characterized by pink skin with small blisters?
What type of burn is characterized by pink skin with small blisters?
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What does dehiscence refer to in wound healing?
What does dehiscence refer to in wound healing?
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What skin type characteristic suggests an increased risk for pressure ulcer development?
What skin type characteristic suggests an increased risk for pressure ulcer development?
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Which layer of skin serves as a potential energy source in an undernourished client?
Which layer of skin serves as a potential energy source in an undernourished client?
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What should the nurse document after a dressing change?
What should the nurse document after a dressing change?
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What should the nurse assess before beginning negative-pressure wound therapy?
What should the nurse assess before beginning negative-pressure wound therapy?
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Adequate blood flow to the skin requires that local capillary pressure must be ___________ than external pressure.
Adequate blood flow to the skin requires that local capillary pressure must be ___________ than external pressure.
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What should the nurse teach about healing of a minor surgical wound by first intention?
What should the nurse teach about healing of a minor surgical wound by first intention?
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What type of healing occurs when a wound like a surgical incision has clean edges with little tissue loss?
What type of healing occurs when a wound like a surgical incision has clean edges with little tissue loss?
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What factor complicates healing in an obese client with a pressure ulcer?
What factor complicates healing in an obese client with a pressure ulcer?
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Study Notes
Skin Integrity and Wound Care
- Susceptibility to impaired wound healing is heightened in individuals who are obese, especially those with diabetes.
- The main goal of debridement is to remove necrotic or infected tissue to enhance the healing process.
- To reduce shearing forces on clients with pressure ulcers, support the client to prevent sliding in bed, as shearing causes tissue damage.
- The inflammation phase of wound healing typically lasts about 3 days.
- For accurate measurement of a tunneled wound, a sterile, flexible applicator moistened with saline is required.
- Dehiscence in wounds refers to an unintentional separation of edges, particularly concerning in surgical wounds.
- When cleaning a wound, it is recommended to move from top to bottom and center to outside to avoid contaminating the wound.
- A diet rich in protein, vitamin A, and vitamin C is crucial for promoting wound healing; fish is an excellent choice for protein.
- When using a heating pad, monitor the application for 20 to 30 minutes to avoid skin damage.
- Clients who slide down in chairs are more at risk for developing pressure ulcers due to the effects of shearing forces.
- Primary intention healing occurs in well-approximated surgical incisions, contrasting with secondary intention, which occurs in larger, complicated wounds.
- Connective tissue is not classified as a skin appendage; hair, sebaceous glands, and eccrine sweat glands are.
- Wounds with smooth edges and no signs of infection should be documented as incisions, not as avulsions or abrasions.
- Clients should avoid douching 24-48 hours prior to a Pap test to preserve diagnostic cells.
- An effective ice pack application involves placing a cloth barrier between the skin and ice to prevent frostbite.
- Contusions result from injuries to soft tissue, commonly appearing as bruises with swelling.
- A Jackson-Pratt drain allows blood and fluid to exit through a bulb-like structure post-surgery.
- Proper care of surgical incisions includes maintaining cleanliness to prevent infection.
- Montgomery straps are essential for managing drainage in dressing changes alongside gauze.
- Assessing a client’s incontinence is critical in determining their risk for pressure ulcers, as moisture vulnerability increases the risk.
- Subcutaneous tissue serves as a potential energy source in undernourished individuals, while the epidermis provides protection.
- A low albumin level (2.8 mg/dL) indicates nutritional deficiency, increasing the likelihood of pressure ulcer development.
- Infants’ skin is highly susceptible to injury due to its delicate nature and can lead to infection.
- Shearing forces, caused by friction between layers of tissue, elevate the risk for decubitus ulcers.
- Assessing areas that blanch and then become red is indicative of ischemia and reactive hyperemia, not a stage I pressure ulcer.
- Impetigo is a common skin infection, particularly among children, caused by beta-hemolytic streptococci.
- Wounds healing by secondary intention typically require more time and tissue formation than those healing by primary intention.
- A Penrose drain is inserted through a stab wound for effective drainage.
- Documenting wound drainage involves noting aspects such as color, odor, amount, and type.
- Negative-pressure wound therapy requires assessment for any active bleeding prior to treatment.
- Four factors are vital for adequate skin perfusion: capillary pressure, cardiac output, blood volume, and patent vascular systems.
- Healing by first intention minimizes scar formation; primary intention wounds generally heal cleanly and quickly.
- Obese clients may face challenges in wound healing due to the poor vascularity of adipose tissue.
- Signs of wound dehiscence may include a sudden feeling of something giving way, especially post-operation.
- Older, incontinent clients with limited mobility, such as those with hip fractures, are at a heightened risk for pressure ulcers.### Pressure Ulcer Prevention
- Use pillows to support a side-lying position, helping to change pressure on bony prominences.
- Change client’s position at least every 2 hours to prevent pressure ulcers.
- Perform incontinent care every 2 hours and as needed to minimize moisture and skin irritation.
- A foot board prevents foot drop but does not lower pressure ulcer risk.
Wound Complications
- Dehiscence: Partial or total disruption of wound layers.
- Evisceration: Viscera protrudes through the incision.
- Postoperative fistula: Manifests as drainage from an opening, often due to delayed healing.
- Symptoms of wound infection appear within 1-2 weeks after injury or surgery.
- Delayed healing in thin clients may stem from malnutrition rather than tissue layer thickness.
- Increased serosanguineous fluid between postoperative days 4-5 can indicate impending dehiscence.
Proper Dressing Usage
- OpSite is ideal for covering central venous access device sites with minimal drainage.
- Aseptic techniques must be employed when changing dressings.
- Sof-Wick should be placed around drain insertion sites to absorb drainage and protect the wound.
- Do not place transparent dressings over ABD pads; use tape instead to monitor drainage.
- Telfa dressings allow drainage to pass through without adhering to the wound.
Dermis Characteristics
- Major cells in the dermis produce collagen and elastin and it is the thickest skin layer.
- The dermis is located beneath the epidermis, the skin’s outer layer.
- Epidermis major cells produce keratin, while basal epidermal cells produce melanin.
Blood Draw Dressing
- Use gauze to cover the site after blood is drawn.
- Transparent dressings like OpSite are meant for IV sites.
- Hydrocolloid dressings maintain moisture in wounds.
Immediate Assessment in Postoperative Client
- Assess for dehiscence when a client feels a "pop" during transfer, signaling potential wound disruption.
- Infection symptoms include redness, warmth, and swelling.
- Evisceration refers to protruding intra-abdominal contents.
Wound Healing Response
- A moist wound bed is beneficial for healing, contrary to the myth that wounds heal better when dry.
Wound Culture Process
- Maintain sterility of the swab and culture tube when obtaining wound cultures.
- Cleanse the wound prior to culture collection.
- Ensure the culture swab does not touch surrounding skin.
- Use separate swabs for multiple culture sites.
Wound Healing in Older Adults
- Healing may take twice as long in older adults compared to younger individuals.
- Consider a home health aide to help reduce caregiver stress.
- Long-term sun exposure can delay wound healing.
- Normal aging changes include decreased appetite, and depression may impact healing but is not a normal response.
Client Education on Cesarean Section Wound Care
- Steri-Strips are insufficient for holding a Cesarean section wound; sutures or staples are used initially.
- Healthcare providers will remove the staples after a set period.
Studying That Suits You
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Description
This quiz focuses on concepts related to skin integrity and wound care as outlined in Chapter 31. It includes recognition of factors affecting wound healing, such as obesity and diabetes. Test your knowledge and understanding of these critical nursing concepts.
