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Questions and Answers
What is the body's largest organ and the primary defense against pathogenic invasion?
What is the body's largest organ and the primary defense against pathogenic invasion?
What are some factors that can influence the appearance of skin and skin integrity?
What are some factors that can influence the appearance of skin and skin integrity?
Internal factors such as genetics, age, health, and nutrition, as well as external factors like activity, sun exposure, and medications.
What type of wound occurs during therapy, such as surgery, vein puncture, or tumor excision?
What type of wound occurs during therapy, such as surgery, vein puncture, or tumor excision?
What type of wound is caused by a blow from a blunt instrument, resulting in bruising?
What type of wound is caused by a blow from a blunt instrument, resulting in bruising?
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A laceration is a closed wound with jagged edges.
A laceration is a closed wound with jagged edges.
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What type of wound is characterized by penetration of the skin and often the underlying tissue by a sharp instrument?
What type of wound is characterized by penetration of the skin and often the underlying tissue by a sharp instrument?
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Which of the following wound types involves a major break in sterile technique and is often associated with inflammation?
Which of the following wound types involves a major break in sterile technique and is often associated with inflammation?
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What type of wound is uninfected and shows no evidence of inflammation?
What type of wound is uninfected and shows no evidence of inflammation?
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What are the other terms used for pressure ulcers?
What are the other terms used for pressure ulcers?
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Pressure ulcers are caused by:
Pressure ulcers are caused by:
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Which of the following is NOT a risk factor for pressure ulcers?
Which of the following is NOT a risk factor for pressure ulcers?
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A patient with impaired mental status is less likely to respond to pain and pressure, making them more susceptible to pressure ulcers.
A patient with impaired mental status is less likely to respond to pain and pressure, making them more susceptible to pressure ulcers.
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What is the main complication of wound healing that can occur in the first 48 hours after surgery?
What is the main complication of wound healing that can occur in the first 48 hours after surgery?
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Wound infection is a common complication that typically becomes apparent 2-11 days after surgery.
Wound infection is a common complication that typically becomes apparent 2-11 days after surgery.
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What are some of the potential risks associated with prolonged coagulation times?
What are some of the potential risks associated with prolonged coagulation times?
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What nursing diagnoses are commonly associated with impaired skin integrity?
What nursing diagnoses are commonly associated with impaired skin integrity?
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Anti-inflammatory drugs, such as steroids and aspirin, can help to promote wound healing.
Anti-inflammatory drugs, such as steroids and aspirin, can help to promote wound healing.
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When assessing a wound, the nurse should pay particular attention to areas that are most likely to ______.
When assessing a wound, the nurse should pay particular attention to areas that are most likely to ______.
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During the assessment of a client's wound, the nurse should determine the extent of tissue damage. How should that be done?
During the assessment of a client's wound, the nurse should determine the extent of tissue damage. How should that be done?
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What is a key consideration when applying heat or cold therapy?
What is a key consideration when applying heat or cold therapy?
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What type of heat therapy is most effective for treating a pressure ulcer?
What type of heat therapy is most effective for treating a pressure ulcer?
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Applying a bandage can help to protect a wound from injury.
Applying a bandage can help to protect a wound from injury.
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What is the primary purpose of applying a bandage?
What is the primary purpose of applying a bandage?
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What are some methods for securing a dressing?
What are some methods for securing a dressing?
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When applying a bandage, it is important to keep the bandage slightly loose to allow adequate blood flow.
When applying a bandage, it is important to keep the bandage slightly loose to allow adequate blood flow.
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What type of bandage is traditionally used in the treatment of a pressure ulcer?
What type of bandage is traditionally used in the treatment of a pressure ulcer?
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What is one significant difference between clean wounds and clean-contaminated wounds?
What is one significant difference between clean wounds and clean-contaminated wounds?
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What is the primary purpose of irrigating a wound?
What is the primary purpose of irrigating a wound?
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What is the appropriate temperature for a hot compress?
What is the appropriate temperature for a hot compress?
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What are some of the effects of cold therapy on the body?
What are some of the effects of cold therapy on the body?
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What are the main areas of pressure that result in a pressure ulcer development when the client is in the supine position?
What are the main areas of pressure that result in a pressure ulcer development when the client is in the supine position?
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A pressure ulcer is not a serious condition, and it will heal on its own.
A pressure ulcer is not a serious condition, and it will heal on its own.
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Which of these statements is correct about pressure ulcers?
Which of these statements is correct about pressure ulcers?
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What is an example of moist heat therapy?
What is an example of moist heat therapy?
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Which of the following is NOT a type of wound dressing?
Which of the following is NOT a type of wound dressing?
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A recurrent bandage is often used to cover a head injury.
A recurrent bandage is often used to cover a head injury.
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A figure-eight bandage is often used to cover a foot injury.
A figure-eight bandage is often used to cover a foot injury.
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Study Notes
Skin Integrity and Wound Care
- Skin is the body's largest organ and first line of defense against pathogens. It helps regulate temperature, prevents fluid loss, and provides sensory awareness.
- Skin appearance and integrity depend on internal (genetics, age, health, malnutrition) and external factors (activity, sun exposure, medications).
- Intact skin has continuous normal skin layers without wounds. Impaired skin integrity is a threat to individuals with restricted mobility, chronic illnesses, trauma, or those undergoing invasive procedures.
Types of Wounds
- Intentional wounds: Result from therapeutic procedures like surgery, vein punctures, or tumor excision.
- Unintentional wounds: Accidental injuries such as fractures from car accidents.
- Closed wounds: Trauma without skin or mucous membrane breakage (e.g., contusions).
- Open wounds: Breaks in the skin or mucous membranes.
Types of Wounds Based on Acquisition
- Incision: Open wound created with a sharp instrument (deep or shallow).
- Contusion: Closed wound caused by blunt force trauma resulting in discoloration (bruising) from damaged blood vessels.
- Abrasion: Open wound involving scraping of the skin surface, either unintentional (e.g., scraped knee) or intentional (e.g., removing pockmarks).
- Puncture: Open wound created by penetrating a sharp instrument into the skin and underlying tissue.
- Laceration: Open wound where tissue is torn apart, often from accidents involving machinery; characterized by jagged edges.
- Penetrating wound: Open wound where the skin and underlying tissue are penetrated, usually by a foreign object such as bullet or metal fragments.
Wound Description Based on Contamination Degree
- Clean wound: Uninfected, minimal inflammatory response; commonly closed and not entering respiratory, genital, or urinary tracts.
- Clean-contaminated wound: Surgical, entering the respiratory, alimentary, genital, or urinary tracts but showing no sign of infection.
- Contaminated wound: Open, fresh, accidental, or surgical wounds with a major break in sterile technique, exhibiting inflammation.
- Dirty or infected wound: Wounds with dead tissue and signs of active infection, such as purulent drainage.
Pressure Ulcers
- Also known as bedsores or decubitus ulcers, pressure ulcers are injuries to the skin due to sustained pressure over bony prominences.
- Etiology: Tissue compression between two surfaces reduces blood supply, depriving cells of oxygen and nutrients, leading to tissue death (ischemia).
Risk Factors for Pressure Ulcers
- Friction and shearing: Force acting parallel to the skin surface, commonly from rubbing against bedding or clothing. Shearing involves a combination of friction and pressure, causing tissue damage.
- Immobility: Inability to change positions, increasing pressure on bony prominences.
- Inadequate nutrition: Insufficient protein, carbohydrates, vitamins (C), fluids, and minerals (zinc) impacts tissue repair and decreases protective padding.
Other Factors Affecting Wound Healing
- Fecal and urinary incontinence: Promotes skin maceration (softening due to moisture).
- Decreased mental status: Patients with reduced awareness may not perceive pain signals, hindering wound care.
- Diminished sensation: Reduced ability to feel heat or cold; complications can occur if these are not detected.
- Excessive body heat: Increases metabolic rate, increasing inflammation, and affecting the body's ability to heal.
- Advanced age: Associated with skin changes like thinning of epidermis and altered blood flow; delays healing.
- Chronic diseases: Conditions such as cardiovascular disease and diabetes compromise oxygen delivery and delay healing.
- Other factors: Poor lifting technique, incorrect positioning, repeated injections, and other factors can hinder wound healing.
Complications During Wound Healing
- Hemorrhage: Due to clot removal, slipped stitches, or blood vessel damage, this risk is heightened within the first 48 hours after surgery.
- Internal hemorrhage: Blood accumulation under the skin (hematoma), potentially compressing blood vessels.
- External hemorrhage: Blood visible under the dressing. Requires sterile pressure dressings and vital signs monitoring.
- Infection: Wound appearance changes, pain, exudate, fever, elevated white blood cell count, and redness are observed.
Wound Healing Complications (cont)
- Dehiscence: Partial or full rupturing of a sutured wound due to obesity, poor nutrition, excessive coughing/sneezing, straining. Managed with large sterile dressings soaked in normal saline, patient placement in bed with bent knees and notification of the doctor.
- Evisceration: Protrusion of internal organs through the wound opening
Factors Affecting Wound Healing (cont)
- Age: Young, adult, elderly patients affect wound healing rates.
- Nutritional status: Diet, obesity impacts healing.
- Lifestyle: Exercise, smoking, and poor hygiene.
- Medications: Anti-inflammatory drugs (steroids, aspirin), and antibiotics that interfere with the immune response impact healing.
- Contamination or infection impairs wound healing
Nursing Process: Assessment
- Obtain a nursing history (review of systems, skin diseases, bruising history, skin condition, skin lesions, healing of sores).
- Conduct inspection and palpation of the skin (skin color, turgor, presence of edema, skin lesions).
- Assess location, extent, length, width, depth, presence of bleeding, foreign bodies, associated injuries, recent tetanus toxoid injection of untreated wounds.
- Assess appearance, size, drainage, presence of swelling and pain of treated wounds.
- Note status of drains/tubes (if used), pressure ulcer location (in relation to bony prominences, ulcer dimensions, undermining, and sinus tracts), stage, color of wound bed, necrosis/eschar locations, surrounding skin condition, and signs of infection for pressure ulcers.
Laboratory Data
- Leukocyte count: Decreased count delays healing and increases infection risk.
- Hemoglobin level: Low hemoglobin indicates poor oxygen delivery to tissues.
- Blood coagulation: Prolonged or abnormal clotting can lead to severe bleeding, whereas hypercoagulability can lead to intravascular clotting, reducing blood supply to the wound site.
- Serum albumin: Albumin level less than 3.5 g/dL shows nutritional impairment, increasing the risk of infection and slowing healing.
- Wound culture: Helps determine potential infection and guide antibiotic choices.
- Sensitivity tests: Guide appropriate antibiotic selection.
Nursing Diagnoses
- Risk for impaired skin integrity
- Impaired skin integrity
- Impaired tissue integrity
- Risk for infection
- Pain
Goals in Planning Client Care
- Risk for impaired skin integrity: Maintain skin integrity, avoid and/or reduce risk factors.
- Impaired skin integrity: Achieve progressive wound healing and regain intact skin.
- Client and family education: Assess and treat existing wounds, prevent future pressure ulcers.
Wound Dressings
- Wet-to-moist gauze (includes several types): Applied to dry wounds to maintain moist wound healing environment.
- Several types of wound dressings: Include transparent film, impregnated no adherent hydrocolloids, hydrocolloids, clear absorbent acrylic, hydrogel, polyurethane foam, and alginate.
Wound Bandages
- Gauze: Restrains dressings on wounds and bandaged hands and feet.
- Elastic bandages: Provides pressure, improves venous return.
- Binders: Support large areas like the abdomen. Examples include triangular arm slings and straight abdominal binders. Bandage tape application considerations, including proper placement.
Wound Care Methods: Heat and Cold Applications
- Dry heat: Examples include hot water bottles, electric pads, aquathermia pads, and disposable heat packs.
- Moist heat: Examples include compresses, hot packs, soaks, and sitz baths.
- Dry cold: Examples include cold packs, ice bags, ice gloves, and ice collars.
- Moist cold: Examples include compresses and cooling sponge baths.
Pressure Ulcer Prevention
- Assess body pressure areas on supine, lateral, prone, and Fowler's positions.
Implementing Wound Care
- Support wound healing: Maintain moist wound environment, proper nutrition, fluid management, and prevent infection and positioning issues.
- Prevent pressure ulcers; treat pressure ulcers based on Red, Yellow, and Black stages.
- Dress and clean wounds; support and immobilize wounds.
- Apply or use heat and cold application based on the needs of the patient or situation, paying attention to the patient's neurosensory, mental, circulatory status; consider time since surgery, type, and condition of the wound.
Wound Specimen Collection
- Describe methods of obtaining a wound specimen; explain appropriate actions for wound specimen collection.
Wound Irrigation
- Explain wound irrigation methods.
Physiologic Effects of Heat and Cold
- Heat: Vasodilation, increased capillary permeability (edema), increased cellular metabolism, increased inflammation, sedative effect.
- Cold: Vasoconstriction, decreased capillary permeability, decreased cellular metabolism, slowed bacterial growth, decreased inflammation, local anesthetic effect.
Other Important Considerations
- Explain the necessity to consider patient neurosensory function, impaired mental status, impaired circulation, and time since surgery, wound type, and status when applying heat or cold.
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Description
This quiz covers essential concepts of skin integrity and various types of wounds. Learn about factors affecting skin appearance and integrity, as well as the differences between intentional and unintentional wounds. Test your knowledge on wound care and its implications for health.
